AMS Capacity Building Strategy & Plan 09.02

Contents Abbreviations

Chapter-1: Background & Context ................................................................................ 1

1.1. Context ................................................................................................................... 1

1.1.1. Health and Institutional Context ............................................................................. 1

1.1.2. Capacity Development & Training Strategy .......................................................... 2

1.1.3. Rationale for Capacity Development & Training Strategy ....................................... 3

1.2. Objectives and Scope of Work for the Assignment ................................................. 3

1.3. Methodology of Development of Capacity Building & Training Strategy ................ 4

1.3.1. Steps for Development of CB&T Strategy ................................................................ 4

1.4. Gap Analysis and Capacity Needs Assessment ........................................................ 5

1.4.1. Overview of the Capacity Assessment ..................................................................... 6

1.4.2. Coverage and Stakeholder Analysis of the Capacity Needs Assessment ................. 6

1.4.3. Capacity Axis and Capacity Areas Covered .............................................................. 8

1.5. Gap Analyses of Competency of Health Staff .......................................................... 9

1.5.1 Competencies in Gaps ............................................................................................. 9

1.5.2 Desired Competencies and Gaps in Competencies of every Stakeholder ............... 10

1.6 Review of Existing Trainings .................................................................................... 22

1.6.1 Stakeholder-wise Trainings ...................................................................................... 22 1.6.2 General Trainings ..................................................................................................... 25 Chapter-2 : Capacity Building & Training Strategy .......................................................... 27

2.1. Guiding Principles for the Capacity Building & Training Strategy ............................ 27

2.2. Strategic Framework for Systems Strengthening .................................................... 28

2.3. Target Trainees ........................................................................................................ 30

2.4. Capacity Building and Training Objectives ............................................................... 32

2.5. Capacity Building and Training Activities ................................................................ 41

2.5.1. Capacity Priority Areas ............................................................................................ 41

2.6. Modes of Training Delivery ...................................................................................... 51

2.7. Target Group-wise Trainings .................................................................................... 54

2.7.1. Developing competencies for Core Competencies .................................................. 55

2.7.2. Developing competencies for Specialized Competencies ....................................... 59

Chapter-3: Capacity Building & Training Plan ................................................................. 60

3.1. Individual Capacity Development Plan .................................................................... 60

3.2. Capacity Development: Organisational/Support System Strengthening ................. 63

3.3. Enabling Environment Development Plan ............................................................... 64

3.4. Human Resource Management & Institutional Roles and Responsibilities ............. 66

3.5. Quality Assurance and Training Management ........................................................ 68

3.5.1 Pre-Training Activities ............................................................................................. 68

3.5.2 During Training Activities ......................................................................................... 69

3.5.3 Post-Training Activities ............................................................................................ 69

3.5.4 Quality Assurance Committee (QAC) ....................................................................... 70

3.5.5 Budgetary Considerations ....................................................................................... 70

Chapter-4: Monitoring & Evaluation Framework .......................................................... 71

4.1. Introduction & Rationale for M&E ........................................................................... 71

4.2. Objectives of M&E Framework ................................................................................ 72

4.3. Target Users of M&E Framework ........................................................................... 72

4.4. Guidelines for M&E framework ............................................................................... 73

4.5. Key Evaluation Questions & Logframe .................................................................... 74

4.6. Methodology and Work Plan ................................................................................... 77

4.7. M&E Operationalization Plan .................................................................................. 79

4.8 Human Resources for CB&T M&E ............................................................................ 80

4.9 Activity Timeline ...................................................................................................... 82

Annexure: Annexure-I: District-Wise Distribution of Health Facilities .............................................. 84

Annexure-II: Year-wise Budget Details ............................................................................. 87

Annexure–III: RCH-II Training ............................................................................................ 96

Annexure-IV: Suggested Training Venues .......................................................................... 112

Annexure-V: State Institute of Health & Family Welfare Indra Nagar, Lucknow .............. 113

Annexure VI: Stakeholder-Wise & Training Wise Budget .................................................. 117

Contents: List of Tables Chapter-1: Background & Context ................................................................................ 1

Table 1.1: Comparative health indicators of India and Uttarakhand ................................ 1

Table: 1.2: Stakeholder Analysis ........................................................................................ 7

Table 1.3: Capacity areas Identified for Assessment ........................................................ 9

Table 1.4: Capacity areas for Medical Officers Cadres ...................................................... 10

Table 1.5: Capacity areas for the PARAMEDICALS – Pharmacists ..................................... 12

Table 1.6: Capacity areas for Medical Technicians ........................................................... 13

Table 1.7: Capacity areas for Nurses ................................................................................. 15

Table 1.8: Capacity areas for Outreach Workers - Frontline Health Workers (FLWs) ....... 16

Table 1.9: Capacity areas for OUTREACH WORKERS- ASHAs ............................................ 18

Table 1.10: Capacity areas for GDAs ................................................................................... 20

Table 1.11: Trainings provided to Medical Officers in the last 2 financial years ................. 22

Table 1.12: Trainings provided to Nurses in the last 2 financial years ................................ 23

Table 1.13: Trainings provided to Nurses in the last 2 financial years ................................ 24

Table 1.14: Training duration for different stakeholder categories .................................... 26 Chapter-2: Capacity Building & Training Strategy .......................................................... 27

Table 2.1: CB&T objectives for the Stakeholders .............................................................. 33

Table 2.2: Priority Core Competencies for Staff ................................................................ 42

Table 2.3: Capacity development plan: Priority Activities ................................................ 49

Table 2.4: Suggested Training Types for Different Capacity Aspects ................................ 54

Table 2.5a: Project Management-Strategic and Coordinated Planning, Monitoring, Reporting, HR management ............................................................................. 55

Table 2.5b: Communication, and Liasoning Skills ............................................................... 55

Table 2.5c: Leadership, Motivation and Teamwork Skills ................................................... 56

Table 2.5d: Medico-Legal Practices .................................................................................... 57

Table 2.5e: Biomedical Waste Management & Infection Control ...................................... 57

Table 2.5f: Quality Assurance ............................................................................................ 58

Table 2.5g: Disaster Preparedness & Response .................................................................. 58

Table 2.5h: Finance and Budgeting ..................................................................................... 59 Chapter-3: Capacity Building & Training Plan ................................................................. 60

Table 3.1: Proposed Training duration for different stakeholder categories .................... 60

Table 3.2: Core competency Trainings .............................................................................. 61

Table 3.3: Capacity development Initiatives at the Organisational Level ......................... 63

Table 3.4: Capacity development Initiatives to Strengthen Enabling Environment .......... 65

Table 3.5: Human Resource Management in Capacity Development & Training of Health Staff of Uttarakhand Health Department ......................................................... 66

Table 3.6 : Tentative Budget for Trainings ....................................................................... 70 Chapter-4: Monitoring & Evaluation Framework .......................................................... 71

Table 4.1: Logframe for CB&T interventions ..................................................................... 74

Table 4.2: Modalities of Reporting and Data Collection Monitoring ................................ 77

Table 4.3: Framework for Developing Operationalization Plan of CB&T M&IE Framework in the state. .......................................................................................................... 80

Table 4.4: Details of Human Resource and their responsibilities ..................................... 80

Abbreviations

ANM - Auxiliary Nurse Midwife

ASHA - Accredited Social Health Activist

AWW - Anganwadi Worker CHC Community Health Centre

CNAA - Community Need Assessment Approach

DMO - District Medical Officer

DPM - District Programme Manager

DTO - District Tuberculosis Officer

EmOC - Emergency Obstetric Care

FP - Family Planning

FRU - First Referral Unit

IDSP - Integrated Disease Surveillance Programme

IEC - Information, Education and Communication

IMNCI - Integrated Management of Neonatal and Childhood Illnesses

IMR - Infant Mortality Rate

IUCD - Intra Uterine Contraceptive Device

LBW - Low Birth Weight

LHV - Lady Health Visitor

LT - Laboratory Technician

MH - Maternal Health

MMR - Maternal Mortality Ratio

MO - Medical Officer

MOHFW - Ministry of Health and Family Welfare

MWCD - Ministry of Women and Child Development

NDCP - National Disease Control Programme

NGO - Non-Governmental Organisation

NICD - National Institute of Communicable Diseases

NIHFW - National Institute of Health and Family Welfare

NLEP - National Leprosy Elimination Programme

NPCB - National Programme for Control of Blindness

NRHM - National Rural Health Mission

NVBDCP - National Vector Borne Disease Control Programme

PHC - Primary Health Centre

PIP - Programme Implementation Plan

PMU - Programme Management Unit

PRI - Panchayati Raj Institution

QAC - Quality Assurance Committee

RCH - Reproductive Child Health

RKS - Rogi Kalyan Samiti

RNTCP - Revised National Tuberculosis Control Programme

RTI/STIs - Reproductive Tract Infections/Sexually Transmitted Infections

SBA - Skilled Birth Attendant

SC - Sub-Centre

SIHFW - State Institute of Health and Family Welfare

SHP - State Health Programme

SPM - State Programme Manager

SRS - Sample Registration System

STLS - State Tuberculosis Laboratory Supervisor

STS - Senior Treatment Supervisor

TOT - Training of Trainers

VHND - Village Health and Nutrition Day

Capacity Building & Training Strategy 1

Background & Context

“Most performance problems can be attributed to unclear expectations, skills deficit, resource or equipment shortages or a lack of motivation.”

- Hughes et al., 2002 -

1.1. Context

1.1.1. Health and Institutional Context

The shortage of trained professionals owing to the challenging terrain of the state, the out-of-reach healthcare facilities and transportation facilities have been persistent challenges in the systematic health care delivery and access in Uttarakhand. Limited service availability had consequently negatively influenced health seeking behavior due to availability, access, cost and quality constraints.

At the same time, the state is witnessing a trend of burgeoning burden of Non-Communicable Diseases (NCDs) as evidenced in the Table 1.1 below, while the status of maternal, neonatal and child care shows only marginal improvement in the state. This is evidence of a dire need for enhancing health care access and improving its delivery.

Table 1.1 : Comparative health indicators of India and Uttarakhand Indicator Status of Health Indicators

(India) Status of Health Indicators

(Uttarakhand)

Infant Mortality Rate 41/1000 (Total,NFHS-4) 57/1000 (Total,NFHS-3)

40/1000 (Total,NFHS-4) 42/1000 (Total,NFHS-3)

Complete Immunization 61.3% (NFHS 4) 58.2% (NFHS 4)

Maternal Mortality Ratio

122/1,00,000 live birth (SRS-2015-17)

167/1,00,000 live birth (SRS-2011-13)

89/1,00,000 live birth (SRS-2015-17)

165/1,00,000 live birth (AHS-2012-13)

Institutional Births 75.1 (Rural, NFHS 4)

63.7 (Rural, NFHS 4)

Men with Slightly above normal Blood Pressure (Systolic 140-159 mm of Hg and/or Diastolic 90-99 mm of Hg) (%)

10.3 (Total, NFHS 4) 9.7 ( Rural, NFHS 4)

7.2 (Total, NFHS 4) 6.7 ( Rural, NFHS 4)

Men with high blood sugar level(>140

mg/dl) (%)

7.9 (Total, NFHS 4) 7.4 (Rural, NFHS 4)

8.8 (Total, NFHS 4) 8.2 (Rural, NFHS 4)

Source: National Family & Health Survey-4; Annual Health Survey, 2012-13; Sample Registration System (SRS), 2015-17

It is against this context that the World Bank is supporting the Uttarakhand Health Systems Development Project (UKHSDP) to improve access to quality health services, particularly in the hilly districts of the state, and to expand health financial risk protection for the residents of Uttarakhand. The project is characterized by two components as described below:

1

Capacity Building & Training Strategy 2

As described above, Component II of the UKHSDP strives to strengthen the capacity of the state machinery to provide effective stewardship to improve the quality of services in the entire health system. To assist in these efforts, it was deemed necessary to plan for system strengthening through a comprehensive capacity development and training of the Department of Health & Family Welfare, GoUK which will strengthen the state institutions and health actors, thus ultimately improve health care access, delivery, utilization of health services and thereby health outcomes.

1.1.2. Capacity Development & Training Strategy

Research shows that Uttarakhand is one of the many states in the country where less than 50% of the required staff is available to serve rural populations, while at times care is provided by non-qualified staff (WHO, 2006). This situation seriously compromises the health status of the communities, as poor performance of service providers leads to inaccessibility of care and sub-optimum quality of care, which contribute to reduced health outcomes as people may not use services or may not receive optimal care. This sub-optimal performance may be attributed to inadequate staff, unmotivated or apathetic staff, staff not providing care according to standards and not being responsive to the needs of the community and patients. Here, performance is understood as a combination of staff being available, competent, productive and responsive1.

Capacity development is one solution to address these performance gaps. Capacity Development Interventions can only be designed based on an analysis of the determinants that influence health workers’ performance. Implementation of these interventions (trainings and institutional/system

strengthening interventions) is expected to yield improved working conditions, improved

motivation, improved staff retention, etc. These, in turn, result in the effects of the intervention in terms of improvements on availability, competence and/or responsiveness of health workers and

ultimately affecting performance of the health system and the health actors. Improved performance in turn contributes to improved health status. Globally, policy makers and planners alike realize that

1 WHO (2006) Improving health worker performance: in search of promising practices, Evidence and Information for Policy, Department of Human Resources for Health Geneva,

Component I Component II

Strengthening institutional structures for stewardship

and service delivery and augmenting the state’s

human resource capacity,

Innovations in Engaging the

Private Sector

Data

Textbox

Reference??

3 Capacity Building & Training Strategy

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attaining Sustainable Development Goals is not possible unless the Human Resource Crisis is addressed, regardless of increase in health financing.

It has also been emphasized that now that success in staff retention and improvement in performance can be ensured by developing capacity development interventions or approaches that are evidence and need-based, to inform policy-makers as to which interventions may be suitable under which circumstances and for which groups of staff (Buchan, 2002).

1.1.3. Rationale for Capacity Development & Training Strategy

Therefore, to aid state-wide system strengthening and implementation of the UKHSDP, a need emerged to identify gaps between the desired and current performance of the Department of Health & Family Welfare staff. A major pre-requisite for providing quality health care services is ensuring the optimum performance of the health personnel by upgrading their knowledge and skills. However, planners must caution themselves from implementing “one-size-fits all trainings” or “policy straightjackets” that do not address the performance or learning/skill gaps of the stakeholders. Therefore, performance gaps were captured through a rigorous capacity gap analysis and training needs assessment of the different cadres of health staff in the State and documented in the Gap Analysis Report. This data allows evidence-based strategic planning to develop a comprehensive capacity building strategy and plan that will provide the framework for the design and roll-out suitable capacity building and training programs that can strengthen the capacities of different cadres of health staff vis-à-vis their performance gaps. This document is the outcome of the capacity analysis and planning, and outlines the comprehensive capacity development and training strategy that will guide the development of state and district level training implementation plans. This document would also be useful for state and central officials and policy makers to understand the training for effective integrated Health, Family Welfare service delivery at below district level. 1.2. Objectives and Scope of Work for the Assignment

The section below describes the overall objective and the scope of work that characterized the entire assignment, including the CB&T strategy given below:

• Conduct a TNA to identify the capacity building needs of the various cadres of the health staff in

the state like MOs, Nurses, ANMs, GDAs etc.

• Conduct needs assessment for PG level specialization training required by medical officers and

identify such institutes across India to fulfil gaps of specialists in Dept. of Health

• Review the existing training programs and materials and identify gaps

• Prepare a training strategy and a plan to meet the training needs of various categories of

healthcare providers

OBJECTIVES OF THE ASSIGNMENT

Data

Highlight

Data

Textbox


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Developing a training and capacity building strategy to

address critical knowledge and capacity gaps for all levels

of staff, that will address

§ Training objectives and needs for each cadre of staff

§ Measures to address identified challenges/ capacity

gaps

§ Profile of trainees at all levels

§ Trainer requirements/ capacity

§ Training approach/ methodology/ duration and

content for each level of trainee

§ Linkages between individual training plans and

performance management system and

§ Indicative training content and broad plan including a

plan for the preparation of training and learning

materials for each type of training and resource

persons to be involved

Development of a detailed annual training

plan with the following components:

§ Training load,

§ Training schedule

§ Costs for various categories of

identified staff.

SCOPE OF WORK 1.3. Methodology of Development of Capacity Building & Training Strategy

The previous section laid out the overall objectives of the current assignment, i.e. to develop a Capacity Development and Training Strategy. This section outlines the methodology that was followed by the AMS to design and develop a comprehensive CB&T strategy that not only strives to meet the diverse training needs of the diverse stakeholders engaged in the implementation of UKHSDP, but is also cost effective and practical with regards to its implementation. 1.3.1. Steps for Development of CB&T Strategy

The Implementation Process has four (4) steps as shown below. The AMS team has been charged with carrying out Step 1 and Step 2 with the support of the Training and Capacity Building Cell in the SPIU. Steps 3 and 4 will be carried out by the Training

Service Provider.


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1.4. Gap Analysis and Capacity Needs Assessment

The previous section describes the methodology and the work plan that was adopted while designing and developing the Capacity Building and Training Strategy for UKHSDP. The following section will describe Step 1 described in the methodology – Capacity Needs Assessment or Training Needs

Assessment. This section will briefly describe the methodology of the TNA exercise; the stakeholders covered and finally detail the stakeholder-wise capacity gaps as well as the results of the Competency analysis undertaken for the different stakeholder categories.

Step 1: Capacity

Assessment

Step 2: Design of Training Programme

Step 3: Preparation of

Action Plan

Step 4:

Implementation & Monitoring

§ Identify and define the target beneficiaries § Identify desired capacities in a competency framework based on

strategy, policies, mandates, etc. through desk review & stakeholder consultations

§ Assess the current capacity of each target group through interviews § Identify capacity gaps and training needs

§ Define objectives for the CB&T § Draft a framework to design training programmes § Identify facilitators to conduct the training § Design a detailed schedule and contents of the training

§ Arrange the venue and needed equipment. § Implement the training § Monitoring the training participants and facilitator(s). § Participants undergo pre and post training assessments § Analyse the process of the training and the results of feedback sheet

§ Form a steering committee at the state level & Nodal officers at District.

§ Present the state action plan & budget in front of DG and senior staff in the participants’ directorate.

§ Capacity Building of District Level Staff on Action Plan § Preparation & Approval of District Level Action Plan and budget.


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1.4.1. Overview of the Capacity Assessment

The overall capacity assessment exercise assessed four ` `Capacity Axis’ for ‘health provider capacity’ and covered a broad spectrum of issues under each axis (Figure 1.1). These were framed by a detailed questionnaire which collected data on each of the axes, and included a Self-Reported

Competency Analysis & Training Needs Assessment. The questionnaire was the main instrument for data collection; field work included few FGDs with various Health staff, some

key stakeholder consultations followed by document analyses that included a desk review of various guidelines and documents related to the State Health Department and UKHSDP will be undertaken to establish an organizational context of the project. These processes provided ample opportunities for the various service providers to discuss the capacity issues that were most seriously inhibiting their ability to perform their tasks effectively. The Training Needs Assessment can be divided into five stages-

• Identifying Problem Needs: Determine organisational context; perform gap analyses and set objectives supported by desk review of secondary literature & project documents.

• Design of Needs Analysis: Determine the target groups; draw up competency framework to establish desired performance criteria using project documents.

• Data Collection: Review documents of existing trainings planned; conduct interviews/surveys to conduct a self-assessed competency analysis; self-reported training needs.

• Analysis of Data: Quantitative and qualitative analyses of data; draw findings, conclusions and recommendations on training content

• Provide Feedback: Share the findings of the TNA with the UKHSDP Project team and discuss framework for the Training Strategy and Plan.

1.4.2. Coverage and Stakeholder Analysis of the Capacity Needs Assessment

Table 1.2. Given below describes all the different stakeholders engaged in different roles in the healthcare service delivery in the state. Along with the stakeholder category, the types of stakeholder, their job role and responsibility and numbers covered in each category out of the total available staff, during the need analysis is outlined below. At least 10% of each stakeholder category has been covered to ensure statistical validity of the findings.

Clinical Management & Administrative

Soft Skills Other Functional Areas

Capacity Axis for Capacity Analysis

Identifying Problem Needs-

Determine design of Needs Analysis

Data Collection

Analyse Data

Provide Feedback

Figure 1. Capacity Axes


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Table: 1.2. Stakeholder Analysis

SN Level Stakeholder Category

Stakeholder Job Role Coverage

1. Medical Medical Officers

• Medical officers

• Specialists

Overall management of the Healthcare facility- proper medical care and treatment of patients.

123 (14%)

2. Para-medical

Pharmacists

• Chief

Pharmacists

• Senior Pharmacists

Responsible for keeping dispensary / pharmacy in a neat and tidy manner;

Supply, maintenance and dispensation of drugs

85 (10%)

Technicians

• Lab

Technician

• Dark room

assistant

• X-Ray

Technician

• ECG

Technician

• Senior Lab

Technician

• Dental

Hygienist

• ICTC Consultation

Health care delivery, especially for services that depend on diagnostic testing for decision making;

Collect and prepare blood, urine and tissue samples; taking MRIs and X-Rays

Maintain patient records and develop exposed radiographs; maintain laboratory inventory levels; keep equipment in good working order and if necessary, place orders for new supplies

30 (10%)

Para-medical Nurses

• Matron

• Staff Nurse

• Assistant

Matron

• Responsible for

managing the care and attending to the needs of the patient; direct patient care like bed making, bed bathing etc.

