Training Needs Assessment Maternal, Newborn and

Training Needs Assessment Maternal, Newborn and Child Health In the Municipality of Covalima and Two Health Centers in Dili, Timor-Leste

Researchers: Domingos Soares, S.Kep, MM,M.Enf (PI) Ivone de Jesus dos Santos, Lic.Sp (CoI) Joaquim Soares, SKM (CoI) Sigia Osvaldinha Patrocinio, ST (CoI) Filomena de Carvalho, Lic.Sp (CoI) Maria de Fatima Moniz, Be. Cp (RA) Dr. Nazario Amaral (RA) Perpetua A.M.F.Laot, Lic.Sp (RA) Fransisco da Silva, ST (RA) Prof DR. Nelson Martins, MD, MHM, PhD (RC)

INSTITUTO NACIONAL DE SAÚDE (INS: National Health Institute) JOHN SNOW INC (JSI) 2016

TABLE OF CONTENTS TABLE OF CONTENTS ..................................................................................................................................................... 3 CHAPTER I: INTRODUCTION ......................................................................................................................................... 5 A.

Background .............................................................................................................................................................. 5

B.

Objectives of Conducting the Training Needs Assessment.............................................................................. 6

CHAPTER II : THEORY AND RESEARCH FRAMEWORK ........................................................................................ 7 A.

History and development of the health sector in Timor-Leste .......................................................................... 7

B.

Framework of the Training Needs Assessment ................................................................................................. 8 1.

Definition ............................................................................................................................................................... 8

2.

Individual indicators ............................................................................................................................................ 9

3.

Institutional indicators: ...................................................................................................................................... 12

CHAPTER III: METHODOLOGY ................................................................................................................................... 14 Population Sample ................................................................................................................................................ 14

B.

Table 1: Distribution of study participants by type of health facility where employed .............................................. 15 Table 2: Distribution of study participants by profession ............................................................................................ 15 C.

Duration and Place of Research ..................................................................................................................... 16

D.

Ethical implications............................................................................................................................................ 16

E.

Instruments used to collect data ......................................................................................................................... 16

F.

Treatment of data .................................................................................................................................................. 16

CHAPTER V DISCUSSION............................................................................................................................................ 16 A.

Results from Assessment of Individual Competencies ............................................................................... 16

1.

General Summary ..................................................................................................................................................... 16

2.

Detailed discussion of individual competencies ................................................................................................... 18 B.

Results from the institutional analysis ............................................................................................................ 22

Chapter IV: Recommendations and Conclusions .................................................................................................. 24 A. B.

Recommendations ................................................................................................................................................ 24 Conclusion .................................................................................................................................................................. 24

REFERENCES .................................................................................................................................................................. 26 APPENDICES .................................................................................................................................................................... 27

LIST OF ACRONYMS

ARH

Adolecent Reproductive Health

ANC

Antenatal Care

BEmONC

Basic Emergency Obstetric and Newborn Care

CBT

Competency Based Training

CEmONC

Comprehensive Emergency Obstetric and Newborn Care

CHC

Community Health Center

CM

Community Mobilization

CSD

Clean and Safe Delivery

DTPS

District Team Problem Solving

ENBC

Essential Newborn Care

FP

Family Planning

FUAT

Follow Up After Training

GBV

Gender Based Violence

HP

Health Post

IMCI

Integrated Management of Childhood Illnesses

INS

National Health Institute (Instituto Nacional de Saúde)

IUD

Intrauterine Device

JSI

JSI Research & Training Institute, Inc.