• Provide comfort to the patients and

82 (10%)


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Table: 1.2. Stakeholder Analysis

SN Level Stakeholder Category

Stakeholder Job Role Coverage

ensure safety of the patients

Outreach Workers

Frontline Health Workers

• ANMs

• Health supervisor

• Lady Health Visitor

• Patient Care- taking and recording vital signs, blood pressure and temperatures

• Conduct independent

deliveries; New born resuscitation; New born and maternal care

504 (12%)

• ASHAs

• Keep record of pregnancies, births, deaths and immunizations in the community

• Creating awareness in the community on health, diet and nutrition, basic sanitation and hygienic practices, health services and the need for timely utilization of health and family welfare services at doorsteps

177

Administrators GDAs • Ward Boy

• Class IV Staff

• Patient Care; managing the front office; handling emergency services; maintaining hygiene etc.

181 (14%)

-

This analysis maps generic and functional competencies of the different stakeholders to gauge the existing gaps in their capacities, which will then inform training interventions outlined in the strategy ahead.

1.4.3. Capacity Axis and Capacity Areas Covered

The main areas of capacity assessment are given below in Table 1.3. Since this Capacity Development Plan is underpinned by the same framework, it ensures that the Plan is also aligned with the actual needs of the health staff.


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Table 1.3. Capacity areas Identified for Assessment

Capacity Axis Capacity Areas

Clinical Care

This competency attempts to understand the perception of the health staff regarding their ability to carry out their clinical duties effectively and efficiently, and also tries to understand the barriers or challenges they face, if any.

This competency attempts to understand the perception of the health staff regarding their ability to carry out their administrative and management duties effectively and efficiently, and also tries to understand the barriers or challenges they face, if any

Soft Skills

This competency attempts to understand the perception of the health staff regarding their personal attributes they use to influence and enhance the way they communicate and relate to patients, colleagues and peers. These relate to attitudes and intuitions.

Other functional competencies

Apart from clinical, administrative and soft-skills, it is also instructive to understand the status of knowledge, awareness and other skills that are critical in undertaking other peripheral functions of the health staff such as disaster management, biomedical waste management and infection control.

1.5. Gap Analyses of Competency of Health Staff

Training & capacity building is the means to ensure that the official stakeholders have the right knowledge and professional skills that can enable them to deliver on their roles & responsibilities with full competency and efficiency. It becomes a necessity when there is a gap between the desired

performance, and the current performance, owing to a lack of the concerned

skill or knowledge (see graphical representation ahead). In other words, gaps in competencies denote current competencies of the stakeholders and its failure to keep at par with the competencies/ skills (mentioned above) desired or expected from the health staff.

1.5.1 Competencies in Gaps

A Gap Analysis exercise was carried as part of this assessment by first benchmarking the desired competencies of each stakeholder based on their job roles. These competencies were then compared with the current competencies of the different stakeholder categories to reveal the gaps in the

clinical, administration and management and soft skills of the stakeholders under scrutiny. This will

in turn translate into the capacity building and training needs for each of the stakeholder category.

Administrative & Management


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1.5.2 Desired Competencies and Gaps in Competencies of every Stakeholder

To understand the capacity needs of the Stakeholders, it is important to separately look at the desired competencies of every stakeholder

described above. The desired competencies of every stakeholder are given below:

Table 1.4. Capacity areas for Medical Officers Cadres

SN. Capacity Axis Desired Competencies Competency Gaps

1. Clinical Care

• Analyzing records, reports and exam data to help

them diagnose patients’ condition

• Effective Clinical Treatment and evaluation

• Follow-up on any patients referred to a higher

facility.

• Conduct basic examinations, & Emergency

Preparedness

• Only 5% reported to provide instructions to the patients on the do’s and

don'ts to be observed at home; 20% were found to be irregular.

• 58% find it challenging to maintain records of medical history, physical

examination, diagnosis and treatment details of each patient.

• 54% Doctors expressed gap in their ability to provide

Emergency/Critical Care Service like – Basic/ Advanced Life Support; Life Saving intubation techniques; Cardiac Life Support; trauma life support, General Emergency Care; Functioning of ICCUs, etc.

• 69% report that patients experience long waiting times to see a doctor

or to receive treatment. One-third of the medical officer positions are

vacant.

2. Administrative

& Management

• General Management (Problem Solving, Time-

management, conflict resolution, M&E, financial

management )

• Record Keeping and Documentation

• Medico-legal Procedures

• Regulation of clinical establishment

• 3 in 10 or more considered tasks like – HR Mgmt., Supervision & Coordination of peripheral services, Scheme implementation, etc. to be

challenging. This becomes more critical when they reach middle or

higher level.

• 1 in 10 considered themselves efficient in prioritising tasks


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Table 1.4. Capacity areas for Medical Officers Cadres

SN. Capacity Axis Desired Competencies Competency Gaps

• 3 in 4 respondents reported to never/rarely prepare written operative

plans with set goals, execution deadlines and indicators to monitor the

goals.

• 18% reported to never have referred to any IT Applications for acquiring

medical information

• About 1 in 3 respondents found it challenging to deal with medico legal

procedures

3. Soft-Skills

• Life Skills, Self-Management – Stress management and time management

• Patient Interaction & Communication

• Team work and coordination

• Ways to improve physician-staff relationship

• Only 1 in 4 of the MOs have poor listening skills when interacting with

patients

• Only 1 in 4 consider patient grievance redressal as an important task

4.

Other

Functional

Areas

• Disaster Management

• Knowledge of Health Policy in Uttarakhand to align

health interventions with policy guidelines and its

objectives.

• Creating health literacy

• Leadership Development & Stress Management

• Infection Control & Biomedical Waste Management

• Open-ended qualitative responses revealed the need for training on

Disaster Management

• One-third of the medical officer posts are vacant

• 61% feel emotionally drained at their job

• Only 55% stated to be highly satisfied with their job

• 49% MOs found working conditions to be motivating

• 42% MOs found the infrastructure and supplies to be adequate.


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Table 1.5 : Capacity areas for the PARAMEDICALS – Pharmacists

SN. Capacity Axis Capacity Areas/ Desired Competencies Gaps in Competencies

1. Clinical Care

• Health Assessment & Diagnosis

• Knowledge of Dispensation of medications by

compounding, packaging, & labelling pharmaceuticals.

• Assisting doctors in emergency cases

• 26% do not report cases of Adverse Drug Reactions

(ADRs) by their patients

• 22% cannot identify problems/errors in prescription

order

2. Administrative &

Management

• Drug Logistics and Supply Chain Management - Stock

Verification and Inventory Management and

distribution

• Record Keeping and Documentation

• General Management (Problem Solving, Time-

management, conflict resolution, M&E, financial

management at facility level )

• More than half of the respondents (around 53%) were

found to be lacking in confidence in using IT tools.

• 19% were found to be unskilled in maintaining

inventory, update patient information, billing etc.

• Around 28% reported to rarely/never store expired

medicines separately/condemned drugs; 7% stated to

be irregular in carrying out this activity and 2% were

found to be unsure at carrying out the activity.

• 40% of the respondents reported to face challenges in

Staff/HR management

• 45% face challenges related to material management

and procurement

• 10% face challenges related to record

keeping/documentation


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Table 1.5 : Capacity areas for the PARAMEDICALS – Pharmacists


3. Soft-Skills


• Interpersonal Interaction & Patient counselling

• While only about 16% of the pharmacists report feeling

stressed and emotionally drained at their jobs, it is

useful to organise trainings time-management & stress

management as pharmacists often have many

responsibilities.

4. Other Competencies


• Leadership Development & Stress Management/Conflict

Resolution

• Infection Control & Biomedical Waste Management

• Open-ended responses highlight that pharmacists, who

are often in-charge of the lower-level facilities – are

inadequately prepared to respond to disasters such as

landslides or cloud-bursts that may affect the facilities.

• Open-ended responses also reveal that pharmacists need

a detailed training on infection control and biomedical

waste management.

Table 1.6 Capacity areas for Medical Technicians


1. Clinical Care

• Rationally Conducting Lab tests/Diagnostic tests

• Knowledge of safety protocols and controlling sources

of error during clinical practice

• Knowledge of molecular diagnosis

• 40% claim difficulties in their ability to interpret

prescriptions and rationally carry out diagnostic tests.

• Around 1/4th of the medical technicians (about 23%)

do not regularly carry out safety procedures in the

laboratory


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Table 1.6 Capacity areas for Medical Technicians


• 16.7% face challenges related to shortage of staffs

• 10% face challenges regarding lack of knowledge in

molecular diagnosis.

2. Administrative &

Management

• General Management

• Record Keeping and documentation

• Medical Equipment Management

• Only 56% of the respondents are aware that patients

must not ideally receive iron or any other metallic

preparations for 5 days

• 40% face challenges regarding Staff/HR Management

• 45% also stated to face challenges related to Material

management/procurement

3. Soft-Skills


• Patient Interaction


-

4. Other Functional

Competencies

• Knowledge of National Health Programmes

• Knowledge of Life Cycle Parameters (Molecular Diagnosis)

• Only 60% of the respondents possess awareness about

RMNCH- stimulations harmful for a newborn having

difficulty breathing

• 13% of the respondents are aware to a little extent

about the life cycle parameters/indicators (e.g. ideal HB

levels for pregnant women etc.); 50% possess

awareness to some extent


15

Table 1.7 Capacity areas for Nurses


1. Clinical Care

• Health Assessment and Diagnosis

• Management of Treatment

• Attention to detail

• Professional, Legal and Ethical Nursing Practice

• Emergency care/Role in assisting clinicians in handling

emergency cases

• Newborn care, especially critical newborn care and

incubation technology

• Only about 1/4th of the respondents reported to confidently

undertake clinical functions like urinary catherization and enema.

• Open-ended responses on desired trainings on clinical care

revealed a strong need for training on dealing with high-risk

deliveries and complications in birth.

2. Administrative &

Management

• Management of Care

• Leadership and Nursing Management

• Only 2 in 5 respondents prepare written operative plans in a

routine manner

• 1 in 3 respondents find HR Management as challenging

• 3 out of 5 respondents reflected absolute confidence in ability to

maintain patients’ files.

3. Soft-Skills

• Life Skills, Self-Management – Stress management and

time management

• Leadership



• Only 63% of the respondents displayed proper communication

skills with different health staff and departments

• 1 in 3 do not give enough importance to two-way communication

with patients and their families i.e. they do not encourage too

many questions from patients regarding diagnosis or treatment

nor do they believe in educating the patients about the potential


16

risks/ side effects of any treatment/procedures during pregnancy,

post pregnancy etc.

4. Other Functional

Competencies

• Knowledge and Awareness about National Health

Programmes

• Bio Medical waste management and infection control

• 65% possess awareness about NCDs and 48% are aware about 5

National Programmes

• 89% of the Nurses reported motivating working conditions.

• Yet, a little less than half of the nurses feel that their work affects

their duties towards their families.

• Also, 54% Nurses claimed they are stressed or emotionally

drained.

• Open-ended responses reveal that nurses require more training

on infection control and biomedical waste management.

Table 1.8 : Capacity areas for Outreach Workers - Frontline Health Workers (FLWs)

SN. Capacity Axis Desired Competencies Gaps in Competencies

1. Clinical Care

• New Born Care /New born Resuscitation

• Screening of NCDs

• Hands on training on administration of

vaccination

• Maternal Death Review & Child Death Review

• About half of respondents reported to face difficulties in conducting basic examinations such as BP, blood Sugar, Hb levels etc.

• 11% lack absolute confidence in their ability to screen for NCD or

confidently diagnose or identify illnesses in children.

• 4 out of 10 ANMs absolutely confident in –

• Diagnosing delivery related complications

• Conducting Newborn resuscitation

• Diagnosing Serious Illnesses in Newborns


17



• 4 in 10 respondents expressed need for training in immunization

covering new vaccines and related diseases, and techniques of

administering them

2. Administrative &

Management


• Record Keeping & Documentation

• Online reporting of vaccination

• 2 out of 5 reported difficulties in organising VHNDs every month

• 1 in 3 found material management to be challenging

• 30% reported to rarely/never discuss diagnosis, problems or challenges

in mobilising resisting groups with their supervisors (MOs);

Open ended responses revealed need for training in –

• Cold-chain management and supplies logistic

• Immunization related programs like Mission Indradhanush & Online reporting systems

3. Soft-Skills




• Over half of respondents reflect less than optimal communication

skills (Scored less than 4 on a 6 point scale)

• 30% do not believe in educating the community about the potential

risks/side effects of any treatment/ procedure such as pregnancy, post

pregnancy etc.

• More than 1/4th believe the FLWs to be sole participants/speakers

during any counselling session.

• (54%) reported to face difficulties in undertaking field activities.

4. Other Functional

Competencies • Knowledge & Awareness on National Health

Programmes

• 71% possess awareness about Leprosy eradication and 65% are aware

about 5 National Programmes


18



• Less than 2 out of 5 respondents reported to manage work/life balance,

especially with regard to duties towards their families

• 85% FLWs expressed their satisfaction with the jobs

• 93% FLWs reported working conditions as motivating.

• 54% FLWs claimed infrastructure & supplies to be adequate

Table 1.9 : Capacity areas for OUTREACH WORKERS- ASHAs


1. Clinical Care

• Analyzing records, reports and exam data to help them

diagnose patients’ conditions

• Patient Care

• Maternal Care

• Basic knowledge of symptoms, treatment and prevention,

especially in malaria prone areas.

• 1/4th of the respondents reported to find Maternal Care

challenging.

• More than 1/4th of the respondents reported to find

activities related to social mobilisation challenging.

2. Administrative &

Management

• Record Keeping/Documentation


• 1/4th of the respondents reported to be ‘less confident’

in preparing village health plans.

• More than 1/4th of the respondents reported to find

activities related to social mobilisation challenging.

• More than 1/4th stated to be less confident in their

ability to keep records and maintain patients’ files.


19

Table 1.9 : Capacity areas for OUTREACH WORKERS- ASHAs


3. Soft-Skills




• Over 1/4th respondents believe in being aggressive and

force the community members to see things their way

• 36% agree in not educating the community about the

potential risks/side effects of any treatment/procedure

such as during pregnancy, post pregnancy,

administration of drugs etc.

• Over 1/4th agree that its appropriate to scold/ force the

community members to speak up in case a patient or a

community member is afraid to speak up

• 72% face difficulties in undertaking field activities

4. Other Functional

Competencies • Knowledge and Awareness on National Programmes

• 88% believe in the long term financial security provided

by their job

• 21% reported to be ‘fairly satisfied’ with their job

• 23% reported to be ‘fairly motivation’ to perform their

tasks as an ASHA worker.


20

Table 1.10 : Capacity areas for GDAs


1. Management Skills

• Routine work related issues, such as, administering

injections, dressing, BP measurement, glucose

administration, hospital bedding, applying splints,

sterilization of equipment, use of safety appliances, first-aid,

oxygenating, applying Vigo, shifting patients to wards, etc.

• Assisting doctors while attending emergency cases

• Open-ended responses by the GDA reveal that regular

trainings on aspects of their routine work would be very

helpful as currently GDA do not receive any trainings.

• Multi-skilling of GDA is instructive to support senior

officers in emergency cases.

2. Soft-Skills




• 22% stated to be unconfident in their ability to address patient grievances

• 16% were found to be unconfident in their ability to successfully identify the issues/discomfort of the patients

• Over1/4th respondents reported to get irritated and speak rudely with the patients


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Table 1.10 : Capacity areas for Office Management

SN Capacity Axis Desired Competencies Gaps in Competencies

Knowledge & Awareness

• Responsibilities

• Skills needed in office Management

• Routine chores to be overseen

• Office procedure

• Handling of incoming & outgoing correspondence

• Handling of files (Preparing office notes, Guidelines for

drafting communication, etc)

• Recording of files & retention schedule

• Common terms associated with Official Correspondence

• Lack of knowledge about handling of files &

movement of files from lower level to higher level

and back

• Lack of knowledge about noting and drafting

Note:- The provisions for office staff may also be incorporated in subsequent sections as and where required.


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1.6 Review of Existing Trainings

Apart from the competency analysis, the training needs of the health staff was also determined after

analysing the trainings provided by the Department of Health in the last three years. An analysis of

the financial activities, funds allocated and spent on different trainings for different components of

the health care programmes running in state. In the following section, the first part describes the

trainings that have been planned and implemented for different health staff categories in the staff,

directing its gaze on the trainings that haven’t been planned for or implemented as per proposal. The

second part focuses its attention on general trainings that are not stakeholder specific.

1.6.1 Stakeholder-wise Trainings

Stakeholder-wise review of the trainings planned and implemented is given below:

(a) Medical Officers

Trainings for medical officers have focused on the National Health Programmes in the last two

financial years – 2018-19 and 2019-20. Trainings have been provided on National Programme for

Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS); National

Vector Borne Disease Control Programme (NVBDCP); Revised National Tuberculosis Control

Program (RNTCP); and other communicable diseases such as etc. Additionally, some non-clinical

trainings have been organised such as `Kayakalp’ under Swachya Barat Abhiyan and `Lakshya’ that

is a Labour Room Quality Improvement Initiative to aid efforts to reduce preventable maternal and

newborn mortality, morbidity and stillbirths associated with the care around delivery in Labour room

and Maternity OT and ensure respectful maternity care. The figure below outlines the different

trainings that have been provided to the staff.

Table 1.11 : Trainings provided to Medical Officers in the last 2 financial years (Source: Training Calendar of Dept. of Health & Family Welfare)

Sl. No Name of Training 2018-19 2019-20

1 NPCDCS Yes

2 Lakshya Yes Yes

3 Kayakalp Swachya Barat Abhiyan Yes

4 Immunization Yes Yes

5 Certificate course in Gestational Diabetes Melitus Yes

6 Training on Malaria Yes 7 Training on Chikungunia/Dengue Yes 8 Training on AES/JE Yes

9 Training on NLEP Yes 10 Training on RNTCP Yes 11 Training on NMHP Yes 12 Training NTCP Yes 13 Training on National Programme for Prevention and Control of Fluorosis (NPPCF). Yes 14 NVHCP Yes

It is self-evident in that most of the trainings were focused around knowledge enhancement and

addressing knowledge gaps around National Health Programmes. None of the trainings sought to develop


23

the skills of the medical officers. A glance at the budget for capacity development and training for the

Department of Health Staff (Refer to Annexure II), demonstrates that budget has allocated and approved

funding for skill upgradation of medical officers though training such as EmoOC or Emergency Obstetric

Care, Life Saving Anaesthesia Skills, BeMOC, or basic emergency obstetric care. Integrated Disease

Surveillance Programme (IDSP, but these trainings have not been implemented. Besides these trainings,

no fund allocation has been done for F-IMNCI training for Medical Officers, NSSK training for Medical

Officers, Family Participatory Care and New Born Stabilisation; Laproscopic sterilization, NSV, Minilap

training for doctors etc. A detailed list of these trainings is given below. It is also evident that there is no

provision for administrative and management training for these medical officers.

(b) Nurses

Like medical officers, trainings for Nurses have also been based on the National Health Programmes

in the last two financial years – 2018-19 and 2019-20. There has been a considerable focus on

Maternal, Newborn and Child Health Care as exhibited in trainings on Immunization, infant and Young

Child feeding, counselling and insertion of contraceptives and post-mortem related procedures such

as Maternal Death Review and Child Death Review since these make-up for a large part of their job

role.

Besides RMNCH, trainings have been provided on National Programme for Prevention and Control of

Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS); Revised National Tuberculosis

Control Program (RNTCP); National Mental Health Program etc. Additionally, some non-clinical

trainings have been organised such as `Kayakalp’ under Swachya Barat Abhiyan and `Lakshya’ that

is a Labour Room Quality Improvement Initiative to aid efforts to reduce preventable maternal and

newborn mortality, morbidity and stillbirths associated with the care around delivery in Labour room

and Maternity OT and ensure respectful maternity care. The figure below outlines the different

trainings that have been provided to the staff.

Table 1.12 : Trainings provided to Nurses in the last 2 financial years (Source: Training Calendar of Dept. of Health & Family Welfare)

S. No Name of Training 2018-19 2019-20

1 Syphilis

2 NPCDCS Yes Yes

3 MDR/CDR Yes Yes

4 Immunization Yes

5 IYCF Yes

6 Injectable Contraceptive Yes

7 Training on NMHP Yes

8 Training NTCP Yes

9 Training of NCD Yes

10 Training on NPPCF Yes

However, a look at the funding allocation for the capacity development of nurses in the last two years

also highlight the focus on Reproductive, Maternal, Neonatal and Child Health. The plan allocated and


24

approves funding for the on-site/exposure visit for nurses of delivery points to strengthen their skills in

assisting in complicated births, classroom training on Skill Birth Attendant, midwifery, trainings on family

planning especially sterilisations and IUCD insertions; however many of these trainings were not carried

out in the last 2 years. Additionally, the plan does not allocate for funding for training in RTI/ST (budgeted

for in 2017-18), F-IMNCI, NSSK, IDSP, and Facility-based Newborn Care among others. There is absolutely

no provision for administration and management trainings for nurses in the last two years, although

these tasks play a key role in the everyday job of the nurses irrespective of the facility.

(c) Pharmacists

The training calendar provided by the Department reveals severe gaps in the trainings planned and

carried out for Pharmacists. A careful review reveals that two of the three trainings were organised

for the pharmacists in the last two years which focused on enhancing the knowledge and skills of

pharmacists on the National Health Schemes; Trainings on Malaria/National Vector borne Disease

Control Program and the National Viral Hepatitis Control Program. The final training was a non-clinical

training to address gaps in biomedical waste management and infection control in the respective

facility. However, there has been no budget allocated for Training for Pharmacists under integrated

Disease Surveillance programme (IDSP) in the last two years either.

(d) Medical Technicians

Mostly targeting the lab technicians, the training calendar only mentions training on National Viral

Hepatitis Control Program, to raise the knowledge and awareness of lab technicians about diagnostics

of this program. No other knowledge enhancement or skill training has been organised or even

planned for any category of Medical Technicians. Quality Assurance Trainings are essential for this

cadre and have been budgeted for, although the proportion of funds directed have reduced in the last

three years.

(e) Frontline Health workers & ASHA

As non-facility based health staff, the frontline workers and ASHAs are the foundation of the public

health care system. Although these outreach workers do not have many clinical duties, ANMs and

LHVs are required to conduct some basic examinations and also assist or conduct normal deliveries.

However, most of the trainings provided to the frontline workers are aimed at enhancing their

knowledge and awareness levels on new health programmes or schemes that are introduced. Much

like the other health staff, trainings for frontline workers have also focused on the National Health

Programmes.

Table 1.13 : Trainings provided to Nurses in the last 2 financial years (Source: Training Calendar of Dept. of Health & Family Welfare)

S. No Name of Training 2016-17 2018-19 2019-20

1 Training at Skill Lab Yes Yes

2 Multi-Skilling of ANM Yes


25

(f) General Duty Attendant

Currently there are no trainings organised or

budgeted for the General Duty Attendant. This

category of staff also do not have any orientation or

refresher trainings.

(g) Accounts Officer

No Public Finance Management Training(s) have

been budgeted and approved since 2017-18 for

Accounts Officer. IDSP training is also instructive for

Accounts officers.

(h) National Health Mission /State /District Program Managers

As programme management staff, it is critical that their management skills are strengthened. These

skills include logistics management, monitoring and evaluation, Human resource management etc.

Programme management training has not be budgeted since 2017-18. Short trainings on data entry

operations and analysis for district and block level programme manager are essential.

1.6.2 General Trainings

Besides the stakeholder-wise trainings, there are some trainings that are vital for the general skill

upgradation of the across the different staff cadres:

(a) Orientation Trainings

Currently, Orientation or Pre-service Trainings are held for medical officers and other senior level

staff. But these trainings are not always regular and not standardised/institutionalised. Staff cadres

such as the Programme Managers, Finance Departments, and even the General Duty Attendants do

not have dedicated orientation trainings. It is thus instructive to institutionalise orientation trainings

or pre-service trainings for all staff cadres. The duration of the trainings may vary depending on the

stakeholder. For instance, for staff medical and paramedical staff, a two week orientation training may

be recommended. On the other hand, outreach workers will benefit from a 20 day training as they

have more frequent refresher trainings compared to the other cadres of staff. Week-long trainings

are recommended for the administrative and Finance Staff at the State, District and Block levels. The

table below summarises the training duration for different stakeholder categories:


26

Table 1.14 : Proposed Training duration for different stakeholder categories

SN Stakeholder Duration of Induction Training

1. Medical 14 Days

2. Administrative (including Procurement &

Finance) at State, District & Block Level

5 Days

3. Paramedical 7 Days

4. Outreach workers 5 Days

5. General Duty Attendants 3 Days

These trainings must have components of requisite skill enhancement, management and knowledge

about the drugs/equipment and services offered at all levels of health care. This must be completed

in a fixed time frame. The foundation course syllabus mentioned in the Annexure V can be referred

to while designing these trainings.

(b) Refresher Trainings

Besides Orientation Trainings, refresher trainings should also be institutionalised, which is absent at

the moment. While refresher trainings for frontline workers are undertaken at the district level with

the introduction of a new scheme but these are rarely organised for

the purpose of skill upgradation, oriented mostly at enhancing

knowledge. 85% Doctors affirmed conduct of Refresher trainings,

but added that these are infrequent & insufficient given the pace

of change.

In the last two years, very few refresher trainings have been

organised. There is an urgent need for skill training across all cadres

of staff.

(c) Training of Trainers (TOTs)

Besides trainings for the medical and paramedical staff, trainers need to be well equipped to carry out

these trainings. Consequently, apart from accreditation, trainings should be regularly organised for

trainers as TOTs. While the Capacity Building and Training budget mentions TOTs, they have not been

allocated funds in the last two years.

Thedistrictmustensurethatallpersonnelareexposedtothetrainingprogrammesatregularspecifiedintervals.


27

Capacity Building & Training Strategy

“Much of the global debate about human resources for health is focused on macro issues, such as the existing or needed absolute numbers of workers with different skills…Insufficient attention is paid to retaining and

managing the health workers available within any health system.”

WHO, 2006

The previous section discusses in details the technical approach and methodology adopted in the

design and development of the capacity building and training strategy, the results of the competency

gap analysis and training needs for different health staff and also a desk review of the existing trainings

that have been planned and implemented in the Department of Health & Family Welfare, Government

of Uttarakhand. Informed by the gap analysis, the following section systematically described the

strategic framework that govern the capacity building and Training Strategy and Plan for the

mentioned Department. The problem analysis and training-needs assessment carried out ensures that

there is no mismatch between training contents and skills required in the field, the choice of target

group or training methods.

2.1. Guiding Principles for the Capacity Building & Training Strategy

The following section outlines the strategic considerations and principles that underpin the process of

developing the Capacity Building and Training Strategy. These principles framing the development of

this strategy will be useful while updating it, if required in the future, and aid the development of a

new strategy.

Stakeholder-driven: The training needs assessment drew its mandate and legitimacy

from the expressed collective will of all of the stakeholders across the different cadres

of health staff across the state–right from the Medical officers to General Duty

Attendant. Special discussions were held with the Project Director, NHM officials and

some CMOs to gain their perspectives on the priority training areas for the different staff members

across the project. This maximizes ownership and empowerment, which contributes to increased staff

satisfaction and motivation.

Demand Driven; Each of the major stakeholder groups/divisions was provided with

adequate opportunities to identify their concerns, outline their perspectives, and clear

doubts, not only regarding the questions asked during the survey but also regarding the

intent and purpose of the survey. This ensured that the solutions/suggestions evolved

through fully participatory consultative processes, although all factors influencing performance can

be addressed at the same time, and because the priorities of health worker needs differ.

2


28

Flexible: As a matter of precaution, the research staff endeavoured to make the

consultative process flexible so that the capacity development interventions could be

adjusted and adapted with ease, to suit the stakeholder category or staff. To ensure this,

individual interviews were undertaken with stakeholders of not just different stakeholder

cadres, but off different age groups and experience levels.

Building Consensus and Holistic Interventions: The participatory processes were strive

to establish a common understanding on different issues affecting performance and build

consensus. Interventions should consist of a combination of actions, addressing working

and living conditions, pay, motivation and accountability.

Decentralised and Horizontally-Integrated Trainings: The Training strategy will ensure

that training programmes are integrated horizontally to ensure that there are no

duplications in organisation of trainings and it will address issues of planning and

operationalisation of health facilities, synchrony of supplies, gender, quality issues and

fund flow mechanism of all training. Furthermore, the development of the detailed

training plan and its implementation will take place at the district level, based on the state level

capacity development and training framework. This ensures local autonomy over financial, material

and human resources, to enable implementation of locally developed strategies, matching the needs

of workers.

2.2. Strategic Framework for Systems Strengthening

Along with the guiding philosophy, the Capacity Building and Training Strategy will be framed by the

strategic framework described below. This framework also lends an insight into the understanding of

individual capacities that characterize the individual performance of the project staff as well as the

systems, processes and the enabling environment that enables and hinders individual performance.

Enabling Environment

Support Systems & Processes

Individual Capacity

(Knowledge, attitude &

Skills)

Will lead to Improved health services &

sector Goals (SDGs)

Figure 2. Strategic Framework for Systems Strengthening (Source: Adapted from WHO,2006)


29

As illustrated in the diagram above, it has been argued that staff performance is not merely a function

of knowledge and skills but is framed by a host of other factors. To effect high performance, it is

important not just to address gaps in the individual capacity but also strengthen systems and

processes along with the enabling environment. The framework argues that sub-optimal performance

consists of a complex set of factors, which are interrelated. Adapting WHO, 20062 conceptual

framework, the different components of this framework:

(a) Individual Capacity

Individual capacity is determined by the Availability, Competencies, Productivity and

Responsiveness. Inadequate knowledge, skills and inappropriate attitudes can all form obstacles to

good health care. Advances in insights into treatment and diagnosis, as well as changes in roles and

responsibilities, require continuous professional development among health workers. Lack of

competences occurs because of limited access to training and inadequate training methods and

subject matter. Along with knowledge and skill gaps that are a critical part of the competency gaps

assessed, health service provider attitude is another factor that can disrupt health provider/patient

relationships, and thereby treatments. This also includes the level of motivation and job satisfaction

of the health service providers. Demotivation and dissatisfaction with work lead to poor attitudes on

the part of providers towards their work and their patients, not using standard protocols for treatment

or behaving rudely towards patients and stigmatizing patients.

(b) Support Systems and Processes (Micro-Level)

Capacity building at the individual and organizational level coincide in order to achieve the

developmental goals in a given time frame. Besides the intellectual resources of the effective

workforce (determined by developing the proper skills, attitudes and knowledge of the workforce),

the efficiency of the organization (the primary health centers and community health centers) is

determined by the effective its cost effectiveness, physical resources, together with processes for

management of the facility through quality management, performance improvement. Quality

assurance and performance improvement require skilled, motivated and well-performing staff

(Martinez, 2001) and therefore these interventions consist largely of human resource management

practice. Some of these practices include granting greater autonomy to staff regarding their work,

delegating more responsibility, and finally enhanced skills and knowledge building and created

opportunities to apply these skills and knowledge within the organization. Here, it is also important to

remember that human resource management practices are aimed at obtaining high commitment can

be achieved only in an organizational culture that enhances trust and mutual respect among

colleagues and staff members.

Additionally, health workers are more responsive to patient needs with financial and non-financial

incentives. Research shows that financial incentives do not necessarily enhance professional

2 WHO (2006) Improving health worker performance: in search of promising practices, Evidence and Information for Policy, Department of Human Resources for Health Geneva.


30

motivation in solitary. Other complementary methods are required, such as supportive supervision,

an appropriate regulatory framework and careful monitoring and evaluation. Performance-

assessment systems must be in place and implementation must be transparent for all involved. All

these reforms can only be successful when this happens in an enabling environment, with committed

management and strong leadership.

(c) Enabling Environment (Macro-Level)

Enabling environment refers to the legal and policy framework at the macro-level that lay out the

framework for micro-level governance systems through health sector reforms. The major impact of

health sector reform on the workforce is in terms of changes in working conditions, payment, labour

relations, the demand for certain skills, and terms of employment. Positive experiences in staff

performance have been gained during the implementation of health sector reforms by creating

autonomy over resources at facility level, together with an accountability system, quality assurance

mechanisms and financial incentives for good performance.

2.3. Target Trainees

Informed by the strategic guidelines and the conceptual framework for the CB&T strategy outlines in

the previous section, this section will map the main stakeholders who will benefit from capacity

development intervention to raise their general and functional competencies. The project design and

implementation plan for the UKHSDP helped identify the different stakeholder categories and how

they relate to each other, we have divided them under the main stakeholder categories –

(a) Medical Officer Cadre- The chief stakeholders covering the Medical Officer Cadre include- MOs,

CMO, dental specialists etc.

E MOs- Medical Officers are typically in charge at hospitals. They serve as

advisors on health issues and disease control, provide medical support,

discover inconsistencies and investigate problem. Aside from treatment

to the patients they also provide training to junior/senior residents, and

paramedical staff in the specialty concerned as per the instructions of

the MS.

E CMOs- Chief Medical Officers or CMOs Chief Medical Officers are

responsible for managing hospital budgets, recruiting and training

healthcare physicians, ensuring that all staff adheres to safety standards

and delivering the highest quality of medical care. Chief Medical

Officers will assume responsibility for the faults of their subordinates

E Dental Surgeons- They are the oral health care providers who perform many types

of surgical procedures in and about the entire face, mouth, and jaw area.

Figure 3. Medical Officer


31

(b) Paramedical Cadre- Paramedics are trained to assist medical professionals and to give

emergency medical treatment. Their functions include-assessing

patients, providing emergency treatment and making diagnoses;

monitoring and administering medication, pain relief and intravenous

infusions and dressing wounds/injuries. The target trainees covering this

category include-

E Pharmacists- They practice pharmacy, focusing on safe and effective

medication use. They are entrusted with the responsibility to ensure

staff and medicines are managed in line with relevant legislation and regulations, and that national

and professional guidance on medicines governance is followed within their facility.

E Medical Technicians- They prepare and analyse the results of

blood and bodily fluid. Mainly working in hospitals and

independent laboratories, their other duties include

collecting, testing and recoding samples. Medical Technicians

comprise Lab Technicians responsible for conducting

experiments, gathering data, and carrying out the basic

investigations like preparing and conducting chemical and

biological analyses; and X-Ray Technicians who use medical

imaging equipment to produce images of tissues, organs,

bones, and vessels and, with advanced training, assisting in the administration of radiation therapy

treatments.

E Nurses- Their roles revolve either directly around patient

care and various responsibilities attached to it. Amongst

nurses, Sisters are the experienced senior nurses

responsible for undertaking management of staff &

delivery of patient care. Staff nurses, on the other hand

are entrusted with the tasks of evaluating patients and

plan, implement and document nursing care like

recording a patient’s medical histories and teaching them

about the ways to handle illness at home.

© Outreach Workers- Their primary role coincides with community sensitization- creating awareness

amongst the community members and sensitising them about the various social issues through an

effective interaction. The Outreach Workers can be sub categorized into-

Figure 6 Nurse

Figure 5. Lab Technician

Figure 4. Pharmacist


32

E Frontline Health Workers (FLWs)– Including the

ANMs, Health Supervisors and LHVs, frontline

health workers are the backbone of the healthcare

delivery system. They form an important link

between the Primary Health Centers and the

community, ensuring no one is left without access

to basic primary health services. Their major duties

include maternal and new born care; organising events like VHND or UHND etc. in collaboration

with other community workers like ASHAs and AWWs.

E ASHAs- An ASHA’s role is three-fold: to be a facilitator of health

services and link people to health care facilities, to be a provider of

community level health care, and an activist, who builds people

understanding of health rights and enables them to access their

entitlements.

General Duty Attendants’ main

functions are- planning and

organising the units, assistance in housekeeping and sanitation;

transportation of patients and specimens to Emergency Rooms;

participation in ward management, post-mortem etc. The GDAs

comprise of hospital staff like ward boys, sweepers and drivers.

2.4. Capacity Building and Training Objectives

The capacity gap analysis and the needs assessment discuss the diverse barriers and challenges to

effective and efficient performance by the different health staff. In line with the strategic framework

outlined in section 2.2, after mapping the target trainees that will benefit from the capacity building

and training exercises, the section 1.5 has clearly identified the target/desired capacities and the

performance challenges; i.e. the knowledge, attitude and skill gaps that comprise individual

competencies. Based on these competency gaps, the capacity building and training objective(s) will

indicate the roadmap for achieving the desired knowledge, attitude and skills change, to what extent

and over what period of time. They have been defined based on the results of the capacity needs

assessment exercise as well as interaction with the senior staff members of the Uttarakhand Health

Systems Development Project, National Health Mission and other relevant staff members.

The matrix given below lays out the capacity building and training objectives for all the Stakeholders.

These objectives have been defined based on the expected/desired change in capacities of the

concerned stakeholders to address the barriers/gaps faced by them. The objectives are defined for

each category of stakeholders below:

Figure 8. ASHA

Figure 7. Frontline Health Workers

Figure 9: GDA


33

Table 2.1: CB&T objectives for the Stakeholders

Stakeholder Category Desired Capacity Areas Capacity Gaps Capacity Building &Training

Objective

1.

MEDICAL OFFICERS-

(MOs & Dental Surgeons)

• Knowledge and Awareness of National Health Programmes

• Knowledge & Awareness of 5 National Programmes

• To refresh the knowledge of the medical officers on the features and benefits of priority National Health Programmes

• Emergency and Critical care services

• Knowledge gaps in Advance Life Support (ALS); Life Saving intubation techniques, Basic Life Support (BLS); Intensive coronary care unit (ICCU); Advance Cardiac Life Support (ACLSC); Basic Cardiac Life Support, General Emergency Care

• To orient medical officers or update them on emergency and critical care procedures such as ALS, BLS, ICCU, ACLSC

• General Management (Problem Solving, Time-management, conflict resolution, M&E, financial management )

• Setting priorities among competing responsibilities

• Planning & Organising activities- devise methods to effectively complete all tasks

• Preparing detailed action and operation plans for tasks

• To provide training on general management practices and procedures such as strategic planning, budget management, monitoring & evaluation etc.

• Knowledge on Medico-legal Procedures

• Medical Jurisprudence

• Medical ethics

• Geneva Declaration

• Professional and medical negligence

• Products liability

• To address knowledge gaps in medico-legal procedures through self-instructional material and peer-group sessions.

• Patient Grievance Redressal & Interpersonal relationships

• Listening Skills

• Patient Grievance Redressal

• Engaging with emotional/distressed patients

• To equip medical officers with the requisite communication skills to not only deal with the grievances of the patients and


34



Objective • Inspiring Trust and honour

• Influence and respect amongst peers

their family but also internal staff members.

• Other functional competencies


• Knowledge on health policy for tracking health outcomes in the state

• To establish and equip medical officers on the procedures and protocols for disaster preparedness and response

2.

PARAMEDICAL PHARMACISTS

(Chief Pharmacists, Hospital

Pharmacists & CHC Pharmacists)

• Drug Dispensation & Basic clinical diagnosis and assessment

• Correct identification of errors or problems in prescription.

• To orient pharmacists in the correct method to handle and dispense drugs and supplies

• Diagnosis and basic health assessment

• Ability to check and record basis vital signs

• Reporting ADRs to medical officers

• To orient pharmacists on basic diagnostic assessments such as checking BP, blood sugar etc.

PHARMACIST

(Chief Pharmacists, Hospital

Pharmacists & CHC Pharmacists))

• Drug supply chain logistics

• Proper drug storage- avoid contamination; disfiguring of labels and infections by pests or vermin

• Ensuring a secured storage environment- adequate temperature; clean conditions & cold storage facilities.

• Ensure proper dispensation of drugs that include knowledge about the expired products and the expiry dates of all the products

• Drug supply/procurement from e-aushadhi

• To train and update the pharmacists on systematic storage and management of drug supply logistics, including procurement, storage, maintenance etc.


35



Objective

• General Management (Problem solving, conflict resolution

• Inventory management and update

• Record keeping and documentation of stock

• To train pharmacists on general management including strategic planning, problem solving, HR Management etc.

• Bio Medical Waste management and Infection Control

• How to dispose chemical and bio-chemical wastes in different types of facilities

• To train pharmacists on methods and protocols for approved and safe disposal methods for waste.

3

Medical Technicians

(Lab Technicians & X Ray

Technicians)

• Knowledge and awareness on molecular diagnosis & equipment management

• Awareness about National Health Programmes

• Awareness on life cycle parameters/indicators (e.g. ideal HB levels for pregnant women etc.)

• To orient medical technicians on molecular biology and hematology

• Knowledge and practice of safe and correct practices related to job

• Knowledge of correct interpretation of prescriptions and rationally carrying out diagnostic tests

• To train medical technicians on how to interpret instructions by medical officers on which tests to conduct and how to conduct them rationally.

• Record Keeping/Documentation

• Transcribing and organising patients’ medical histories, symptoms and diagnosis

• Categorizing treatments and procedures for insurance billing

• To train medical technicians on how to keep records of the observation and analysis of diagnostic tests carried out.


• How to conduct dispose of chemical waste and other medical and biomedical wastes.

• To orient medical technicians on how to dispose off and treat chemical wastes from the lab.


36



Objective

Nurses

(Sisters and Staff Nurses)

• Clinical Function

• undertake clinical functions like urinary catherization and enema. Regular refresher trainings is instructive for these respondents.

• training on dealing with high-risk deliveries and complications in birth

• To orient and refresh the knowledge and awareness of Nurses on the features and benefits of National Health programmes.

Record Keeping/Documentation

• Maintaining Patients' records- a clear account of a particular episode of care but also a comprehensive and concise record of what has occurred

• Healthcare record of the patients

• To train medical technicians on how to keep records of the observation and analysis of diagnostic tests carried out.

General Management

• Goal setting and meeting goals

• Managing appointments

• Strategic thinking

• Implementing strategy

• Reviewing, reporting, and research

• Analysis, Assessment & evaluation

• To train nurses on strategic planning and management to ensure they perform their duties efficiently.

Time Management & stress management

• Focus on the most important activities first-

focus on the tasks with the highest priority.

• frame.

• To train nurses on time management between clinical and non-clinical duties.

Leadership and Coordination

• Inspiring Trust and honour

• Influence and respect amongst peers

• Effective Interaction with co-workers

• To conduct workshop and encourage nurses to develop their capacities as leaders

Patient Interaction • Taking questions from the patients

• Active Listening • To train nurses on how to

communicate efficiently with


37



Objective • Educating Patients- explain disease processes,

medications, and self-care to the patients

• Inspire Trust- Listen to your patients and take

all their complaints or concerns seriously

• Show Compassion- Treat patients with respect

and dignity; Put yourself in the shoes of your

patient; convey empathy.

other staff members as well as with patients and their families.

Bio Medical Waste management and Infection Control

• How to conduct dispose chemical waste and other medical and biomedical wastes.

• To orient nurses on how to dispose and treat chemical wastes from the lab.

OUTREACH WORKERS-

Frontline Health Workers (FLWs)

• Diagnosis and basic health assessment

• Ability to check and record basis vital signs such as checking BP, pulse, blood sugar etc.

• To orient frontline health workers on basic diagnostic assessments such as checking BP, blood sugar etc.

• Clinical services like Delivery & Newborn Care

• Diagnosing delivery related complications

• Conducting Newborn resuscitation

• Diagnosing Serious Illnesses in Newborns

• To orient frontline health workers to perform delivery and newborn care, especially addressing complications in these procedures

• Latest advancements in Immunization & Cold Chain Mgmt.