MLM

Mid-level Management

MNCH

Maternal, Newborn and Child Health

MOH

Ministry of Health

SoC

Standard of Care

SoP

Standard Operating Procedure

TNA

Training Needs Assessment

TLDHS

Timor-Leste Demographic and Health Survey

VCCN

Vaccine and Cold Chain Management

CHAPTER I: INTRODUCTION A. Background

1. The Institution The National Health Institute (INS) is an autonomous body within the Timor-Leste Ministry of Health (MOH). Its main mandate, as per Decree Law 09/2011, is to conduct and manage in-service training and continuing medical education for all health professionals in Timor-Leste. Most of the health professionals working in health posts (HPs), community health centers (CHCs) and hospitals regularly receive professional training, refresher courses and practice in order to improve their general health competencies. The main responsibility of INS is to provide competency based training (CBT) that ensures all health professionals in Timor-Leste have the knowledge, skills and competencies required to deliver high quality and effective health care. Currently at the INS, there are some elements of CBT in every training course. However several components are lacking, such as the execution of regular training needs assessments, carrying out of competency assessments during each training event, inadequate infrastructure and shortages of equipment, and clinical practice experiential trainings appear not sufficiently able to instill confidence in the learner to perform indicated skills in the workplace. In 2015, the INS five year (2015-2019) strategic plan was launched as part of INS‘ commitment to improve the competency and quality of in-service training and continuous medical education provision to health professionals. Competency based training is a major part of this commitment to quality health care training. One of the key activities listed under strategic priority number 7 is to conduct an annual Training Needs Assessment (TNA) (INS, 2015), with the goal of ensuring that a comprehensive training plan be developed that responds to the needs and priorities of healthworkers and the system itself. The challenge for INS in the implementation of this activity was the fact that conducting a TNA requires certain techniques and methodologies that are unfamiliar to most INS trainers. Therefore, it was important to equip INS trainers with the knowledge and skills required to design and implement a TNA. In May 2016, INS and JSI Research & Training Institute (JSI) signed a Memorandum of Cooperation (MOC) to enhance the training and institutional capacities of INS in the area of reproductive, maternal, newborn, child and adolescent health. One of the important components outlined in the MOC was for JSI to assist INS trainers in conducting a TNA for health professionals and training institutions in the municipality of Covalima, in the Comoro and Vera-Cruz Community Health Centers (CHCs) in Dili, and in the INS itself.

B. Objectives of Conducting the Training Needs Assessment The overall objectives of this TNA were as follows: 1. To identify detailed information about individual training needs in the area of maternal and child health; 2. To identify the conditions and institutional training needs required in order to offer quality maternal, newborn and child health (MNCH) trainings to health service providers. Specific objectives: 1. To identify all trainings which have been conducted in the area of MNCH; 2. To identify the rate of participation in these trainings; 3. To discover the impact that these trainings have had on participants‘ feelings of competency related to the use of skills trained upon in the workplace; 4. To analyze the implementation process of MNCH policies in the health facilities covered in this assessment; and 5. To describe the conditions found in the training institute in the area of MNCH, in order to: 1. Enable INS to better and more effectively design its training programs; 2. Assist the Ministry of Health in devising evidence-based recommendations about specific trainings that will enable better solutions to be found, as well as recommendations that are relevant in general to the MNCH program in the Ministry of Health

CHAPTER II : THEORY AND RESEARCH FRAMEWORK A. History and development of the health sector in Timor-Leste Timor-Leste is the youngest nation in Asia. It occupies one half of the island of Timor, with a geographic area of 14,610 km2 and a population of almost 1,200,000. Timor-Leste was occupied from foreign entities during 475 years – first as a Portuguese colony, briefly by the Japanese during World War II, and lastly as an annexed territory of Indonesia. On the 20th of May, 2002, Timor-Leste became once again an independent nation, after voting overwhelmingly against becoming an autonomous region of Indoneisa three years before. Currently Timor-Leste is composed of 12 municipalities and one special economic zone, 67 administrative posts, 442 villages (or ‗sucos‘) and 2,336 sub-villages (or ‗aldeias‘). The country has made great strides in development, most noticeably in the economic and security sectors, but as a young country continues to face many challenges to its development – including in the health sector. Although the road towards becoming a fully independent and stable nation has not been easy, Timor-Leste‘s development is continuing, guided by the National Strategic Development Plan. In the health sector, although some major problems still exist, some notably good results have been obtained, such as the sharp reduction in malaria cases. The National Strategic Development Plan 2011-2030 for the Health Sector has been the overall and overreaching orientation guiding the health sector during this decade. In the area of maternal, newborn and child health, continuous progress is being made since the country‘s restoration of indendence.

But although this steady progress inspires hope, there are other challenges that need to be addressed in order to achieve full MNCH coverage for all. Data from the Timor-Leste Demographic Health Survey 2009-2010 (TLDHS 2009-10) shows that ―the vast majority of Timorese are young people, with almost 42% of the population under the age of 15.‖ The fertility rate of 5.7 children per family is the highest in Southeast Asia, which means that this youth population will continue to grow. The maternal mortality rate, which has dropped in recent years, is still considered high at 557/100,000. MOH data reveals that approximately 20% of pregnant mothers are between the ages of 15-19 years. Approximately 86% of pregnant women received antenatal care (ANC) at least once, while only 55% made at least four visits to a health care worker during pregnancy—mostly to a midwife/nurse. More than 25% of women have a body mass index (BMI) of less than 18.5 kg/m2; and only approximately 30% of births are delivered by a skilled provider (doctor, midwife, nurse or assistant nurse). Timor-Leste is considered an early achiever in the reduction of the under-five mortality rate at 64 deaths per 1000 live births in 2009. If this rate is compared with the Millenium Developent Goal (MDG) 4 target of 60 deaths per 1000 live births in 2015, we can see that Timor-Leste came very close to achieving this goal (source: TLDHS 2009-10).