• Cold-chain management and supplies logistic

• Immunization related programs like Mission Indradhanush & Online reporting systems

• To orient frontline health workers on cold-chain management and manage supply and logistics of drugs


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Objective

• General Management, especially concerning VHNDs

• Micro planning of events, coordinating supply

and logistics

• Systematic reporting- systematic recording of all attendees of the given event, and that prescribed formats for the event reporting all filled and submitted.

• To train nurses on strategic planning and management to ensure they perform their duties efficiently.

• Patient/Community Interaction

• Treat patients with respect and dignity.

• Counselling skills-Explain disease processes,

medications, and self-care techniques to

patients and their families; breakdown medical

jargon into simple terms.

• Active Listening

• To conduct workshop and encourage nurses to develop their capacities for effective communication

• Self-Management

• Planning & Organising activities- devise

methods to effectively complete all tasks

• Minimising 'time-wasters'- interruptions,

distractions and other delays that reduce

productive time.

• To train FLWs on time management between clinical and non-clinical duties.

• Bio Medical Waste

management and Infection Control


• To orient FLWs on how to dispose and treat chemical wastes from the lab.

General Duty Attendant

• Routine non-clinical care of patients

• Looking after all the non-clinical needs of

patients

• First aid & glucose administration

• To orient GDA on how to carry out non-clinical duties such as making the bed, making sure GDA is comfortable


39



Objective • Patient/Community

Interaction

• Treat patients with respect and dignity.

• Active Listening

• Counselling skills

• To conduct workshop and

encourage GDA for effective

communication & counselling



• To orient GDA on how to dispose and treat chemical wastes from the lab.

Clerical & Administrative Staff

(Program Managers at State, District & Block level)

• Office Management & Documentation skills

• Rules for handling correspondence; Handling and indexing of office files, Preparing Office Note and order by decision taking Officer, etc.

• To orient the administrative and clerical staff on the Govt. of Uttarakhand’s rules for handling correspondence; Handling and indexing of office files

• General Management (time management, decision making, problem solving, etc.)

• Micro planning of events, coordinating supply

and logistics

• How to take better decisions and problem

solve

• Systematic reporting- systematic recording of

all attendees of the given event, and that

prescribed formats for the event reporting all

filled and submitted.

• Quality Assurance,

• Supportive Supervision,

• Management of logistics of supplies and

maintenance of adequate stock of lab material,

medicines,

• To orient the administrative and clerical staff on how to improve general management


40



Objective

• IT Skills • Use of Tally, MIS, and basic MS Office. • To orient the administrative and

clerical staff on how to use MS

Office software and other IT

tools

Finance Department & Accounts Officers

• Financial Rules & regulation

• Financial Rules & regulation Govt. of Uttarakhand

• To orient the Accounts Officer on how to use MS Office software and other IT tools


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2.5. Capacity Building and Training Activities

The previous section laid out the capacity building and training objectives for the diverse project staff.

The proposed activities seek to address key capacity gaps of the health staff engaged in Uttarakhand,

identified in the capacity assessment study. These activities also complement and build on various

activities already organised and carried out by the state. However, these trainings are mostly

restricted to introduction of a new health scheme or a new procedure or technology, sometimes.

2.5.1. Capacity Priority Areas

Framed by the conceptual framework described in section 2.2, the capacity priority areas will not only

address the target group specific capacity gaps described in Section 1.4 of the report. At the heart of

the Capacity Development Plan Activities is the development of a range of competencies that include

a combination of few ̀ Hard’ (Clinical & Management) as well as and ̀ Soft’ (interpersonal skills) which

are appropriate to the needs and constraints of the target groups. The following section presents

competencies which are considered, as a whole, a priority for upgrading:

(a) Individual Capacity While the project staff have been recruited after due procedure,

advances in insights into treatment and diagnosis, as well as changes in

roles and responsibilities, require continuous professional development

among health workers. Individual performance is influenced by

retention, motivation and job satisfaction, obtaining knowledge, skills and attitudes, accountability and working conditions, all interrelated. All of these factors have demonstrably adversely affected performance,

and interventions to address these gaps will be explored in great detail below.

The method most frequently used to upgrade skills and knowledge is off-site training courses and seminars. To ensure that there is no mismatch between the training content and the skills that need

upgradation, the capacity building interventions are informed by the knowledge and skill gaps

identified by the Gap & Training needs analysis. Now, Knowledge and Skill training will be divided into

two categories: (i) Core Skills, which need to be possessed by all personnel of each category; (ii) Specialised Skills to be imparted as per the institutions where the trainees are posted.

Core Skills: Regarding the core skills, the basic nature of the skill gaps may be the same across

different staff categories or even for the same stakeholder category, for staff members it is primary,

secondary or tertiary care institution, there will be substantial variation in skills required for

management of complications


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Table 2.2 : Priority Core Competencies for Staff

1. Competency 1: Project Management - Strategic and Coordinated Planning, Monitoring, Reporting, HR management

• Establishing a clear vision for the goal/objective

• Designing and developing activities to achieve said vision

• Budget discipline and monitoring

• Ability to carry out tendering and procurement, and effective contractor

supervision

• Establishing baseline development data, indicators, benchmarks

• Translating development data, indicators and benchmarks into realistic development plans which take

account of budget capacities

• Establishing result-oriented management systems for performance, monitoring and review, reporting

and assessment outcomes and outputs

• Ensuring the planning is both top-down (clarity of direction) and bottom-up (taking

account of feedback from the clients on priorities)

• Disciplinary proceedings

• Maintenance of Service books and personal files

2. Competency 2: Communication & Liasoning

• Providing regular reports to key stakeholder agencies

• Operational coordination with key stakeholder agencies

• Identifying various interest groups within civil society & Strategies on

how to work with different interest groups

• Managing differing points of view and conflicting interests

• Maintaining channels of communication with patients & staff

• Using the role of feedback from patient & family to improve development planning, management, and

services

• How to put across one's points sensitively & empathetically to patient & family

• How not use complex terminology to refrain from confusing patients & family

• Speak at an appropriate speed, volume, tone and pitch to communicate the idea effectively to the

audience

• Rapport building techniques including precision in communication, patience, team spirit, conflict

resolution and promoting positive communication patterns

• Role of communication in improving health literacy

3. Competency 3: Self-Management

• Motivating staff for greater productivity

• Approaches to instilling discipline

• Decision Making & setting priorities

• Time Management


43

• Conflict Resolution

• Stress Management and Problem-Solving Techniques

• Self-Assessment Exercises

• Use of IT Tools for documentation and reporting

• HR management - Maintenance of Service books and personal files & staff appraisal

• Legal safeguards to Public Servants / Medical Professionals

4. Competency 4: Leadership &. Motivation

• Leadership Concept & types of Leaders

• Ensuring observance of Office Decorum by staff

• Ways to improve Doctor-Staff Relationships

• Influencing skills and techniques

• Team Building

• Managing change effectively

• Introducing and sustaining organizational change effectively and Action planning

• Stress Management

• Motivational techniques and practices

5. Competency 5: Budgeting & Accounts

• Functioning and basic rules of Treasury

• Audit and functioning of AG Office

• Accounting network system

• Condemnation procedure and disposal of dead items

6. Competency 6: Medico-legal Practices

• Reporting of accidents and police cases

• Medico Legal examination

• Post mortem examination guidelines (Rules for CMOs, Directions for preserving and packing Viscera, etc.)

• Instructions for the guidance of MOs regarding Medico Legal Work and Expert Professional Opinion

• Medical negligence Syn. Mal Practice

• Contractual relation between Doctor and Patient

• Preparation of medico legal reports in different situation and police formalities

• Issuing Death Certificate

7. Competency 7: Biomedical Waste Management & Infection Control

• Waste Management

• Segregation of Biomedical Waste

• Collection and transportation of Biomedical waste

• Sharp Management

• Storage of Biomedical Waste


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• Disposal of Biomedical waste

• Management Hazardous waste

• Solid general waste management

• Liquid waste management

• Equipment and supplies for Bio Medical Waste Management

• Statuary Compliances

• Hand Hygiene

• Personal Protective Equipment & Practices

• Decontamination & Cleaning of Instruments

• Disinfection & Sterilization of Instruments

• Spill Management

• Infection Control Program

• Hospital / Facility Acquired Infection Surveillance

8. Competency 8: Disaster Management

• Types of Disasters

• Phases of Disaster Management

• Key Components of effective emergency management plan

• State Emergency Management Authority & Executive Committee

• Obligation of Health Department as per clause 30 of the Disaster Management Act

• Development of Disaster Management Plan by Health Department under section 40 of the Act

• Preparing Disaster Response Plan

• Preparedness Checklist for public health department

Specialised Skills: Unlike the Core Skills, specialised skills are not only stakeholder specific but also

specific to the specific job role and position and the institutions where the trainees are posted. Most

of the specialised skills concerning our target trainees are clinical skills.

(b) Organisational Capacity/Support Systems & Processes

Training is successful in improving performance only when it is embedded in a broader strategy that

includes job satisfaction and motivation issues, working conditions and accountability to patients,

colleagues or managers. Good performance and responsive staff is enabled via a supportive working

environment and thus reduces turnover, absenteeism and enhances productivity.

§ Physical Infrastructure & Working Conditions: This not only encompasses having sufficient

equipment and supplies in the respective facility that can hamper performance of skilled

personnel; but also includes systems issues, such as decision-making and information-exchange

processes, and capacity issues such as workload, support services and infrastructure. Suggested

guidelines for facility-level level capacity development & system strengthening are:

• The facility must ensure adequate supplies and infrastructure.


45

• Currently, acute workforce shortage results in high workload on existing staff. Well-defined

and targeted HR policies can help reduce turnover.

§ Human Resource Management: Besides financial incentives, the lack of supportive supervision

and heavy workload due to inadequate human resources plays a critical role in low motivation

and poor performance. Moreover, the lack of professional development opportunities in the

absence of regular skill upgradation exacerbates low job satisfaction. Professional development is

important for staff, but various learning approaches can be applied to learning such as though on-

the-job training and at the workplace through supportive supervision, clinical meetings or peer

support and through distance-learning schemes.

Additionally, staff members need to be able to work in teams, and a relationship of trust between

staff and management is imperative. Given the limited management capacity at lower levels of

the health system such interventions must be preceded by efforts to build management capacity.

Suggested guidelines for facility-level level capacity development & system strengthening are:

• Weekly staff meetings at the facility, headed by the head of the facility, will ensure better

communication & support between colleagues. The minutes of these weekly meetings should

be recorded and documented by the staff.

• Fostering improved communication between supervisors and subordinated to ensure free

communication channel.

• Organising daily morning meetings during which medical officers plan for the day ahead.

• Grievance redressal box for those wishing to submit grievances anonymously should be

provided for and addressed at weekly meetings.

• Positive affirmation and supportive supervision go a long way towards helping the staff feel

valued.

• Gender-sensitive strategies at the workplace may further raise the motivation levels of staff.

For example, rules may be in place that allow the female staff to return while the daylight is

still out.

§ Quality Assurance (QA) & Performance Management Strategies: Unethical behaviour through

forms of mismanagement and corruption or the non-adherence to protocols, can occur because

of a lack of accountability mechanisms and also heavy workloads. Holding staff accountable for

their performance towards their clients, colleagues or managers through structural supervision

and support, might offer opportunities to improve performance. Here, structural support means supervision, performance appraisals, rewards and punishment to ensure quality and

productivity of their staff. This allows a continuous supervision and motivation of staff, ensure

appropriate tools and resources, and identify performance gaps and address them. Supervisors

must be appropriately trained to implement these procedures. Some of these procedures


46

• Quarterly performance appraisals should be conducted by the head of the facility.

• Peer reviews will be co-terminus with the quarterly performance appraisals to receive input

from colleagues as well as supervisors.

• Third Party Quality Audits should be conducted every-six months.

• inputs from the Performance appraisals and peer reviews should feed into development of

district action plans for Capacity building.

(c) Enabling Environment

Sustainability of capacity development interventions can only be ensured when there is an enabling

environment that supports the transfer of knowledge within the organization, upgradation of skills

and knowledge and also creates and maintains a positive atmosphere for the cultivation, sharing and

enhancement of this knowledge. Health sector reforms through a robust policy framework at the state

have shown to support this endeavour.

This framework seeks at strengthening the health workforce in by addressing working conditions, payment, labour relations, the demand for certain skills, and terms of employment at a macro-level. But the success of such approaches requires the commitment of senior management, availability of financial resources and delegation of decision-making to lower levels/decentralisation of public health governance. Research indicates that such changes have a significant impact on productivity of

services, which indirectly shows an increased productivity of staff.

Some of the following strategies must be adopted to strengthen the enabling environment are given

below.

1. Mainstreaming Capacity Development & Training: It may be useful to increase Government

Commitment for mainstreaming Capacity development in State Policy to ensure sustainability of

any such interventions undertaken. The state will develop the strategic framework that will be

converted into detailed district level training plans.

2. Dedicated State Capacity Building and Training Cell: Currently, the state does not have a

dedicated Capacity Building and Training Cell to closely implement and monitor these

interventions. Having a dedicated cadre of professionals to plan and implement trainings across

the State will benefit programme implementation and overall effectiveness of health care service

delivery in the state. Accordingly, district level training officers should be trained in the CB&T

policy and plans.

3. Develop Digital Platform for Capacity Building & Training : To keep the momentum of the digital

transformation in India going, it is recommended that the State Monitoring Cell team up with the

Capacity building & Training Cell/Staff to create a digital platform to develop Training MIS that

may be integrated with HMIS of the state. This MIS be useful in carrying out the following:


47

(a) HR Management System: Information on the health staff currently in position such as their

age, experience, skills, certifications, availability etc. is useful to keep track of available resource

people. This information from the district level should feed into the State MIS.

(b) Performance Management System: To track progress on individual staff members, i.e. Inputs

from performance appraisals and Peer reviews should feed into development of district action

plans for Capacity building.

(c) Monitoring & Evaluation System: A continuous monitoring and evaluation system should be

designed and operationalised by the State M&E department in concert with the newly formed

Training Cell. A tentative strategy with input-output monitoring and outcome-impact evaluation

indicators and methodology has been outlined ahead in Chapter 4.

(d) Training Curricula & Material/Modules: Will contain training curricula along with pre-existing

ones developed by NHM, DHFW, and other training institutions. It should also have annotated

digital library with downloadable learning material and e-modules available for reference of

Health Staff.

(e) Develop and Institutionalise Training Institutions: There is a need for upgrading training

institutes by providing requisite equipment & ICT Infrastructure. It is also instructive to

restocking physical libraries with updated reference books and journals. Developing Skill labs

for various clinical trainings for different cadre of staff and Model facilities for organizing

exposure visits to gain hands on learning will complement individual capacity building efforts.

The State has already done a lot of work on upgrading the Divisional Health & Family Welfare

Training Center, Motibagh, Haldwani (NTL) as the ‘State institute of Health & Family Welfare’.

The State has also developed a framework to commission and operationalize the Institute. In

order to strengthen the training competent, The State could expedite the process. Once

operationalized, many of the functions as outlined above could be transferred to the SIHFW.

District-Level Training Implementation: While public health governance and implementation of

health programmes is already decentralised in the context of Uttarakhand, it is recommended that

District Health Programme Management Units develop and incorporate district capacity building and

training plans in the District Action Plans to address local training needs and other operational

problems. This also ensures optimum utilisation of available resources and programmes without any

duplication. The district training plan will adhere to the following guidelines to ensure smooth and

sustainable implementation of trainings:

(a) Annual District Training plans will be prepared with the time-frame for the trainings based on

the State Strategy

(b) Trainings can be organised in synergy with the availability of continuous supply of drugs and

equipment so that the trainees can practice the skills.


48

(c) Synchronous Trainings in area: Training of all functionaries in an area/institution in a

synchronous manner or integrated manner such that the respective facilities that already suffer

from workforce shortages is not deprived of essential personnel.

(d) District Training Plan will include the plan for monitoring the quality of training and also the

utilisation of trained personnel, based on the budget provided by the state.

(e) While a norms for training load and batch size will be outlined in the State Strategy, they should

be suggestive only. The total training load should be calculated on the basis of the health

functionaries currently in position and existing functional health facilities. Batch size to be

decided according to the skills which are to be provided to the health functionaries and the

training venues available.

• Convergence with non-health departments that work on health and family/nutrition components - Convergence with PRI, WCD, AYUSH & Department of Drinking Water & Sanitation

at the district level will help in delivery of specialised skill trainings effectively such as regarding

Safe Sanitation, Infection Control, RMNCH+ etc. Additionally, as part of an overall system

strengthening and capacity development effort, strong support of PRI, WCD etc. will facilitate any

local level health interventions that are carried out by the health Department in collaboration.


The framework of activities essentially creates the space the health staff of the Uttarakhand Health Department to learn a range of skills to effectively meet

the challenges identified by the capacity assessment exercise. The capacity development activities in Table 2.3 are broken down into high and low priority

areas, and into short (6 months), medium (1 year) and long term (1-2 years) targets. They approach capacity building at three analytical levels—individual, organizational, and enabling environment—with particular reference to the gaps identified in the capacity assessment process.

Table 2.3 : Capacity development plan: Priority Activities

Short-Term (6Months) Medium (1 Year) Long-term (1-2 years)

Individual

§ Ensure Induction/Pre-service training incorporating

Foundation course is provided to all

§ Increased frequency of Capacity development and

trainings by training in batches. More demonstration

and field-based training

§ To organise peer learning sessions facilitated by

self-instructional materials to address knowledge and awareness gaps related to the National Health

Programme components and their roles and responsibilities

§ Preparation of District Training Plans informed by the Annual Training Strategy & Plan

§ Develop and Institutionalise existing

Training Institutions at Haldwani and Dehradun. Upgrade Training Institute

at Chandernagar to establish it as SIFHW.

Organisation

§ Weekly staff meetings at the facility, headed by the

head of the facility, will ensure better communication &

support between colleagues. The minutes of these

weekly meetings should be recorded and documented

by the staff. Also, organisin/g daily morning meetings

during which medical officers plan for the day ahead.

§ Quarterly performance appraisals should be conducted by the head of the facility.

§ Peer reviews will be co-terminus with the quarterly performance appraisals to receive input from colleagues as well as supervisors.

§ Third Party Quality Audits should be

conducted every-six months.

§ Currently, acute workforce shortage results in high workload on existing staff. Well-defined and targeted HR policies can help reduce turnover.


Table 2.3 : Capacity development plan: Priority Activities

Short-Term (6Months) Medium (1 Year) Long-term (1-2 years) § Grievance redressal box for those wishing to submit

grievances anonymously should be provided for and

addressed at weekly meetings.

§ Gender-sensitive strategies at the workplace may

further raise the motivation levels of staff. For example,

rules may be in place that allow the female staff to

return while the daylight is still out

§ inputs from the Performance appraisals and peer reviews should feed into development of district action plans for Capacity building.

Enabling Environment

§ Standardize and integrate trainings to prevent course

duplications and gaps. This may be done by developing

a State Manual for Capacity Development & Training

guided by the Strategy by AMS

§ Prepare Annual Training plan informed by the Training

Strategy

§ Create a detailed M&E plan with the M&E cell and CB&T

cell to monitor the efficiency of the training and

capacity building exercise

§ Digital platform to should also have annotated digital

library with downloadable learning material and e-

modules available for reference of Health Staff.

§ Establish Training of Health – MIS that is linked H-

MIS to keep track of trainings and trained

manpower

§ Establish a performance management system as

part of the HR management system and the data should feed into TH-MIS

§ To provide essential equipment at the facility level

§ Along with Pre-Post Training Assessments, regular monitoring of Training Quality needs to be done through audits, evaluations, along the lines of TNA


2.6. Modes of Training Delivery

The previous section outlined the capacity development activities addressed through the capacity

development plan. This section describes the different modes of delivery that will ensure effective

reach and consumption of the trainings. Mode of delivery of training programmes determines the

structure, nature, and contents of training modules and learning materials that need to be developed.

A sustainable cost effective training programme for a large number of staff will require delivery modes different from those conventionally used, bound by time and space, and face-to-face training workshops which are also costly.

Thus, both conventional components such as lectures and handbooks, and modern components such

as peer-to-peer learning groups and on-the job mentoring is recommended as effective training

modalities. Looking beyond formal learning modalities (ex. Classroom lectures) that involve high costs

and time (including long-distance travel) are not always practical. Some of these modes of delivery

are described below:

(a) Master Trainers Training or Training of Trainers

The strategy encourages the ‘train-the-trainers’ programme to develop the ability of senior project

staff to ensure that the Trainers have adequate training and pedagogy skills to impart to the trainees.

If trainings are supported by external institutions or medical colleges or nursing colleges, the faculty

of state level institutions and Medical Colleges need to update their skills on a continuous basis to be

able to provide quality training. It is also important that any private health facility or trust-run hospital

that may be supporting this capacity building must be accredited. A database of guest faculty to

support the in-house faculty must be available with the State.

The train-the-trainers’ programme is therefore intended to initiate the process of developing capacity

to work within the community and the project framework. The component of on-the- job mentoring

can also be achieved through the use of a ‘train-the-trainers’ network.

(b) On-the-Job Mentoring

On-the-job mentoring is an effective that way to provide an

environment in which these skills can be more effectively

acquired by the staff members by improving team-work and

team collaboration, thereby the enabling environment to

provide effective capacity development. It is particularly

instructive after a training course by a district training officer to

follow up on the impact of the trainings provided and provide

handholding support in case of any difficulties.


(c) Peer-to-Peer Networks/Group Mentoring

The creation of peer-to-peer networks to

enable staff to come together and learn

from one another is not only cost-effective

but facilitates discussion, engagement and

better learning. Such a modality could play

a key role in ensuring that relevant skills are

transferred among those who hold similar functional roles.

Where possible, organizations should enable staff members who

have undertaken training to work with their colleagues who have

not, in order facilitate transfer of information between these

peer networks.

(d) Development of Trainers Manual

Development of materials should include a trainer’s manual, which includes facilitation techniques for

mentoring and coaching learners, presentations and small group activities. Trainers should act more

in the role of mentors to alleviate learning difficulties of learners, and as motivators to encourage

learners’ self-esteem and incite active participation in the training programmes.

(e) Classroom Lectures/Seminars/Workshops

One of the most common training method, off-site classroom method or lecture method involves a

classroom to give training by trainer in the form of lectures. It is effective

for the purpose of teaching to make aware of procedures and to give

instructions on a particular topic. But not only is this method costly given

the number of staff, it is not very engaging and generates little interest in

the trainees. Using audio-visual in the form of films, Video, and

Presentations etc. have been successful in encouraging students to

understand and assimilate easily and help them to remember forever.

Additionally, it is also recommended that role-playing activities and other

games may be used by the trainer to create a more engaging environment conducive to learning.

A critical addition may be the use of demonstrations using models and practice exercises to encourage

applied learning. Currently states use mannequins for Anaesthesia and EmOC training. Similarly, Zoë

model is being used for Family Planning Trainings especially IUCD. Female pelvic models are being

given to all district hospitals and many ANM Training Schools. Exposure visits or monitoring of

actual/live procedures in the field will boost the confidence of the trainees.

Mentoring as a mechanism, of supportive supervision for bringing attitudinal change in health care providers, needs to be restored. Team leaders need to be provided with skills for mentoring and supportive supervision on the job.


(f) Self–instructional Materials

Instructional materials will facilitate self-directed learning as well as peer group interactions. These

texts should be prepared in the language that is easy to read and understand, and is able to maintain

sustained interest. Materials should take into consideration the following:

• Having clear set of leaning objectives/outcomes at the beginning of each unit of the course

• Keeping sentences short, simple consistent and structured

• Visually appealing with illustrations

• Local Context

• Relevant Examples

• User friendly

To facilitate learning, problem-solving exercises, case studies, assignments, group works contained in

the learning material should be prepared and be relevant to the work place. The instructional

materials should be tailored to the needs of the different target groups. For example, for the outreach workers, instructional materials should be brief, crisp with well-illustrated graphics used to describe

a point. On the other hand the self-instructional material for the state and district staff members will

be more detailed in the form of a handbook.

(g) Webinars/E-learning modules

E-learning is the act of engaging in an educational course in an online

setting. E-learning courses can exist in a variety of forms, using a range of

technologies, including audio and video recordings, presentations,

quizzes, surveys, games, discussion groups, and more. The curriculum

and modules can be prepared by the regional training institutes and

medical colleges. E-learning can help learners complete education and

training objectives with greater ease and flexibility than they can with traditional classroom-based

learning. This mode can be particularly helpful in the Garhwal area, where the terrain is difficult and

vast to facilitate communication with regional medical colleges and other training institutes.

Besides its cost effectiveness, e-learning modules and webinars can be available as and when needed

without any disturbance to the work schedule of the health staff in the state. Along with post training

follow-up and support, webinars ensure quality assurance by participants’ support, faculty support

and evaluation and assessment. However, this mode may not be recommended for the delivery of

core skills’ training, and may be useful only for more specialised or niche trainings. NIFHW has a online

PG diploma course for programme management - PG Diploma in Management (PGDM-Executive), recognised by AICTE, that can be completed online.


The Table in the following page outlines the suggested mode of training delivery for the different core skill areas for the different health staff:

Table 2.4 : Suggested Training Types for Different Capacity Aspects

SN Aspect of capacity Required Activities Training Type

1. Knowledge and Awareness

• Knowledge of the National

Programmes

• Peer-Group Sessions

• Self-instructional materials

(Booklet or e-learning

modules)

2. Clinical Skills

Effectively carry out clinical

functions like-

• Patient Care (follow up &

required instructions)

• Accurately Interpreting

diagnostic results

• Knowledge of drugs

• Peer-Group Sessions



modules)

• Off-site

training/demonstration/expos

ure visit

3. Management Skills


(Project management, HR,

budget, procurement etc.)

• Performance & Quality

Management

• Record

keeping/documentation



modules)

• Workshop/Classroom session

• Off-site

training/demonstration/expos

ure visit

4 Soft Skills

• Motivation Levels

• Patient/Community

Interaction

• Communications &

Coordination.



modules)

• Workshop/Classroom session

5.

Other Functional competencies

• Biomedical Waste

Management

• Infection Control



modules)

• Demonstration/Field-visit

2.7. Target Group-wise Trainings

In terms of skill and knowledge requirements, the different target stakeholder categories will require

slightly different set of competencies. Since the training they undergo may vary, a clustering of

competencies and broad training objective for each group is necessary. The Tables given below


presents an outline of the priority competencies for each learning group. Furthermore, attempt has

been made to develop the training modules required for enhancing the functional knowledge of the

concerned staff; improving their skills to become more effective in their role; and help them change

attitude.

2.7.1. Developing competencies for Core Competencies

The following tables present the breakdown of competencies for building core skills that is important

for most target groups, irrespective of their functions. However, the level of these competencies will

vary from one stakeholder to another depending on their job role and qualification. It includes training

components and the resulting competencies, from the list of priority competencies identified in the

previous section.

Table 2.5b:: Communication, and Liasoning Skills

Target Groups MO, Nurse, Technicians, Pharmacists, FLWS, ASHAs

Objective: Instil key communication and liasoning techniques

• Interpersonal communication

• How to put across one's points briefly.

• Does not use complex terminology to refrain from confusing the other

stakeholders

Table 2.5a: Project Management-Strategic and Coordinated Planning, Monitoring, Reporting, HR management

Target Groups State Administration, MOs, DPMs, Nurses, Pharmacists, FLWs

Objective: Instil key programme and project planning techniques

Training Components • Introduction to project cycle management

• Project identification & formulation

• Approaches to project planning

• Participatory techniques

• Stakeholder analysis and interventions

• Working with the Logical Framework Approach

• Project documentation and reporting, Effective report writing

• Analysis of numerical data

• Contingency plans

• Work plans (1-3 months), Operational plans (6-12 months)

Competencies Developed

Competency 1: Strategic and coordinated planning, monitoring, reporting

Mode of Delivery Workshop, Self-instructional material/Brochure

Training Duration (No. of Days)

5

Frequency of Training

Annual


Table 2.5b:: Communication, and Liasoning Skills

• Uses appropriate grammar and language when communicating with others.

• Break down explanations of complex processes, rules into everyday situations to

engage listeners.

• Speak at an appropriate speed, volume, tone and pitch to communicate the idea

effectively to the audience.

• Connecting with stakeholders to nurture relationships over time to build trust

and to develop a basis for future interactions.

Competencies

Developed Competency 2: Effective communication and liasoning

Mode of Delivery Workshop Training and Self-Instructional material

Training Duration (No.

of Days) 5

Frequency of Training Workshop (Nos.1)

Table 2.5c: Leadership, Motivation and Teamwork Skills

Target Groups MOs, Nurses, Pharmacists, ANMs

Objective: Provide skills and techniques to develop team, increase motivation, manage organizational change, and understand and communicate with people

Training Components:

• Management and leadership (and their difference)

• Leadership styles: from vision to implementation

• Developing, communicating and implementing the vision-building capability

• Matching staff capability to facility needs

• Influencing skills and techniques

• Matching influencing to target audience

• Building trust

• Building and sustaining high performing teams

• Managing change effectively

• Introducing and sustaining organizational change effectively

• Action Planning

Competencies

Developed Competency 5: Self-Management

Mode of Delivery Workshop Training, Self-instructional Material

Training Duration (No.

of Days) 4 Days

Frequency of Training Workshop (Nos.1)


Table 2.5d: Medico-Legal Practices

Target Groups MOs, Nurses, Pharmacists, ANMs

Objective: Instil basic programme and project planning techniques

Training Components

• Reporting of accidents and police cases

• Medico Legal examination

• Post mortem examination guidelines (Rules for CMOs, Directions for preserving and packing Viscera, etc.)

• Instructions for the guidance of MOs regarding Medico Legal Work and Expert

Professional Opinion

• Medical negligence Syn. Mal Practice

• Contractual relation between Doctor and Patient

• Preparation of medico legal reports in different situation and police formalities

• Issuing Death Certificate

Competencies

Developed Competency 6: Medico-legal Practice

Mode of Delivery Self-instruction/webinar

Training Duration

(No. of Days) 3

Table 2.5e : Biomedical Waste Management & Infection Control

Target Groups MOs, Nurses, Pharmacists, Medical Technicians, FLWs, GDA

Objective: Instil techniques and protocols for biomedical waste management

Training Components

• Improving Hospital/Facility Upkeep

• Improving Sanitation and Hygiene

• Improving waste Management

• Infection Control

• Hospital Support Services

• Hygiene Promotion

Competencies

Developed Competency 7: Biomedical Waste Management & Infection Control

Mode of Delivery Workshop, self-instructional manual (NHM-`Kayakalp’ Implementation Manual)

Training Duration

(No. of Days) 4


Table 2.5f: Quality Assurance


Objective: Instil knowledge of QA protocols and procedures

Training Components

• Understanding Quality Assurance

• Framework of Quality of Care (QoC)

• The Organisational Structures

• The Process of Implementation

• The Process of Implementation

Competencies

Developed Competency 9: Quality Assurance

Mode of Delivery Self-instructional manual (NHM; Operational Guidelines for QA in public health facilities)

& workshop

Training Duration

(No. of Days)

4

Table 2.g: Disaster Preparedness & Response



Training Components

• Types of Disasters

• Phases of Disaster Management

• Key Components of effective emergency management plan

• State Emergency Management Authority & Executive Committee

• Obligation of Health Department as per clause 30 of the Disaster Management

Act

• Development of Disaster Management Plan by Health Department under

section 40 of the Act

• Preparing Disaster Response Plan

• Preparedness Checklist for public health department

Competencies

Developed Competency 8: Disaster Preparedness, Management & Response

Mode of Delivery Workshop

Training Duration

(No. of Days) 2


Table 2.5h : Finance and Budgeting

Target Groups Accounts Officers


Training Components

• Overview of budgeting in government, including key concepts and who does what in

the government of Uttarakhand

• Functioning and basic rules of Treasury

• Keeping accounts

• Financial planning

• Financial monitoring

• Internal control

Competencies

Developed Competency 3: Managing budget effectively

Mode of Delivery Workshop , Self-instructional material

Training Duration

(No. of Days)

3

2.7.2. Developing competencies for Specialized Competencies

This section describes the breakdown of competencies for building specialised skills. Specialised skills

mean that these competencies are specific to target groups. However, most of the specialised skills

refer to the clinical skills and some functional competencies that are required by the individual

stakeholder to perform their job roles and duties. These competencies not only vary from one

stakeholder to another, but is also contingent on the type of health programme and component of

health care delivery in the state.

The National Health Mission has already developed Training Modules and Training Plans for the

capacity development of several National Health Programmes that cater to the specialised skills

mentioned. It is instructive for the Training and Capacity Building Cell to refer to the NHM website to

access these competencies. Besides these individual trainings, it is instructive for medical officers to

take up/participate in a PG diploma specialisation course that is available at AIIMS Rishikesh. These

courses are short-term courses that provide technical capacity building without the need for a MD.


Capacity Building & Training Plan

The previous sections described a framework for the different capacity building and training activities

that will serve to address the capacity gaps of the different target groups. This section will lay out a

structural framework for implementation or roll out of the Training suggested in the previous sections.

The implementation framework will be broken down according to the following categories of capacity

development (i) Individual; (ii) System Strengthening & Processes; (iii) Enabling Environment. 3.1. Individual Capacity Development Plan

We have already argued that individual competencies and attitudes form an integral part of the overall

capacity of the health staff of the Department of Health in Uttarakhand.

It is instructive to plan for and provide refresher trainings on some aspects

of the project (especially for the grassroot level staff) and also support the

enhancement of certain identified skills that are instrumental to the

smooth planning and implementation of the project. Here we have laid

out a plan for the organization of the activities suggest for capacity

building and training of the staff in two broad categories: (i) Induction Training for new recruits; (Ii) In-service Training for all health cadres that includes orientation trainings as well as refresher trainings -

• Induction Training: At the time of entry into service, Induction Training must be made mandatory

for newly joined staff across all categories of health care workers. This must have components of

requisite skill enhancement, management and knowledge about the drugs/equipment and

services as well as management, planning and financial planning offered at all levels of health

care. This must be completed in a fixed time frame. The Induction training course curriculum must

be developed at the state level based on the framework provided by the foundation courses

prepared & developed in Uttar Pradesh. It may be instructive to revise and update this curriculum

to align with current health needs, learning gaps and responsibilities.

A draft curriculum for medical officers is attached in the annexure 5. The proposed duration of

induction/orientation training for different stakeholder categories are given below.



1. Medical 14 Days

2. Administrative (including Procurement &

Finance) at State, District & Block Level

5 Days

3. Paramedical 7 Days

3




4. Outreach workers 5 Days

5. General Duty Attendants 3 Days

• In-service Training: In-service Training is the major component of training. As refresher training

or Continuous Professional Education, it must be provided to all categories of health care workers

to upgrade their knowledge and skills in technical and management fields at least once every two

years or earlier based on the capacity development need. Based on the capacity development

activities outlined in Section 2.5, a draft training and capacity building plan is described below.

It is instructive to remember that the CB&T plan is designed as a State Level framework. It is

supposed to serve as a rubric for respective district level training cells to prepare district level

training plan as trainings will take place at the district level. A tentative list of Training venues is

also given in the Annexure IV.

Table 3.2: Core competency Trainings

SN Types of Training

Category Durati

on (Days)

Batch Size

Venue Mode of Training

Responsibility

1

1

.

.

1.

Strategic and Coordinated Management, Monitoring, Reporting, HR management

Orientation

Training State PMU, MOs, DPMs,

Nurses, Pharmacists,

FLWs

5 30 Region

al Level

Classroo

m

District Training

Coordinator

/DPMU

Refresher

Training 2 30

District

/ Block Level

Self/

Manual/

E-module

2

Communication, and Liasoning Skills

Orientation

Training MO, Nurse, Technician, Pharmacist,

FLWS, ASHAs

5 30

District

/ Block Level

Classroo

m

District Training

Coordinator/DPM

U

Refresher

Training 2 30

strict/

Block Level

Self/

Manual/E-

module

4. 3

.v

3.

Leadership, Motivation and Teamwork Skills

Orientation

Training

MO, Nurse, Technician, Pharmacist,

4 30

District

/

Block

Level

Classroo

m

District Training

Coordina


Refresher

Training

FLWS, ASHAs

2 30

District

/

Block Level

Self/

Manual/

E-module

tor

/DPMU

5. 2

.

25.

4.

Medico-Legal & Ethics

Orientation

Training MOs, Nurses,

Pharmacists, Medical

Technicians

3 30

District

/

Block Level

Classroo

m

District Training Coordina

tor /DPMU

Refresher

Training 1 30

District

/

Block Level

Self/

Manual/E-

module

6.

5.

Biomedical Waste Management & Infection Control

Orientation

Training MOs,

Nurses, Pharmacist,

Medical Technicians, FLWs, GDA

4 30

District

/

Block Level

Classroo

m

District Training

Coordinator

/DPMU Refresher

Training 2 30

District

/

Block Level

Self/

Manual/E-

module

7. 7

6.

Quality Assurance

Orientation

Training MOs,

Nurses, Pharmacist,

Medical Technicians, FLWs, GDA

4 30

District

/

Block Level

Classroo

m

District

Training Coordina

tor

/DPMU

Refresher

Training 2 30

District

/

Block Level

Self/

Manual/

E-module

7.

Disaster Preparedness & Response

Orientation

Training MOs,

Nurses, Pharmacists

, Medical Technicians, FLWs, GDA

3 30

District

/

Block Level

Classroo

m

District

Training Coordina

tor

/DPMU

8.

Refresher

Training

1 30

District

/

Block Level

Self/

Manual/E-

module


9.

Finance and Budgeting

Orientation

Training

MOs,

Nurses,

3 30

District

/

Block

Level

Classroo

m

District

Training Coordina

tor

/DPMU

Refresher

Training

1 30

District

/

Block

Level

Self/

Manual/ E-

module

With regard to the specialized competency skills, it is advisable for the State and District level capacity

development staff or cells to refer to the existing training strategy by NHM to prepare State and

District level Training Plans. Refer to the Annexure III for the Strategy for RCH-II and National Health

Programmes Training Strategy.

3.2. Capacity Development: System Strengthening & Processes

Along with individual competencies, the organisational environment plays

a critical role in serving as enablers or barriers in allowing the individual

staff members to perform their roles and responsibilities in a systematic

and smooth manner, and therefore achieve organisational and

institutional change. The lack of good working conditions at the facility

level, very restrictive HR rules and regulations, or the pace of the project

with little visible outputs can impede performance by creating discontent

and lower the motivation of the staff. The table 3.2 given below outlines some initiatives that should

be taken to improve the facility-level capacity of the Department of Health & Family Welfare, Govt. of

Uttarakhand –

Table 3.3 : Capacity development Initiatives at the Organisational Level

SN Capacity development initiative Stakeholder Responsible

1. Regularly conducting weekly staff meetings at the facility, headed by

the head of the facility, will ensure better communication & support

between colleagues. The minutes of these weekly meetings should

be recorded and documented by the staff.

Head of Facility or MO I/C

2. Fortnightly district-level meetings with the MO-I/C

Head of Facility or MO I/C &

CMO

3. Grievance redressal box for those wishing to submit grievances

anonymously should be provided for and addressed at weekly

meetings

Respective Cells of the SPIU


Table 3.3 : Capacity development Initiatives at the Organisational Level

SN Capacity development initiative Stakeholder Responsible

4. Gender-sensitive strategies at the workplace may further raise the

motivation levels of staff


CMO & DPM

5. The facility must ensure adequate supplies and infrastructure.


CMO & DPM

6. Well-defined and targeted HR policies can help reduce turnover and

address acute workforce shortage. This includes keeping track of

workforce details (skills, experiences, certifications), attendance,

trainings attended. This data will be shared in the MIS at the District

level.


CMO & DPM

7. Quarterly performance appraisals should be conducted by the head

of the facility. Inputs from the Performance appraisals should feed

into development of district action plans for Capacity building.

Head of Facility or MO I/C,

DPM & CMO

8. Peer reviews will be co-terminus with the quarterly performance

appraisals to receive input from colleagues as well as supervisors.

Inputs from peer reviews should feed into development of district

action plans for Capacity building.


DPM & CMO

9. Third Party Quality Audits should be conducted every six-months. Head of Facility or MO I/C,

DPM & CMO

10. Pre and Post Training Tests & Feedback


DPM & District Training

Nodal Officer

11. Non-monetary and monetary incentives for those performing well

after performance appraisal or trainings.



Nodal Officer

12. Action against those not attending trainings after due process



Nodal Officer

13. Regular Liasoning with PRI members, WCD/ICDS Dept. to collaborate

and ensure smooth implementation of services.


DPM & CMO

3.3. Enabling Environment Development Plan

An important aspect of the capacity development is the sustainability of the

trainings provided and/or any organisational changes made. Sustainability can

only be ensured when there is an enabling environment that supports the

transfer of knowledge within the organization, upgradation of skills and


knowledge and also creates and maintains a positive atmosphere for the cultivation, sharing and

enhancement of this knowledge.

Table 3.4: Capacity development Initiatives to Strengthen Enabling Environment

SN Capacity development initiative Conducted by

State-Level

1. • Commitment for mainstreaming Capacity development in

State Policy. Development of strategic framework that will be

converted into detailed district level training plans.

Project Director, UKHSDP,

Director, HSS & State

Training Coordinator/Cell

2. • Dedicated cadre of professionals to plan and implement

training – State CB&T cell



3.

• Digital Platform for Capacity Building & Training. This should

include HR and Performance System that contains a database

of workforce with personal details including age, qualifications

experience etc along with the skills, certifications, trainings

attended. Should be linked to HMIS.



4 • The digital platform should contain training curricula along

with pre-existing ones developed by NHM, DHFW, and other

training institutions. It should also have annotated digital

library with downloadable learning material and e-modules

available for reference of Health Staff.



5. • Develop and upgrading training institutes by providing

requisite equipment & ICT Infrastructure. It is also instructive

to restock physical libraries with updated reference books and

journals. Special focus is required to operationalise the SIFHW



District-Level

6 • Annual District Training plans will be prepared with the time-

frame for the trainings based on the State Strategy

District Training

Coordinator

7 • District Training Plan will include the plan for monitoring the

quality of training and also the utilisation of trained personnel,

based on the budget provided by the state.

District Training

Coordinator

8. • The total training load should be calculated on the basis of the

health functionaries currently in position and existing

functional health facilities. Batch size to be decided according

to the skills which are to be provided to the health

functionaries and the training venues available.

District Training

Coordinator


3.4. Human Resource Management & Institutional Roles and Responsibilities

With all the capacity development and training activities laid out in the

previous sections, this section will define the institutional set-up of the

capacity development plan and the various stakeholders that will be engaged

in its implementations along with their respective roles and responsibilities.

The set-up is given below:

Table 3.5 : Human Resource Management in Capacity Development & Training of Health Staff of Uttarakhand Health Department

S. No. Institution(s)/Stakeholder Roles and Responsibilities

STATE/REGIONAL

1. State Nodal Officer

(Project Director, HSS and NHM Director)

• Facilitate in preparing database of training centres and health care

service delivery institutions in all sectors, the training courses offered

and trainee load.

• Planning and implementation of State Training Plan.

• Liaison with State Programme Officer/District Programme Officer,

Director of Training Institution, Medical Colleges and Nursing

Colleges.