The total population of the Covalima municipality is 65,301 (National Bureau of Statistics, 2015). This municipality has seven administrative posts: Fatululic, Fatumea, Fohorem, Maucatar, Suai, Tilomar and Zumalai. There are 30 sucos made up of 148 aldeias. The municipality is home to seven community health centers (CHCs), one referral hospital and 16 health posts (HPs). There are a total of 176 health care professionals, including doctors, nurses and midwies, in the Covalima municipality (National Bureau of Statistics, DNRH MoH, 2015). Health facilities were first established in Covalima during the period of Portuguese colonialism, with the construction of one health center in Covalima during the last decade of colonial rule. During the Indonesian occupation a municipal health post was opened, which was later elevated to the level of hospital and given the name Rumah Sakit Umum Daerah (RSUD) Suai in 1990. After the restoration of independence in 2002 the name was changed from RSUD to the Referral Hospital of Suai. In 2016 the number and percentage of births attended by health personnel in the municipality of Covalima was 1,575 births (78%), which put it in fourth place nationally amongst the 12 municipalities and the Special Economic Zone of Oecusse. There were 39 reported pregnancy complications in Covalima in 2016, according to the draft 2017 Health Statistics Report, which was the 7th highest amount of complicated births in the nation. There were 13 stillbirths recorde amongst all the CHCs in the municipality. As these figures are relatively high, it was deemed an appropriate place to conduct a needs assessment. There are other conditions as well that need to be improved through capacity building of human resources. To reduce maternal and newborn mortality, the ―3 delays‖ of (1) making the decision to seek care, (2) reaching appropriate care, and (3) receiving adequate care should be overcome. The third delay can be partly overcome with higher competency and skills of health officials to be able to provide professional care. B. Framework of the Training Needs Assessment 1. Definition Training is ‗the process of learning skills that are needed to do particular tasks or activities‘ (Collins Cobuild English Language Dictionary, 2011). Training is a planned process focused on the exchange of knowledge, skills and behavior in order to attain a pre-determined result or ability.‘ (Tovey,M.D, 2010) According to Mangkunegara (2003), a training needs assessment (TNA) is ‗the systematic study of an educational problem using data collection methods and information from a variety of sources, in order to find a solution or elaborate recommendations about a following action‘. TNAs are also analyses of specific needs in the workplace with the hope of defining which training topics are the highest priority. The information gleened from these assessments can be used to help institutions utilize their resources (time, financial and others) efficiently and effectively, as well as helping them to avoid spending money and time on unnecessary trainings. A TNA is a type of diagnostic test implemented in order to define problems encountered at the time, as well as threats of problems that could occur in the future and that will necessitate being countered by training and development. (Rivai and Sagala, 2009 in Probosemi 2011).

Goldstein and Bukton in 2014 emphasize that determination of training needs should be decided at an organizational, position/employment and individual level, including: 1.

Analysis at the organizational level in order to identify which parts of the organization need training the most urgently.

2.

Analysis at the position/work level to identify the type of training package necessary, based on what the specific duties of each worker are and what they need to learn to be able to perform these duties.

3.

Analysis at the individual level; in order to identify which specific skills and capacities each person needs in order to perform his or her job.

According to Pangabean, 2004, Training Needs Assessments should be done with the following objectives in mind: 1.

Identify specific aspects of the job that need to be improved in order to improve performance and productivity.

2.

Analyze personal characteristics in order to guarantee that the program corresponds to individuals‘ levels of education, experience and abilities, as well as fits with his or her attitude and is motivational.

3.

Develop specific knowledge that can be measured objectively.

According to Tees, David W., You, Nicholas., and Fisher., (1987) in Idris 2014, TNAs can be divided by two important stages: the first stage is the implementation stage (Figure 1, stage 1-8) and the second stage is the analysis of results (Figure 1, stage 9-10). Figure 1. Stages of a Training Needs Assessment

STAGE 1

Define goals and objectives

STAGE 2

Define methodology

STAGE 3

Determine feasibility

STAGE 4

Develop instruments

STAGE 5

Select sample

STAGE 6

Conduct pre-test

STAGE 7

Revise instrument

STAGE 8

Conduct research

STAGE 9

Analyze data

STAGE 10

Prepare report

2. Individual indicators

This training needs assessment on MNCH was divided into two major categories: individual clinical competencies of healthworkers, and institutional indicators. Maternal, newborn and child health is a broad area, with various aspects that can be broken down into many training categories. Healthworkers have the opportunity to be trained in the following programs, which are the programs analysed in this TNA.