• To release funds for Training under UKHSDP component or NRHM.

• Ensure completion of training within a fixed time frame.

• Ensure that each training is synchronized with provision of necessary

supplies and development of referral linkages.

• Ensure that report on training is an integral part of routine reporting

of RCH (as per prescribed format).

• Ensure that training is an agenda item in all meetings with District and

State Officials to discuss programme issues.

• Ensure the linkages of training with operationalisation of health

facilities.

• Build a system for monitoring and evaluation of in-service training

using available training infrastructure in the district.

• Develop a district wise database of trained manpower to prevent

duplication and gaps in training of personnel and perhaps facilitate

their posting in appropriate health facility.

2. State Level Training

Institutions3

• Identification of training centres and hospitals for various types of

training based on case load/faculty position.

• Assist the state in listing training centres and health care service

delivery institutions in all sectors (district-wise), the services provided

in these and the case load.

3 Yet to be formed. Meanwhile the regional/divisional training institute such as in Haldwani can perform this function.



S. No. Institution(s)/Stakeholder Roles and Responsibilities • Assist the state government and provide guidance to the districts in

preparation of district training plans in accordance with the state and

national guidelines and strategy such that health facilities with skilled

manpower could be made operational at the earliest.

• Support the state in developing training materials from nodal agency,

adapt/translate and reproduce as per requirement of the state. • Identify training opportunities and institutions within and outside the

state for emerging and critical issues, within and outside the state, at

any point of time.

• Conduct additional research

2. Joint Director, HSS

• Overseeing the development and implementation of all District Action

Plans including trainings.

• Designing systems and procedures for independent feedback

mechanisms for assessing access to and quality of services and

updating of database of trainings.

• Liaison with SIHFW/CTIs, State Programme Officers and District

Programme Officers.

• Monitoring appropriate utilisation of trained personnel.

• Ensuring up-to-date data of persons trained and being trained

DISTRICT

6. District Training

Officer

• Prepare a training calendar for the trainings to be conducted in the

district.

• Ensure the proper implementation of district training programme.

• Develop database of personnel and update the same from time to

time.

• Plan implementation and monitoring of trainings at regular intervals

• Ensure that best options be given to the poor people by providing

skills appropriate to the job functions of health personnel and

available facilities in the various institutions.

• Ensure maximum utilisation of resources within the district for

training like ANM schools, district training centres, district hospitals,

sub-district hospitals/FRUs/PHCs/hospitals in other sectors.

• Procure adequate funds, modules and materials from the State/

Central Government.

• Ensure training of trainers of district in consultation with the State

Government/State Training Institution.

• Ensure completion of training within a time frame



S. No. Institution(s)/Stakeholder Roles and Responsibilities • The district level trainer will use and interpret standardized training

material and ensure appropriate skill upgradation.

7. District Programme

Manager (DPM)

• Assist DMO in preparing work plans.

• Create and maintain district resource database for the health sector.

• Procurement of supplies, logistics and inventory management to

dovetail with training.

• Develop strategies/plan to improve the quality of services.

• Liasion links with SIHFW, State Programme Officers and District

Programme Officers.


Officer/Coordinator

• Assist DPM in preparing training work plans.

• Create and maintain district resource database for trainings and link

with HMiS

• Create and maintain district resource database for workforce to

record status of trainings

• With DPM, maintain district resource database of performance

appraisal and internal competency evaluations

• Record pre-post training assessment data

• Procurement of supplies, logistics and inventory management to

dovetail with training.

• Develop strategies/plan to improve the quality of trainings services.

• Liasion links with SIHFW, State Programme Officers and District

Programme Officers.

3.5. Quality Assurance and Training Management

The key processes and measures that should be followed during the implementation of the training

are described below:

3.5.1 Pre-Training Activities

Training needs assessment carried out should inform the preparation of a training plan. While the

existing training needs assessment focused on non-clinical aspects of health care service delivery, it

has considered the capacities required to address or strengthen the IMR/MMR/TFR/ Disease

prevalence of the state and its linkage with plan for making its facilities operational. It will be more

appropriate to have district specific training needs which will help in prioritizing the training activities

needed in the particular district. This should include the following:


• Identification of Training institutes: Essential infrastructure required for training to be made

available in the training institutes and attached hospitals. Identified centres for training shall have

adequate infrastructure, availability of trained trainers and case load for training.

• Identification of Faculty for training: Besides the trainers at the respective training institutes, it is

instructive to identify resources who will serve as trainers for the trainings. This may include

retired medical professionals, faculty at training institutes from within and outside the state.

• Trainees and Training Load: Identification of categories of trainees and types of training.

• Adequate external capacity: Supplies, equipment and drugs required for trainings should be

made available continuously with interruptions.

• Adequate Training material: Training manuals for trainers and training. Kits for trainees should

be prepared and ready. The training material for RCH–II has already been provided.

3.5.2 During Training Activities

• Cascading model of Trainings: Health personnel at each level will be trained by personnel of one

level above them/team leader/supervisor.

• District-level Trainings: The training of primary health care functionaries eg. frontline health

workers, ASHA, lab technicians, pharmacist etc. should be at the district level.

• Residential Trainings: Residential facilities including basic amenities in the hospitals and transport

facilities for field visit need to be provided.

• Practical Skills- The trainers conducting trainings should be practicing the skills as per protocols

which are to be taught to trainees. Necessary supplies need to be continuously provided in

training institutions.

• Regular monitoring/assessment of skills: Assessment of skills should be done by the immediate

supervisor (PHC MO) and also by the functionaries of FRUs/District hospitals (appropriateness and

timeliness of referral. This needs to be collated at district level for identification of lacunae and

appropriate correction).

• Proficiency certification of Training: Proficiency certification of trainees by the trainers based on

norms (whether the trainee has acquired the skills) should be mandatory. The proficiency

certificate should be validated after assessing performance at the place of posting over a period

of 6-12 months after the training.

• Monitoring: Regular monitoring needs to be done for assessing extent of adherence to norms as

per course reports.

3.5.3 Post-Training Activities

• Database of trained personnel should be maintained at state/district level.


• Follow-up of trained professional to assess extent of service utilization of skills is essential. This

may be done by Master Trainers at the district level or block programme managers at the block

level to assess the extent of the effectiveness of the trainings.

• Mentoring as a mechanism, of supportive supervision and handholding for bringing attitudinal

change in health care providers, needs to be restored. Team leaders need to be provided with

skills for mentoring and supportive supervision on the job. These will include proficiency in

technical skills and ability to observe and identify mistakes and correct them after six-months of

the training.

• After each training cycle the outcome of the training should be evaluated at the field level in terms

of improvement of service delivery.

3.5.4 Quality Assurance Committee (QAC)

Quality assurance means maintaining high quality of health care by constantly measuring the

effectiveness of the organization that provide it. As per the Operational Guidelines (2013) for Quality

Assurance in Public Health Facilities issued by MoHFW, Quality Assurance Committees in the State at

State, District & District Hospital Level need to be set up to ensure that standards for various Health

Care Services / facilities as laid down by the GOI are being followed.

3.5.5 Budgetary Considerations

A tentative budget has been drawn up at a stakeholder level for different trainings. It is instructive to

understand that this is not an annual budget but a stakeholder and training-wise budget that may be

spread across the different years. A detailed budget with training wise cost break-up can be found in

Annexure VI.

Table 3.6 : Tentative Budget for Trainings SN Stakeholder Budget 1 Medical Officers 32,78,70,194

2 Pharmacist 41,95,36,783

3 Nurses 7,07,26,206

4 Technicians 1,86,23,280

5 FLW 6,54,99,280

6 GDA 2,74,20,867

TOTAL 92,96,76,610


Monitoring & Evaluation Framework

4.1. Introduction & Rationale for M&E

The success of the implementation of UKHSDP relies on various factors, particularly the capacity of

the staff charged with the responsibility of designing, planning, and managing the implementation of

the project. To support the process of state-wide system strengthening and implementation of

UKHSDP, a need emerged to identify critical and functional gaps in the service providers involved in

this project. Capacity Building and Training interventions will be designed to address the capacity gaps

as laid out in the Capacity Building and Training Strategy & Plan.

Regular monitoring and evaluation of the campaign can strengthen the effectiveness of the Capacity Building interventions. Period tracking of the training plan is critical to build a compelling evidence

base which can be used to support the CB&T campaign – not only to ensure effective utilisation of

resources, but in a larger context to improve the staff’s ability to strengthen the implementation and

management of the UKHSDP, viz-a-viz improving overall health outcomes by improving the individual

competency through developing knowledge, skills and attitude. This is not an easy task because of

multiple reasons such as the sheer number of health staff that would constitute as the trainees and

the difficulty in measuring performance in the governance and management.

Here, a monitoring and evaluation framework will support in building institutional capacity and

strengthen the existing training and capacity building efforts for this project. The technical support in

this regard, is aimed at enabling the institution and key stakeholders carry out the activities with

informed evidence based planning yielding better results. The activities proposed under this partnership seeks to make a long-lasting and sustainable impact at three levels described ahead.

Level 1: Enabling Environment/Policies & Guidelines: The support activities proposed under this

partnership will seek to develop data and evidence for advocating quality improvements in the

existing policies and guidelines that influence the implementation of varied training interventions

being carried out. The project attempts to ensure sustainability of results by – ensuring that the

concerned departments have comprehensive programme and district specific data that can help them

make informed policy decisions that will guide future plans and interventions of the Project.

• Developing benchmark indicators that will help set goals and assess progress of training

interventions/activities in the future.

• Demonstrating certain best practices in management and learning.

4


Level 2: Organisation/ Systems And Procedures: The support offered during the project period will

have sustainable impact on the systems & procedures by –

• Building the capacities of concerned officials and key functionaries for planning, implementing

and monitoring project interventions in a better way.

• Facilitating hierarchical and interdepartmental convergence, and ensuring that the concerned

stakeholders also develop the ability to continue such efforts in future as well.

LEVEL 3: INDIVIDUAL CAPACITY : While working to develop the individual capacities of the staff, the

project will have brought certain changes. The project will seek to ensure that –

• The staff members are better informed not only about technical knowledge but also about their

roles and responsibilities, obligations and are empowered to demand better services.

• The individual develops the ability to undertake cohesive and collective action for bringing about

quality changes in the management of the healthcare service provision in the state.

• Some of staff members may develop into becoming harbingers of change influencing adoption

of desired health seeking behaviour among masses.

Establishing and instituting a Monitoring and Evaluation Framework will support the efforts to ensure that the communication intervention is able to leave behind lessons and capabilities that will continue to bring about positive changes in future as well.

4.2. Objectives of M&E Framework

Overall, this primary objective of the monitoring and evaluation framework described in this

document is to help the state program team spearheading the implementation of health care delivery

by strengthening routine M&E of the training and system strengthening activities. A framework for

this exercise described in this document will more specifically help:

E Develop comprehensive M&E plans in parallel with CB&T intervention planning.

E Utilize a strategic and practical mix of M&E methods to design, implement, and assess the

outcomes of CB&T activities.

E Systematically apply results of M&E to adapt and improve the performance of CB&T

interventions.

4.3. Target Users of M&E Framework

The M&E framework is at the overall level for the state and not micro-level monitoring and evaluation

of a single training programme/event. Therefore, formats will need to be developed for reporting units

at regional/district/block/trainer levels as appropriate when the detailed M&E system is

operationalized.


This guiding document is envisaged to be utilised by the state for the monitoring of the CB&T and

evaluate the impacts that can be attributed to CB&T initiatives of the project. The users of this

document will include:

• State Capacity Building and Training Cell/Staff

• District level Training officers

• Technical partners/Service Providers who are providing support in the design and implementation

of the UKHSDP activities

4.4. Guidelines for M&E framework

The guiding principles that will frame and inform the process of monitoring and evaluation of the

Capacity Building and Training Activities of UKHSDP are described below: -

• Performance-Oriented’ Approach instead of `Output-Oriented’

Traditional Monitoring and Evaluation exercises were focused on input-output. However, the

approach was not observed to be adequate to generate result-oriented information and does not

guarantee or capture results/outcomes nor does it any provide any information on the value for

money spent on training activities. The following document outlines a performance-oriented

planning framework that will be result-oriented and robust outcome-based M&E.

• Systems Approach to assess effectiveness of CB&T interventions; Looking beyond `individual’

The outcomes and impacts are influenced not only by the outputs (and inputs) but are subject to

many external influences and factors. However, it is important to make it clear to what extent the

planned CB&T interventions’ outputs have contributed to the outcomes/impact, i.e., trainings and

institutional changes have lent to strengthening health systems, improving health facility access

and utilization and ultimately the health outcomes in the state.

• Comprehensive & Uniform Reporting of CB&T across the state

A comprehensive strategy that monitors all the CB&T across the state and not just a single training

programme and intervention is required currently. Moreover, regular data in terms of coverage,

expenditures, utilization certificates and future needs of funds should be reported to the state. It

is important to compile information received from across the state according to standard

definitions of performance indicators across states/UTs, M&E systems currently are utilized

largely for the purpose of reporting rather than as a system for providing feedback on and

strengthening implementation.

• M&E should be embedded in the CB&T programme cycle

M&E should not be a retrospective exercise and should be embedded in the Capacity Building and

Training cycle that is designed to address the capacity needs of the project staff.


4.5. Key Evaluation Questions & Logframe

The figure 4.1 below comprises the “Theory of Change’, i.e. the major steps of a capacity

building/training cycle with major externalities. This framework informs the design of the monitoring

and evaluation activities to track the progress of the CB&T activities and the Key Evaluation Questions

are the high-level questions that the M&E activities will attempt to address.

Figure 4.1 : Analytical Model of the CB&T

Table 4.1 : Logframe for CB&T interventions

S.N Stage Key Evaluation

Question Indicators

Means of Verification

1.

Planning for CB&T

(INPUT)

Are the CB&T interventions suited to address the capacity gaps?

• CB&T Strategy & Policy

Development

• CB&T Monitoring

Framework

• CB&T Training Needs

Assessment & Baseline

Evaluation

Desk Review of

MIS & Project

Reports

EXTERNALITIES

CB&T Planning

Individual Learning

CB&T Implementa

tion

Organisational Performance &

Health Outcomes

INPUT OUPUT OUTCOME IMPACT

Training Reaction

Social Environment

Individual Learning Capacity

Organisational Environment




Question Indicators


• Module & Material

design and

Development

• CB&T planning including

resources (facilities,

service providers,

infrastructure, funds)

• CB&T budgeting

• ToT development

• Resources development

(faculties selection,

ToTs)

• Micro Planning and

scheduling

2.

CB&T

Implementation

(PROCESS/OUTPUT)

To what extent is the

relationship between

the inputs-outputs

timely, cost-effective

and to expected

standards?

(INPUT-OUTPUT MONITORING)

• No. of self-instruction

materials prepared

• No. of modules

prepared for training

• No. of Training batches

• Payments and

Accounting

• No. of CB activities

organized and

operationalized

• No. of Trainers

• Participant attendance

in trainings/CB events

(%)

• % of participants

covered under various

CB activities

• Desk Review

of MIS &

Project

Reports

3.

Training Reaction

(OUTPUT)


program producing

worthwhile results

(outputs, outcomes),

and/or meeting each of

its objectives?

End of training/Post-Test

evaluation on

- Trainer

- Content

- Presentation

Pre-Post Test

evaluation &

Trainer

Observations




Question Indicators


(INPUT-OUTPUT EVALUATION

- Training

Arrangements

4.

Individual

Performance

(OUTCOME)


program achieving the

intended outcomes, in

the short, medium and

long-term?

(OUTCOME-IMPACT EVALUATION).

• Increase in knowledge,

attitude and skills/

behavior regarding

responsibilities and

functions of the

individual staff and

therefore functioning of

the

• Sample

Survey and

Training

Needs

Assessment

for baseline

• Training

Needs

Assessment

Report

5.

Organisational

Performance

(IMPACT)

• Changes in efficiency,

effectiveness,

timeliness, in

functioning and

achievement of

outcomes,

6.

Externalities/

Institutional

Capacity

(ENABLING ENVIRONMENT)

• Learning Capacity (Ability to

absorb the inputs provided

through the CB&T)

• Facilitation/Support of

state government

functionaries and other

local level government

functionaries

• Extent of peer learning and

support

• Infrastructure:

Building/space, computers,

furniture, connectivity,

availability of varied

information and databases

• Political Will of the state

level unit

• Timely and adequate fund

flows

•


4.6. Methodology and Work Plan

To accurately capture, analyze and report data on the indicators mentioned in table above. Reporting

on these indicators may be done on paper, although using web-enabled software with the help of IT

or IT-enabled technology. This data may be captured using the following methods and techniques:

Table 4.2: Modalities of Reporting and Data Collection Monitoring

SN Indicator/Parameter Purpose/Objective Frequency Source of

Verification/Assessment

1

Training Strategy &

Plan

To assess the relevance of

Training Strategy & Plan

Annual • Capacity Building and

Training Strategy

Document

• Proof of

operationalization of

CB&T– annual report of

the program, contracts,

monitoring reports, etc.

2.

Training

Institutional

Arrangement

To assess the adequacy of the

Training Institutional

Arrangement

Annual • Proof of





3. Training Needs

Assessment



Arrangement

Annual • Training Needs

Assessment Report

4 Module Design

Development

To assess the relevance,

effectiveness and adequacy of

the Training Institutional

Arrangement

Quarterly • Capacity Building and

Training Strategy

Document

• Training Modules

developed by the

Centre/State

• Experiential learning

aids designed in the

modules provided by

the state

5

Micro-Planning To assess the adequacy of the


Arrangement

Quarterly • Proof of






Table 4.2: Modalities of Reporting and Data Collection Monitoring

SN Indicator/Parameter Purpose/Objective Frequency Source of

Verification/Assessment

6

Budgeting & Cash

Flow



Arrangement

Quarterly • Proof of





7

Training Experience To assess the adequacy of the


Arrangement

Quarterly • Feedback forms of

Trainees

• Training Reports

8

Training

Infrastructure



Arrangement

Quarterly • List of Training Venues

• Feedback forms by

Participants

• Photos of Training

Venues

9

HR management of

Capacity Building &

Training



Arrangement

Quarterly • Training Strategy

10 Knowledge

Assessment

To assess the knowledge and

awareness of the health staff

Annual • Sample Survey and

Training Needs

Assessment for

baseline

• Training Needs

Assessment Report

11 Attitude

Assessment

To assess the attitude of the

health staff

Annual

12

Skill

Assessment

To assess the skills of the staff Annual

Outcome/impact evaluation is an exercise that does not have to be conducted frequently since

outcomes and impact is witnessed over longer time periods. Therefore, it is recommended that a

Mixed-Methods study to be carried out annually to track the progress in the achievement of the

outcomes of the CB&T interventions across all the staff in the Department of Health.

Outcome Evaluation: This study evaluates the outcomes of capacity strengthening and competency

development of the staff across knowledge, attitude and skills as outlined in the Table above. A

mixture of qualitative and quantitative techniques will be employed to collect the data. The sample

size and strategy used in the Training Needs Assessment which also serves as the Baseline Evaluation,

may be referred to for subsequent rounds of evaluation.

Impact Evaluation: It would also study its impact on the overall performance of the state of

Uttarakhand in delivering adequate health service. This would be measured by tracking the progress


of the project in achieving performance outputs as earmarked in the Project Log frame for UKHSDP by

referring to Monitoring Informatics System of the Project.

4.7. M&E Operationalization Plan

With the methodology and brief work plan for the different evaluations described in the previous

sections, this section will illustrate the work plan for finalisation and implementation of the

Monitoring and Evaluation Framework. Monitoring and Evaluation is part of a continuous process of

learning and improvement that enables assessment of the performance of your communications

against the aim and objectives. The broad framework that should be followed for preparing and

implementing an M&E plan is given below.

A framework is provided for developing the operationalization plan of the M&E framework based on

the overall methodology illustrated above.

Set Monitoring aims & Objectives

Identify Activities to be monitored

Develop Indicators

Identify data requirements

Collect Data

Analyze & Evaluate Data

Identify Improvements

Take Action

A

B

C

D

H

E

G

F

Feedback on aims & objectives

CONTINUOUS IMPROVEMENT LOOP


Table 4.3 : Framework for Developing Operationalization Plan of CB&T M&IE Framework in the state.

TASK RESPONSIBILITY TIMELINE

Finalizing the M&IE framework with State specific modifications M&E Cell & State

CB&T Officer

M1

Formalizing the M&IE Data flow structure and nominating the

functionary responsible for data compilation and reporting at each

level

M&E Cell & State

CB&T Officer

M1

Identifying any additional requirements for operationalizing the

framework, if any

M&E Cell & State

CB&T Officer

M1

Developing reporting formats for Block/district/regional levels M&E Cell M2

Developing data compilation structure in Excel or compatible

software and installing the same at all reporting units M&E Cell

M2

Conducting Training of all Concerned M&E Persons (A training

schedule may be prepared and shared)

M&E Cell & State

CB&T Officer

M3

During the State level ToT Workshops on the M&E Framework, formats will be provided for

developing:

§ Data Flow structure: Reporting Units through which data for M&E systems will flow in the state

§ Training Plan for training of concerned M&E functionaries of the state

§ These formats will be developed as per their need and structure.

4.8 Human Resources for CB&T M&E

The human resources and budget required for carrying out monitoring and impact evaluation will be

drawn from the overall budget of PRI CB&T. We suggest the following Human resources for this

exercise.

Table 4.4 : Details of Human Resource and their responsibilities

SN Institution Designation of

Stakeholder Roles & Responsibilities

State

1. Capacity Building &

Training Cell

Training

Coordinator

• Overall supervision of the monitoring and evaluation of

the CB&T intervention.

• Supporting the preparation of templates for process

monitoring.


Table 4.4 : Details of Human Resource and their responsibilities

SN Institution Designation of Stakeholder Roles & Responsibilities

State

2. MIS and

Monitoring &

Evaluation

Coordinator

• Supporting the supervision of the monitoring and

evaluation of the CB&T intervention, including contract

management of Third-Party Agency.

• Prepare templates and formats for monthly progress

reports and Quarterly Progress Reports for CB&T

activities at state, district and cluster levels.

• Support the development of MIS for program monitoring

along with hired agency.

• Develop and finalise program indicators for tracking

progress of CB&T intervention

supervise and monitor

3. Third Party

Evaluation Coordinator

• Primary responsibility of undertaking M&E activities at

the Central, district and cluster level.

• Support preparation of templates for process monitoring.

• Undertaking quarterly qualitative I/O analysis, outcome

and impact evaluation.

District/Cluster


Officer

Field Level

Coordinator & Data

Monitoring

• Supervise data monitoring of MIS at the cluster level

• Support data collection at the field level

• Provide support to the Third-Party Agency during data

collection

• Support Training of Cluster Level staff in completion of

monitoring formats

5. District Programme

Manager

Field Level

Coordinator & Data

Monitoring

• Ensure data monitoring of formats at the cluster level

• Assist in computerization of data generated during data

validation exercise.

6. Training Officer

CB&T

Field Level

Coordinator & Data

Monitoring

• Ensure data monitoring of formats at the cluster level

• Support data collection at the field level

• Support Training of Cluster Level staff in completion of

monitoring formats


4.9 Activity Timeline A tentative activity schedule for the Monitoring and Evaluation Activities for the Capacity Building and Training Activities are given below.

Monitoring & Evaluation

2019 2020 2021

Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 5 Quarter 5 Quarter 6 Quarter 7 Quarter 8

May June July Aug Sep Oct Nov. Dec. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov. Dec. Jan Feb Mar Apr May Jun Jul

Output

Monitoring

Weekly MIS

reporting

Training

Reports

Outcome

Evaluation

Training

Reports

which

includes pre-

post training

formats

Outcome-

impact

Evaluation

Field

validation

* * * * *


ANNEXURE


Annexure - I

DISTRICT-WISE DISTRIBUTION OF HEALTH FACILITIES

(Source: Department of Medical Health & Family Welfare, Govt. of Uttarakhand, Health Resources -Medical & Paramedical4)

HEALTH FACILITIES IN UTTARAKHAND

Division District SCs PHCs CHCs SDHs DHs

Garhwal

Total Sample Total Sample Total Sample Total Sample Total Sample

Bageshwar 84 9 12 2 2 1 1 1

Pithoragarh 155 16 18 2 4 1 2 1

Almora 206 21 28 3 4 1 2 1 2 1

Champawat 68 7 6 1 2 1 1 1 1 1

Nainital 143 15 19 2 8 1 4 1 2 1

U.S. Nagar 153 16 27 3 6 1 1 1 1 1

Kumaon

Uttarkashi 82 9 10 1 4 1 2 1

Chamoli 110 11 13 2 5 1 1 1

Rudraprayag 68 7 13 2 2 1 1 1

Tehri 204 21 28 3 5 1 1 1 1 1

Pauri 239 24 32 4 5 1 3 1 2 1

Dehradun 175 18 23 3 7 1 4 1 2 1

Haridwar 160 16 28 3 6 1 1 1 2 1

1847 190 257 31 60 13 17 8 20 13

GRAND

TOTAL

TOTAL 2201

SAMPLE 255

4 http://health.uk.gov.in/pages/display/113-human-resource-medical-and-paramedical


HEALTH CADRE-WISE DISTRIBUTION OF AVAILABLE

HEALTH STAFF & SAMPLE SELECTED

(Source: Department of Medical Health & Family Welfare, Govt. of Uttarakhand, Health Resources -Medical & Paramedical5)

HEALTH STAFF OF DIFFERENT CADRES

SN Staff Position Total Nos in Position* Sample

1 Medical Officer /Lady Medical Officer 825 97

2 Deputy CMO/ Administrative 121 14

3 Super Specialist -

4 Dental Surgeon 39 5

5 Matron/Assistant Matron/Sister-in-charge 21 3

6 Assistant Matron 15 2

7 Sister 143 17

8 Staff Nurse 626 74

9 District Pharmacy Officer 10 1

10 Chief Pharmacist/treatment supervisor 170 20

11 Pharmacist 715 84

12 X-Ray Technician 70 8

13 Dark Room Assistant 32 4

14 BCG Team Leader 4 1

15 BCG Technician 17 2

16 Occupational Therapist /Physiotherapist 6 3

17 Health educator/NHM/Vertical program

counsellor 8 1

18 Dental Hygienist 17 2

19 Senior Lab Technician /SLS -

20 Lab Technician 132 16

21 ECG Technician -

5 http://health.uk.gov.in/pages/display/113-human-resource-medical-and-paramedical


HEALTH STAFF OF DIFFERENT CADRES

SN Staff Position Total Nos in Position* Sample

22 OT Technician 3 1

23 Health Supervisor (Male)/TB health visitor 417 49

24 Health Supervisor (Female)/TB health

visitor 343 40

25 Female Health worker (ANMs) 1925 227

26 ANM (As per NRHM) 1631 192

27 District Malaria Officer (DMO) District

NVDC Officer/IDSP district epidemiologist 13 2

28 ASHA ~12,000 177

29 Ward Boys 170 20

30 Class 4 Staff 1170 138

TOTAL 8,643 1,024


Anneuxre-2 YEAR-WISE BUDGET DETAILS

Sl. No.

Training Particulars Budget

(2019-20) Budget

(2018-19) Budget

(2017-18) Proposed Approved Proposed Approved Proposed Approved

Maternal Health Trainings

1 Maternal Death Review 9.43 9.43 9.43 9.43 2.67 2.67

2 Onsite monitoring delivery points /Nursing institutions/ Nursing school 2.6 2.6 2.6 2.6 1.43 1.43

3 TOT for skill Lab 0 0 0 0

4 Training at skill Lab 3.43 3.43 3.43 3.43

5 TOT for SBA 0 0 0 0 9.97 9.97

6 Training of staff Nurses/ ANMs/ LHV in SBA 6.13 6.13 3.83 3.83 9.97 9.97

7 TOT for EMOC 0 0 0 0 7.16 7.16 8 Training of Medical Officer in EMOC 7.58 7.57 0 0 7.16 7.16 9 TOT for Anaesthesia skills training 0 0 0 0 0.32 0.32

10 Training of medical officer in life saving anaesthesia skills 9.62 9.62 0 0 13.94 13.94

11 Training of Medical Officers in ATLS/BLS Trg. 0 0 0 0 4.63 4.63

12 TOT for safe abortion services 0 0 0 0 0 0

13 Training of medical officers in safe abortion 1.44 1.44 0.79 0.79 3.16 3.16

14 TOT for RTI/STI training 0 0 0 0 4.22 4.22

15 Training of laboratory technicians in RTI/STI 0 0 0.98 0.67 0.98 0.98

16 Training on ANM/Staff nurses in RTI/STI 0 0 0.98 0.67

17 Training on Medical Officer in RTI/STI 0 0 1.09 1.08 2.18 2.18 18 TOT for BMOC training 0 0 0 0 0.29 0.29 19 BMOC training for Mos/LMOs 1.4 1.44 1.4 1.4 6.66 6.66 20 DAKSHATA training 9.94 9.94 4.26 4.26 20.62 20.62 21 TOT for DAKSHATA 0 0 0 0 0 0 22 Onsite Monitoring for DAKSHATA 0 0 0 0 0 0 23 Lakshaya training /workshops 13.48 13.48 18.49 18.4

24 Training for Mos/SNs 0 0 0 0

25 Onsite Monitoring at delivery points 0 0 0 0 1.43 1.43

26 Training of Nurse Practitioners in midwifery 19.5 19.5 - -

27 Other maternal health training 0.72 0.72 46.52 30.77 Child Health Trainings

1 IMNCI 0 0 0 0 0 0 2 Orientation on IDCF/ARI (Pneumonia) 6.83 6.82 0 0 13 0


Sl. No.


(2019-20) Budget

(2018-19) Budget


3 6 weeks training at State Nodal Center

9.72 9.72

4 Orientation on activities on vitamin A supplementation and Anemia Mukta

Bharat Programme 0 0

5 Child Death review training 7.88 7.88 7.88 7.88 0 0

6 Provision for State & District level (Training and workshop) 0 0 0 0

7 TOT on IMNCI (pre service- in service) 0 0 0 0 0 0 8 IMNCI training for AMN/LHVs 0 0 0 0

9 TOT on F-IMNCI 0 0 0 0 0 0 10 F-IMNCI training for Medical Officer 0 0 0 0 0 0 11 F-IMNCI training for Staff Nurse 0 0 0 0 0 0

12 Training on Facility based

management of service acute malnutrition(including refresher)

0 0 1.13 1.12 0 0

13 TOT for NSSK 0 0 0 0 0 0 14 NSSK training for Medical Officers 0 0 0 0 0 0 15 NSSK training for SNs 0 0 0 0 0 0 16 NSSK training for ANMs 0 0 0 0 0 0

17 4 days training for facility based newborn care 0 0 0 0 1.92 1.92

18 2 weeks observer ship for facility based newborn care 0 0 0 0 13.19 13.19

19 4 Days training for IYCF for Mos, SNs, ANMs, all DPs, and SCs 19.5 19.5 0 0 24.5 24.5

20 Orientation on National Deworming Day 44.8 44.8 44.8 44.8 13 13

21 TOT (MO, SN) For family participatory Care (KMC) 0 0 0 0

22 Training for family participatory care (KMC) 4.62 4.62 4.62 4.62

23 New Born Stabilization training

package for Medical Officer and Staff Nurses

0 0 0 0

24 Other Child Health Training 4.62 4.62 0 0 52.61 52.61

25 NRC (Nutritional Rehabilitation Center Training) 0 0 0 0 1.13 1.13

Family Planning Training


Sl. No.


(2019-20) Budget

(2018-19) Budget


1

Orientation/ review of ANM/AWW as applicable for New Scheme, FP-LMIS, New contraceptives, post-partum and

post abortion, family planning scheme for home delivery of

contraceptive (HDC), Ensuring spacing at birth (ESB{wherever applicable},

pregnancy testing kits(ptk)

4.75 4.75 4.75 4.75 4.18 4.18

2 Dissemination of FP manuals and guidelines (workshop only) 0 0 0 0 0

3 TOT on laparoscopic sterilization 0.42 0.42 0 0 0.3 0.3

4 Laparoscopic sterilization training for doctors (team of doctors, SN and OT

assistant) 0.71 0.71 0.71 0.71 0.71 0.71

5 Refresher training on laparoscopic sterilization 0 0 0 0 0 0

6 TOT on minilap 0 0 0 0 0 0 7 Minilap training for medical officer 0.92 0.92 0.92 0.92 2.77 2.77

8 Refresher training on Minilap Sterilization 0 0 0 0.52 0.52 0.52

TOT on NSV 0 0 0 0 0 0 9 NSV training of Mos 0 0 0 0 0.41 0.41

10 Refresher Training on NSV sterilization 0 0 0 0 0.26 0.26

11 TOT (IUCD insertion training) 0 0 0 0 0 0

12 Training on Medical officer (IUCD insertion training) 1.04 1.04 1.04 1.04 2.07 2.07

13 Training of AYUSH doctors (IUCD insertion training) 0 0 0 0 0 0

14 Training of Nurse (Staff

Nurse/LHV/ANM) (IUCD insertion training)

0.86 0.86 0.86 0.86 0.86 0.86

15 TOT (PPIUCD insertion training) 0 0 0 0 0 0

16 Training of Medical officers (PPIUCD insertion training) 0.5 0.5 0.5 0.5 1.01 1.01

17 Training of AYUSH doctors (PPIUCD insertion training) 0 0 0 0 0 0


Nurse/LHV/ANM) (PPIUCD insertion training)

0.44 0.44 0.44 0.44 0.87 0.87

19 Training for post abortion family planning 0 0 0 0 6.55 6.55

20 Training of RMNCH+A/FP Counsellors 1 1 0 0 1.5 1.5


Sl. No.


(2019-20) Budget

(2018-19) Budget


21 TOT (Injectable Contraceptive Trainings) 0 0 0 0 0 0

22 Training of Medical Officers (injectable Contraceptive Trainings) 0 0 5.56 5.56 5.56 5.56

23 Training of AYUSH Doctors (Injectable Contraceptive Trainings) 0 0 0 0 0 0


Nurse/LHV/ANM) (Injectable Contraceptive Trainings)

6.8 5.23 6.8 6.8 6.8 6.8

25 Training of Logistic Personnel on injectable Contraceptive 0 0 0 0 6.8 6.8

26 Oral Pills Trainings 0 0 0 0 0 0

27 Contraceptive update seminar/ meeting 0 0 0 0 1 1

28 FP-LMIS Trainings 2 2 1 1

29 Other Family Planning Trainings 0 0 0 0 Adolescent Health Trainings

1 Dissemination workshop under RKSK 3.5 3.5 1.95 1.95 1.85 1.85

2 TOT for Adolescent friendly Health service Trainings 0 0 0 0 0 0

3 AFHS training of Medical Officers 4.5 4.5 0 0

4 AFHS training of ANM/LHV/MPW 3.44 3.4 0 0

5 Training of AH counsellors 0 0 0 0 1.85 1.85

6 Training of Peer educators (District level) 0 0 0 0 0 0

7 Training of Peer educators (Block level) 0 0 0 0 0 0

8 Training of Peer educators (Sub Block level) 0 0 0 0 0 0

9 WIFS training (District) 0 0 0 0 0 0 10 WIFS training (block) 0 0 0 0 0 0 11 MHS Training (District) 0 0 0 0 0 0 12 MHS Training (block) 0 0 0 0 0 0

Programme Management Training (e.g. M&E, Logistics Management,

HRD, etc.)

1 Training of SPMU Staff 0 0 0 0 12 12 2 Other Training 0 0 0 0 2.6 0

Intensification of School Health Activities

1 Training of Master trainers at district and block level 15 15 0 0 2 0


Sl. No.


(2019-20) Budget

(2018-19) Budget


2 Training of two nodal teachers per school 0 0 0 0 2 0

3 Any other 0 0 0 0 0 0 Account Training 0 0 0 0 0 0

1 Public Finance Management (PFMS) Training for Accounts personnel 0 0 0 0 2.66 0

RBSK Trainings

1 RBSK Trainings- trainings of mobile

health team-technical and managerial (5 days)

0 0 0 0 24.94 24.94

2 RBSK DEIC Staff Training (15 Days) 0 0 0 0 0 0

3 One Day orientation for MO/ other staff Delivery points (RBSK trainings) 0 0 0 0 0 0

4 Training/ Refresher training - ANM (one day) (RBSK trainings) 0 0 0 0

5 Other RBSK training 0 0 0 0 0 0

Training for Blood Services & Disorder

1 Blood bank/blood storage Unit (BSU) training 6.9 6.9 0 0

2 Training for Haemoglobino-pathies 0 0 5.13 5.12 2.38 0 3 Any other 2.08 2.08 0 0 0 0 Training under NPPCD

1 Training at District Hospital @20rs. Lakh/dist. 0 0 0 0

2 Training of PHC medical officer,

Nurse, Paramedical workers& other health Staff under NPPC

10 10 3.5 3.5

3 Any other 0 0 0 0 Training under NPPCF

1 Training of medical and paramedical personal at district level under NPPCF 7.06 7.06 0 0

2 Any other 15.23 15.23 0 0

Training under Routine Immunization

1 Training under Immunization 30 30 30 30

2 Any other 15.23 15.23 15.23 15.23 Training under IDSP

1 Medical Officer (1 day) 4.34 4.34 4.34 4.34

2 Medical collage doctor (1day) 0 0 0 0

3 Hospital Pharmacists/Nurses Training (1 day) 0 0 0 0


Sl. No.


(2019-20) Budget

(2018-19) Budget


4 Lab Technicians (3 days) 0 0 0 0

5 Data managers (2 days) 0 0 0 0

6 Data entry Operations cum Accountant (2 days) 0 0 0 0

7 ASHA & MPWS, AWW & community volunteers (1 day) 3.43 3.43 3.43 3.43

8

One day training for data entry and analysis for block Health Team (including block programming

manager)

0 0 0 0

9 Any other 12.18 8.31 1.3 1.3 Training under NVBDCP

1 Training / capacity building (Malaria) 3.66 2 9.75 9.75

2 Training /workshop (Dengue ad Chikungunia) 2 2 2 2

3 Capacity building (AES/JE) 0 0 0 0

4 Training specific for JE prevention and management 0.31 0.31 0 0

5 Other Charges for Training/workshop meeting (AES/ JE) 0 0 0 0

6

Training / sensitization of district level officers on ELF and drug distributors including peripheral health workers

(AES/JE)

0 0 0 0

7 Training under MVCR 0 0 - -

8 Any other 0 0 0 0 Training under NLEP

1 Capacity building under NLEP 7.2 7.2 1.52 1.52

2 Any other 0 0 1.65 1.65 Training under RNTCP

1 Training under RNTCP 18.66 18.66 20 20

2 CME (Medical Collage) 1.4 1.4 1 1

3 Any other 0 0 0 0 Training under NPCB

1 Training of PMOA under NPCB 1.95 1.95 1.95 1.95

2 Any other 0 0 0 0 Training under NMHP

1 Training of PHC medical officers,

Nurses, Paramedical workers & other health Staff working under NMHP

10 8 21 21

2 Any other 0 0 0 0 Training under NPHCE


Sl. No.


(2019-20) Budget

(2018-19) Budget


1 Training of Doctors and Staff from CHC and PHC under NPHCE 5.25 5.25 4 4

2 Training per CHC under NPHCE 0 0 0 0

3 Training per PHC under NPHCE (IEC to be budgeted) 0 0 0 0

4 Any other 0 0 0 0 Training under NTCP

1 Training for district Tobacco Control Center 5.07 5.07 8.12 8.12

2 Orientation of stakeholder organization 3.25 3.25 7 7

3 Training of Health Professionals 1.17 1.17 0.72 0.72

4 Orientation of Law enforcers 0.65 0.65 0.4 0.4

5 Other training /orientation -sessions incorporated in other trainings 0 0 0 0

Training for State Tobacco Control Centre

1 State Level Advocacy Workshop 1 1 1 1

2 Training of Trainers, Refresher Trainings 0.5 0.5 0.5 0.5

3 Training on Tobacco cessation for health care providers 0.25 0.25 0.5 0.5

4 Law enforces training / sensitization programme 0 0 0 0

5 Any other 0 0 0 0 Training under NPCDCS

1 State NCD cell 0.3 0.3 0.5 0.5

2 District NCD cell 2.6 2.6 6.5 6.5

3 Training for Universal Screening for NCDs

151.98 142.6 91.02 15.83

4 Any other 0 0 0 0 PMU Training

1 Training on Finance 2 2 2 2

2 Training in on HR 4 4 8 8

3 Any other 31.52 31.52 0 0 Training of DPMSU


2 Training on HR 0 0 0 0

3 Any other 0 0 0 0 Training of BPMSU



Sl. No.


(2019-20) Budget

(2018-19) Budget


2 Training on HR/ 0 0 0 0

3 Any other 0 0 0 0 PNDT Training

1 PC/PNDT training 1.6 1.6 1.6 1.6 0 0 2 Any other 0 0 0.24 0.24 0.24 0.24 ASHA Facilitators/ ARC Trainings

1 Training of District Trainers 0 0 0 0

2 Capacity Building of ASHA Resource Center 0 0 0 0

3 HR at State Level (PM & HR only) 0 0 0 0

4 HR at District Level (PM & HR only) 0 0 0 0

5 HR at Block Level 0 0 0 0

6 Any other 0 0 0 0 Training on Outreach Services

1 Trainings / orientation (MMU) 0 0 0 0

2 Trainings / orientation (MMV) 0 0 0 0

3 Trainings / orientation (Ambulance) 0 0 0 0

4 Any other 0 0 0 0 Training under AYUSH

1 Training under AYUSH 0 0 0 0

2 Any other 0 0 0 0 Quality Assurance Trainings

1 Quality Assurance Training 6.7 6.7 12.02 12.02

2 Miscellaneous Activities 3.69 3.69 3.69 3.69

3 Kayakalp Training 8.78 8.78 15.1 15.1

4 Any Other 0 0 0 0 HMIS/MCTS Training

1 Training cum review meeting for HMIS & MCTS state level 1 1 1 1

2 Training cum review meeting for HMIS & MCTS district level 1.9 1.9 1 1

3 Training cum review meeting for HMIS & MCTS at Block Level 51.65 51.65 50.81 50.81

4 Any other 0 0 0 0

Trainings for Health & Wellness centre (H & WC)

1 Bridge Course/ Training on the Standard Treatment protocols 0 0 0 0

2 Multi-skilling of ANMs ASHA, MPW 25.4 25.4 0 0


Sl. No.


(2019-20) Budget

(2018-19) Budget


3 BSc Community Health/Bridge Course for MLPs for CPHC 413.6 413.6 341.22 341.22

4 Any other 28.28 28.27 0 0 Any other Trainings

1 PGDHM Courses 0 0 0 0

2 Training (Implementation of Clinical Establishment Act) 7 7 7 0

3 Promotional Training of ANMs to lady health visitor, etc. 0 0 0 0

4 Training of ANMs, Staff Nurses, AWW, AWs 0 0 9.72 5.51 3.82 3.82

IMEP Training

1 TOT on IMEP 0 0 0 0 0 0

2 IMEP training for State and district programme managers 0 0 0 0 0 0

3 IMEP training for medical officers 0 0 0 0 0 0 4 Other 0 0 0 0 0 0

96


Annexure - III RCH-II TRAINING

(Source: National Training Strategy for In-service under National Rural Health Mission)

Sl. No.