1. Family Planning (FP) training: Modern methods: a. b. c. d. e. f. g. h. i.

Knowing the benefits of FP, Knowing the reproductive system and its function, FP counseling, Inserting interuterine device (IUD), Providing oral contraceptive pills, Providing condoms, Inserting implants, Providing progestine injections, and Providing post-partum FP;

Natural methods: j. k. l. m.

Ovulation Billings method, Standard days method, Lactational amenorrhea method, and Two-day method.

2. Clean and safe delivery training: Basic aspects of labor and delivery a. b. c. d.

Clinical decision-making, Care of the mother and child, Infection prevention, Referrals for mother and child

First stage of labor: a. b. c. d. e.

Anamnesis, Making a physical assessment of the mother in labor, Early detection of problems and illnesses, Preparation of birthing care, and Partographs

Second stage of labor: f. g. h. i.

Preparation for assisting during childbirth, Physiological management of second stage of labor, Birthing assistance, Observation during second stage of labor,

Third and fourth stages of labor: j. Physiology of third stage of labor, k. Active management of the third stage of labor,

l. m. n. o.

Manual removal of placenta, Uterine atony, Care of and observation of fourth stage of labor, and Observation of mother‘s general condition

Essential newborn care: p. Actions to prevent infection during birthing, q. General prevention of fevers in newborns, r. Care of the umbilical cord, s. Motivation of mothers to breastfeed, t. Breast and lactation care, u. Prevention of eye infections in newborns, v. Provision of vitamin K1, w. Provision of immunization in newborns, x. Newborn assessment, Management of newborns with asphyxia a. Newborn rescusitation b. Post resuscitation care Newborn care training: i. ii. iii. iv. v. vi. vii.

viii.

ix.

x.

xi.

Universal precautions, Treatment of fever in newborns, Examination of newborns, How to get breastfeeding off to a good start, Newborn exam, Detection and management of illness in newborns, Breastfeeding mothers: 1. Successful breastfeeding, 2. Difficulties and challenges of breastfeeding, 3. Alternative breastfeeding methods, 4. Care of low birth weight babies Newborn care until discharge: 1. Rescusitation of newborns, 2. Routine care for infants before discharge, 3. Provision of intra-muscular (IM) injections. Optional infant care: 1. Provision of IM injections, 2. Kangaroo Mother Care (KMC), Home visits during pregnancy: 1. Beginning home-based infant care, 2. Interaction with the family, 3. First home visit during pregnancy, 4. Second home visit during pregnancy. Home visit after birth: 1. Supporting breastfeeding, 2. Assessment of danger signs and weighing of newborns, 3. Infant care based on assessments, 4. Care of mothers, 5. First post-natal home vist, 6. Infant care,

7. Referral assistance for mother and infant, 8. Second and third post-natal home visit. xii. Care for infants with diverse problems: 1. Care of infants in incubators; 2. Care of babies with asphyxia; 3. Care for low birth weight newborns, 4. Care of newborns with sepsis, 5. Care of newborns with jaundice c. A. B. C. D. E. F.

Basic Emergency Obstetric and Newborn Care (BEmONC): Introduction to maternal and child health, Approach to reduce maternal and newborn mortality, Gender-based violence (GBV), Infection prevention, Rapid initial assessment and Management of emergencies a. Effective preparation for emergency response, b. Initial rapid assessment, c. Principals of emergency management, d. Attending to patients in shock, e. Attending patients with breathing difficulties, G. Care of Pregnant Women: a. Basic antenatal care (ANC), b. Care for problems and complications during pregnancy (anemia, vaginal bleeding, fever, abdominal pain, etc.) H. Newborn care: a. basic intranatal care, b. Care and referrals for patients with complications, c. Basic post-partum care for mothers, d. Care for pain and complications post-partum, and e. Basic post-natal care for newborns (home visits). d. Clinical Emergency Obstetric Care e. A. B. C. D. E. F. G. H. I. J. K.

Adolescent Reproductive Health Importance of adolescent and sexual reproductive health Importance of adolescent sexual reproductive health in emergency situations Special attention to high risk adolescents Human rights, ethical and legal considerations Appropriate interventions for adolescents Motivation of communities to help prevent adolescent sexual health issues Re-integration into families and communities Consideration of legal rights of adolescents UN Convention on Child Rights Prevention of Violations of Child Rights Gender based violence

The second part of the TNA was specifically aimed at gathering information about institutional indicators of all of the health workplaces surveyed. The topics covered were as follows: 3.