Type of Trg. Category of Participants Duration Batch Size Venue Trainers Responsibility

1. SBA SN/ANM/LHV 3 – 6 Weeks 2 – 4 Identified District Hospitals

TOT trained Obstetrician/MO/ SN& Paed. M.O.

MH Division/ NIHFW

2. EmOC MOs 16 Weeks Up to 8 Identified Medical Colleges

Faculty Med. College (Gyn)/Dist Gynaecologist.

MH Division/ FOGSI

3. Life Saving Skills in Obs. Anesthesia

MOs 18 Weeks Up to 8 Identified Medical Colleges

Faculty Med. Coll. (Anes)/Distt. Anaes

MH Division

4. Blood Storage MOs, Lab. Tech. 3 Days 2 – 3 Instt. where Blood Banks are available

I/c of trg. instt. State/SIHFW

5. RTI/STI MO/SN/ANM/ LHV 2 Days 5 Identified Medical Colleges/RHFWTC

Oriented team of trainers at State Level

MH Division

6. MTP including MVA

MOs 15 Days 5 Identified Trg. Institutes Gynaecologist from Medical Colleges

MH Division

7. IMNCI MO/ANM/LHV/ AWW, etc.

8 days 24 National/State/District Trg. Centers

Faculty of Paediatrics and P&SM deptt.

CH Division/State

8. Immunisation Health Workers 2 days 20-25 District Trg. Centers Trained Trainers Imm. Division 9. Mini Lap MOs for CHCs/ FRU & DH 12 Working

Days 1 - 2 Identified Trg. Institutes Gynaecologist FP Division

10. Lap. Ster. Gynaecol./Surgeon with OT Nurse & Assistant

12 Working Days

1 team at a time

Identified Trg. Institutes Gynaecologist FP Division

97


Sl. No.

Type of Trg. Category of Participants Duration Batch Size Venue Trainers Responsibility

11. IUCD ANM/LHV 5 days 5 – 10 Identified Trg. Institutes FP Division

12. NSV MOs 5 days 4 Master/State Level Trainers

FP Division

13. Adolescent Health MOs/ANM 5 Days 25 – 30 IEC Division

14. PDC CMO/Civil Sur./ Hosp. Suptd.

10 Weeks 20 - 25 Identified 13 Trg. Institutes

Faculty of NIHFW NIHFW & Trg. Div

15. PMU 5 Days 20 – 25 NIHFW/SIHFW Faculty of NIHFW NIHFW & DC Div.

98


TRAINING UNDER NATIONAL DISEASE CONTROL PROGRAMMES (Source: National Training Strategy for In-service under National Rural Health Mission)

Sl. No.

Types of Training Category Duration Batch Size Venue Responsibility

1. National Leprosy Elimination Programme (NLEP)

Orientation Training

MO/HA (M)/HA (F), MPW

3 days

30

District/Block Level

State/District Leprosy Officer

Refresher Training MO/HA (M)/HA (F), MPW

1 day 30 District/Block

Level State/District

Leprosy Officer

2. Revised National Tuberculosis Control Programme (RNTCP)

Initial Training STD/DTO 14 days 20 Identified Director

MO – TC 12 days 20 Central Instt. Central Instt.

MO STS/TO/SA/ 5 days 20 Identified Director

IEC 6 days 12 Central Instt. STDC

STLS Lab. Tech. 15 days 6 STDC

MPHS MPHW/ 10 days 8 STDC I/c DTC

TBHV Pharmacist 3 days 25 STDC

Trg. of Staff Drug 2 days 25 Dist. Trg. Centre

Mgt. Accountant 2 days 25 (DTC)

Community 1 day 25 DTC

Volunteer Private 1 day 25 DTC

99


Sl. No.

Types of Training Category Duration Batch Size Venue Responsibility

Practitioner 2 days 25 DTC

Pvt. LTs 20 DTC

8 DTC

Update Training EQA Trg. Update Training TB – HIV

Master Trainers & Microbiologist IRL & LTs

STDC (Dir.)/STD DTO/ MO – TC STLS LTs

Master Trainers

DTO/MO – TC MO STLS/STS

2 days

14 days

2 days 2 days 2 days 1 day

10

6

15 25 6

25

10

10 30 10

Identified Central Instt.

Identified Central Instt.

STDC STDC STDC DTC

Identified

Central Instt. STDC DTC

STDC

Director Central Instt Director STDC

Director Central Instt. Director STDC

I/c DTC

100


Retraining STO 5 days 20 Identified Central Instt.

Director Central Instt.

DTO/MO – TC 5 days 20 STDC Director

MO 3 days 20 STDC STDC

STLSSTS/ TO/ SA/IEC 3 days 6 STDC I/c DTC

Off. 2 days 20 DTC

Lab. Tech. 2 days 8 DTC MO-TU

MPHS 1 day 25 Dt/TU

MPW/TBHV 1 day 25 Dt/TU

Pharmacist 1 day 15 Dt/TU

3. Training under National Iodine Deficiency Disease Control Programme (NIDDCP)

State Programme Officer, State Technical Officer & Lab. Tech.

4 days - NICD – New Delhi/AIIHPH

- Kolkata

GOI

District Level Programme Officers, MO (PHC) & ANM

1 day -

4. Training under National Programme for Control of Blindness (NPCB)

Dt. Ophthalmic Surgeons/Medical College Faculty in IOL implantation, SICS, PHACO, Emulsification & other specialties

8 weeks 1-2 10 NGO Hospitals & Medical Colleges

GOI

101


Training in Ophthalmic Nursing (Induction)

4 weeks 10-15 Base Hospital (District Hospital/ Medical College)

State

5. Training under National Programme for Control of Blindness (NPCB)

Refresher Training for PHC MO

3 days 15-20 Medical College State

Refresher Training of PMOAs 5 days 15-20 District Hospital State

Trg. of Health Workers/ MPWs/Link workers etc.

1 day 25-30 District Hospital DBCS

Trg. of Teachers 1 day 25-30 DTC/other places

DBCS

Trg. of DPMs 2 days 15-20 State HQ GOI


102 102

102

NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME (NVBDCP) (Source: National Training Strategy for In-service under National Rural Health Mission)

National Level Training Courses

Sl. No.

Name of Training Courses/ Workshop

Category Duration Batch Size

Name of the Institution/ Venue

Responsibility

1 Tertiary level training for medical college faculty

Medical College Faculty 2 days 25 Medical Colleges Concerned Regional Director

2 Rapid Response Team on management of VBD

Members of State/ Distt Rapid Response Teams

2 days 25 AIIMS/NICD Concerned Institute

3 Trg. on Laboratory Diagnosis of JE & Dengue/ HF

Microbiologists/Lab. Technicians.

2 days 25 Apex Referral Labs./ NICD/NIMHANS

Concerned Institute

4 Trg. on Prevention & Control of VBDs

State/District Level Officers. 20 working days

25 NICD NICD

5 Trg. for Entomologists & Biologists

Entomologists/Biologists 20 working days

25 NIMR/IVCZ Hosur Concerned Institute

6 Trg. for Laboratory Technicians for Military/ Para Military Forces.

Lab. Technicians 5 days 25 To be conducted in coordination with respective organisations.

Concerned Institute

7 Trg. for Medical Officers/Military/Para Military forces

Medical Officers 2 days 25 To be conducted in coordination with respective organisations.

Concerned Institute


103 103

103

Sl. No.




Responsibility

8 Trg./Workshop on QA of District evel Programme Managers

Distt. Level Programme Managers

2 days 25 NVBDCP (Regional Level)

NIMR

9 Trg. for Programme Managers on M&E

State/Distt. Level Staff 2 days 25 NVBDCP HQ/States Specific Regional Directors

10 Entonolgical Assistants AMOs, Insect Collectors 12 days 20 IVCZ Hosur/DMRC Jodhpur

Concerned Institute

11 Trg. for Private Practitioners Private Practitioners 1 days 50 IMA HQ/States IMA concerned

12 Regional Training of State Core Team of Trainers on Clinical Management of Malaria/Dengue Japanese Encephalitis

Medical College Faculty 2 days 25 AIIMS Concerned Institute

13 Medical Officers (Secondary level) on Clinical Management of Malaria/Dengue/JE

Distt/CHC Medical Officers. 2 days 25 Medical College in Endemic areas

Concerned Medical College

State Level Training

1 Training of Medical Officers (secondary level)

Medical Officers in Districts

3 days 25 State Training Institutes

State

2 Trg of Laboratory Technicians (induction level)

Lab. Technicians. 10 days 20 State Laboratories/ RO H&FW Lab./ ICMR Institutes

State


104 104

104

Sl. No.




Responsibility

3 Trg of Lab. Technicians (re-orientation level)

Lab. Technicians. 5 days 20 State Laboratories/ RO H&FW Lab./ ICMR Institutes

State

4 Trg of Health Supervisors, Health Workers

Health Supervisors/ Health Workers

2 days 25 Block level PHC MO of block PHC

5 Trg of Community Health Workers

Community Health Workers 1 day 50 PHC MO of PHC

6 Trg of ASHAs (Proposed) ASHA 3 days 25 Block level PHC MO of block PHC

105


Model District Training Plan

Sl.

No.

Type of Facility

No. of Facilities

No. of Staff required as per the NRHM framework for

Implementation

Desired Training

Load

1. Sub – Centre 400 @ 2 ANM per SC 800

2. Primary Health Centre

60 – 70 @ 1 MO 60

(PHC) @ 3 SN 180 – 200

@ 1 PHN Practitioner 60 – 70

@ 1 Lab. Technician 60 – 70

@ 1 Pharmacist 60 – 70

3. Community Health

15 – 20 @ 7 Specialist MOs (Paed., Obs. 45 – 60

150 – 200

15 – 20

15 – 20

15 – 20

15 – 20

Centre (CHC)/First

& Gynae., Surgeon, Anaes. & 3

Referral Unit (FRU)

MOs)

@ 10 SN

@ 1 Lab. Technician

@ 1 Pharmacist

@ 1 BEE

@ 1 Radiographer

4. District Hospital (DH)

1

106


Anneuxre-IV

SUGGESTED TRAINING VENUES (Based on stakeholder consultation & desk review)

CLINICAL TRAININGS

Medical College, Haldwani, Dehradun, Sri Nagar

District Skill Lab Haridwar, Pauri, TehrI

Nursing College Dehradun, Chamoli, Nainital

AIIMS Rishikesh

FOR INDUCTION, MANAGEMENT & SOFT SKILL TRAININGS

ANM Training College U.S Nagar, Pithoragarh, Dehradun, Pauri & Chamoli

Administrative Training Institute Nainital

Indian Institute of Management Rudrapur

Divisional Health & Family Welfare Training Centre (DHFWTC)

Dehradun & Haldwani

Medical College Sri Nagar For the use of Medical colleges, it may be instructive to sign MOUs with medical colleges in the area.

107


Annexure-V

STATE INSTITUTE OF HEALTH & FAMILY WELFARE INDRA NAGAR, LUCKNOW

FOUNDATION COURSE FOR NEWLY APPOINTED MEDICAL OFFICERS

Duration- Six Weeks

OBJECTIVE

1. To provide motivation towards Administrative, Professional. Human and Medical values.

2. To make the participants familiarize with different programmes related to Medical, Health & Family Welfare and there implementation.

3. To make the participants aware about different concept of management and to provide skills.

COURSE CONCEPTS & TIME SCHEDULE

Sl. No. Topic

Part-I Medical, Health & Family Welfare Department.

1. Administrative structure and functioning : State Division- District-CHC-PHC-Grassroots Level

2. Job responsibility of PHC Staff & Ideal PHC :Criteria

3. NRHM/RCH-II- approach, different components, different new formats under CAN

4. NRHM Financial Management at PHC

5. Rogi Kalyan Samiti & Operation of Bank Account

6. Functioning of ASHA

7. Sanitation & Safe Drinking Water

8. Community participation & Role of NGOs (CBDs)

9. National Leprosy Eradication Programme

10. Blindness Control & IDD Programme

11. T.B. Programme

12. AIDS Control Programme

13. Vector Born Disease Control Programme

108


Sl. No. Topic

14. Immunization- Vaccine Storage and Cold Chain Maintenance

15. Home Based New Born Care

16. Child Care-Diahorria, Pneumonia, Malnutrition

17. Maternal Health, Institutional Delivery, PNC, ANC

18. FP Programme- Method, Counseling (Cafeteria Approach, Gather Approach) MTP Services, FP Camps

19. Fare Festival & Meals, Huz Duties

20. 21.

Monitoring and Evaluation of Programmes Population Issues & Factors affecting population growth, National Health policy, National Population Policy & State Population Policy

22. Demographic Indicators (BR, DR, DPR, IMR, MMR, NRR & Growth rate

23. Communicable Disease-Prevention & Control

24. RTI/STI Management

25. IMEP/Hospital Waste Management

Part- II Management

1. Meaning, principals and Technique of Management

2. H.R.D.- Motivation and work performance, Leadership and Team Work

3. Supportive Supervision

4. Communication: Strategy in Health & F.W. Programme

5. Decision making & Problem solving Techniques

6. Hospital Management: Emergency services, Hospital performance appraisal, Ambulance & Transportation, Medical audit, Store management, Display chart of services, Getting feedback, Hospital statistics etc.

7. Public dealing, Grievance handling and dealing with Public representatives.

8. Disaster Management & Out Break Investigation

9. Stress Management

Part-III Personnel Management and Service Procedure

1. Government servant conduct rule & M.G.O.

2. Cadre Restructuring & Division of Labor

3. Service rule and disciplinary proceedings

4. Annual Charter Role (ACR) entry

109


Sl. No. Topic

5. Reservation , Promotion, Annual increment

6. Confirmation, Voluntary retirement etc.

Part-IV Financial Procedure

1. Basic Concept of Financial Management. Functioning and Basic Rule of Treasury

2. Duties and responsibilities of DDO

3. TA/DA Rules and preparation of TA bills

4. Pay fixation, Leave rules, Loans and Advances, Pension and Other welfare schemes

5. Audit and functioning of A.G. Office

6. Store Purchase rules

7. Condemnation procedure & disposal of dead items

8. Income Tax Rules & Investment Counseling

Part-V Office Procedure

1. Noting drafting & correspondence Receipt & dispatch Filing system and Record Keeping

2. Maintenance of office records: Service book, GPF Pass Book personal file and register of registers etc.

3. Meeting, inspections, Tours and their Report Celebrations of National day & Special Day e.g. - Doctors Day, Population Day, Safe Motherhood Day etc.

Part-VI Constitution & Legal Procedures

1 Legal safeguards to public servants

2. Structure and jurisdiction of different Courts, Writ petition, Counter Affidavit, Stay order, Appeal and Contempt of Court

3. Consumer Protection Act, Food Adulteration Act, Drug & Cosmetic Act, PPNDP Act, Death- Birth Registration Act, IMA Act, RTI Act, MTP Act etc.

Part-VII Medico Legal

1. Meaning and procedure

2. Preparation of Medico Legal Report under situation like:- Accident, Injuries, Electric burn, Burn MTP, Death, Rape, Legation death, Poisoning

3. Informing Police, Keeping body in Mortuary and its disposal

4. Post-mortem

110


Sl. No. Topic

5. Dying declaration & Issuing Death Certificate

6. Treatment and referral of Convicts and under trials

Part-VIII Medical Ethics

1. Medical values and Standards, Human and Social Commitment of a Medical Practitioner

2. Doctor- Patient relation, Issuing of Certificate, Referral System and Patient’s Counseling

Part-IX Development and Planning

1 Different Development Scheme related to Medical Health & FW.

2. Intersectoral Co-ordination and Cooperation

3. Planning Process, Decentralized Planning, District Plan

4. Panchayati Raj, ICDS, Medical Health & FW

Part-X Computer and MIES

1. Use of Computer in Hospital Management

2. PMIS & HMIS

Part-XI General Arrangement

1. Registration

2. Introduction-SIHFW, Course & Curriculum

3. Self Introduction (Ice breaking)

4. Pre test

5. Visit to District Hospital Male & Female (Pre Lunch)

6. Visit to Health Directorate (Post Lunch)

7. Visit to Family Welfare Directorate (Post Lunch)

8. Post Test & Course Evaluation

9. Viva

10. Panel Discussion & Valedictory


Annexure VI

STAKEHOLDER-WISE & TRAINING WISE BUDGET

TRAINING FOR MEDICAL OFFICERS

Training Course Title Total Staff Batches Days

No. of

Trainees

per

batch

Total

Training

Days

Residential/

Non-

Residential

Place of

Training Total

A B C D E F G H I (J+K+L+M+N+O)

1 Induction Training @10% of total strength 139 5 14 30 65 Residential Regional 1,22,12,834

2 Strategic and Coordinated Management,

Monitoring, Reporting, HR management 1394 46 5 30 232 Residential Regional 5,08,11,300

3 Communication, and Liasoning Skills 1394 46 5 30 232 Residential Regional 5,08,11,300

4 Leadership, Motivation and Teamwork Skills 1394 46 4 30 186 Residential Regional 4,07,18,740

5 Medico-Legal & Ethics 1394 46 3 30 139 Residential Regional 3,06,26,180

6 Biomedical Waste Management & Infection Control 1394 46 4 30 186 Residential Regional 4,07,18,740

7 Quality Assurance 1394 46 4 30 186 Residential Regional 4,07,18,740

8 Disaster Preparedness & Response 1394 46 3 30 139 Residential Regional 3,06,26,180

9 Finance and Budgeting 1394 46 3 30 139 Residential Regional 3,06,26,180

TOTAL 32,78,70,194


SL.

No.

TRAINING FOR NURSES


No. of

Trainees

per

batch

Total

Training

Days

Residential/

Non-

Residential

Place of

Training

Total


1 Induction Training @10% of total strength 112 4 7 30 26 Residential District 15,78,321


Monitoring, Reporting, HR management 1117 37 5 30 186 Residential District 1,13,37,550

3 Communication, and Liasoning Skills 1117 37 5 30 186 Residential District 1,13,37,550

4 Leadership, Motivation and Teamwork Skills 1117 37 4 30 149 Residential District 91,14,720

5 Medico-Legal & Ethics 1117 37 3 30 112 Residential District 68,91,890

6 Biomedical Waste Management & Infection Control 1117 37 4 30 149 Residential District 91,14,720

7 Quality Assurance 1117 37 4 30 149 Residential District 91,14,720

8 Disaster Preparedness & Response 1117 37 3 30 112 Residential District 68,91,890

9 Finance and Budgeting 1117 37 3 30 112 Residential District 68,91,890

TOTAL 7,07,26,206


SL.

No.

TRAINING FOR PHARMACIST

Training Course Title Total

Staff Batches Days

No. of

Trainees

per

batch

Total

Training

Days

Residential/

Non-Residential

Place of

Training Total


1 Induction Training @10% of total strength 140 5 5 30 23 Residential District


Monitoring, Reporting, HR management 1399 47 5 30 233 Residential District 81165317

3 Communication, and Liasoning Skills 1399 47 5 30 233 Residential District 81165317

4 Leadership, Motivation and Teamwork Skills 1399 47 4 30 187 Residential District 53768233

5 Medico-Legal & Ethics 1399 47 3 30 140 Residential District 31967150

6 Biomedical Waste Management & Infection

Control 1399 47 4 30 187 Residential District 53768233

7 Quality Assurance 1399 47 4 30 187 Residential District 53768233

8 Disaster Preparedness & Response 1399 47 3 30 140 Residential District 31967150

9 Finance and Budgeting 1399 47 3 30 140 Residential District 31967150

TOTAL 41,95,36,783


Sl.

No.

TRAINING FOR MEDICAL TECHNICIANS


Staff Batches Days

No. of

Trainees

per

batch

Total

Training

Days

Residential/

Non-

Residential

Place of

Training

Total



2 Strategic and Coordinated Management, Monitoring,

Reporting, HR management 381 13 5 30 64 Residential District 42,19,575

3 Communication, and Liasoning Skills 381 13 5 30 64 Residential District 42,19,575

4 Leadership, Motivation and Teamwork Skills 381 13 4 30 51 Residential District 33,94,710

5 Biomedical Waste Management & Infection Control 381 13 4 30 51 Residential District 33,94,710

6 Quality Assurance 381 13 4 30 51 Residential District 33,94,710

TOTAL 1,86,23,280


Sl.

No.

TRAINING FOR FRONTLINE HEALTH WORKERS


Staff Batches Days

No. of

Trainees

per

batch

Total

Training

Days

Residential/

Non-

Residential

Place of

Training

Total



2 Strategic and Coordinated Management, Monitoring, 2046 68 5 30 341 Residential District 1,48,16,450

3 Communication, and Liasoning Skills 2046 68 5 30 341 Residential District 1,48,16,450

4 Leadership, Motivation and Teamwork Skills 2046 68 4 30 273 Residential District 1,19,55,460

5 Biomedical Waste Management & Infection Control 2046 68 4 30 273 Residential District 1,19,55,460

6 Quality Assurance 2046 68 4 30 273 Residential District 1,19,55,460

Total 6,54,99,280


Sl. No.

TRAINING FOR GDA


No. of

Trainees

per

batch

Total

Training

Days

Residential/

Non-

Residential

Place of

Training

Total


1 Induction Training @10% of total strength 134 4 3 30 13 Residential Block 491780

2 Communication, and Liasoning Skills 1340 45 5 30 223 Residential Block 8017666.667

3 Leadership, Motivation and Teamwork Skills 1340 45 4 30 179 Residential Block 6467733.333

4 Biomedical Waste Management & Infection Control 1340 45 4 30 179 Residential Block 6467733.333

5 Quality Assurance 1340 45 4 30 179 Residential Block 6467733.333

TOTAL 2,74,20,867

AMS Capacity Building Strategy & Plan 09.02

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