Institutional indicators:

1. Management and System Administration: a. Management center b. Secretariat c. Implementation of policies and programs d. Finances e. Education and training 2. Infrastructure, equipment and supplies: i. Infrastructure support for process of service provision, education and training ii. Skill labs iii. Equipment and furniture for meetings and knowledge sharing iv. Adequate logistical support v. Availability of trainings/SoC vi. Adecuacy of SoC/ SoP for MNCH, RH and ARH work, or training subjects vii. Access to and availability of new literature and references viii. Desire of organization to learn and environment that is conducive to learning ix. Breakroom x. Toilet xi. Warehouse/storage 3. Administrative Procedures and Management System; 4. Personal qualifications of trainers.

CHAPTER III: METHODOLOGY

A. Type of Research The type of research used for the TNA were two: quantitative and descriptive studies. B. Population Sample The TNA was conducted with the following professions: 55 doctors, 78 nurses and 53 midwives, for a total of 186 health professionals. All of those who fulfilled the criteria and work in the Municipal Health Services in Covalima as well as in Comoro and Vera Cruz CHCs in Dili were part of the sample population of the TNA, as listed in Table 1 below.

Table 1: Distribution of study participants by type of health facility where employed No 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Health Facility Covalima Municipal Health Services Suai Referral Hospital Tilomar CHC Lalawa HP Foholulik HP Maucatar CHC Ogues HP Haas Ain HP Suai Vila CHC Beco HP Labarai HP Gala HP Zumalai CHC Bulu HP Beilaku HP Fatumea CHC Alas Tehan HP Fatululik CHC Fohorem CHC Dato Rua HP Dato Tolu HP Laktos HP Vera Crus CHC Comoro CHC Quarantina Fronteira Salele Matai Treatment Post Sanfuk Treatment Post Total

No. of Participants 8 53 7 3 3 6 4 2 18 6 2 2 11 2 2 4 3 5 4 1 1 1 20 13 1 2 2 186

% 4,3 28.5 3.8 1.6 1.6 3.2 2.2 1.1 9.7 3.2 1.1 1.1 5.9 1.1 1.1 2.2 1.6 2.7 2.2 .5 .5 .5 10.8 7.0 .5 1.1 1.1 100.0

Table 2 below gives a summary of the participants who took part in this study, by their profession. Table 2: Distribution of study participants by profession

C. D uratio n and Place of Research This Training Needs Assessment was conducted in Dili and Covalima during an 8 month period, beginning from the proposal design in July, 2016, until the elaboration of the final results in February of 2018.

D. Ethical implications This TNA was approved by the Ethics and Research Commission of the INS.

E. Instruments used to collect data The data collection instrument used was a checklist with closed-ended questions for the participants to complete. F. Treatment of data Data management and analysis used the following stages: data clearance, data entry (using program SSPS version 20), classification and basic description of coding, data analysis and interpretation, writing of final report on results, and the submission of the final report.

CHAPTER V DISCUSSION

A. Results from Assessment of Individual Competencies 1.

General Summary

The majority of participants in this TNA were between the ages of 18 to 65. This sample was composed of a majority of women, and the majority of these healthworkers worked in the referral hospital. It can be safely said that the largest number of healthworkers needing more training are those working in this referral hospital. When broken down in terms of specific employment, the largest number of participants needing further training were nurses, with the lowest number needing further training being midwives. This data corrolates with data from the Ministry of Health. ( DNRH, 2015). A note about competency based training Competency based training (CBT) is a way of training that allows participants to focus specifically on what they can achieve in the workplace after the course, involves hands-on practice, and includes workplace experience. Once a

CBT is completed, the participant will have the skills and knowledge necessary to complete specific health-related tasks to a specific performance standard. It is not time based – once a health worker can show that he or she has reached the target level of competency, he or she can move on to the next competency. This provides for a more efficient and hopefully more effective system of training, that will ensure health workers have enough practice, as opposed to only theoretical knowledge, that allows them to be high quality service providers. In surveying participants about their competency based training needs, participants were asked if they had ever participated in a training related to a certain relevant skill, and if they had they were then asked to rate their self-perceived level of competency in that skill. The researcher classified the responses according to the following table:

Table 3. Categories of Self-Reported Levels of Competency

The results from this study show that the majority of participants have not yet been given the opportunity to participate in trainings on management, such as on the integrated management of childhood illnesses (IMCI), district team problem solving (DTPS), and community mobilization (CM), programmatic training such as on vaccine and cold chain manageent (VCCM), adolescent reproductive health (ARH), mid-level management (MLM), and clinical training such on FP, CSD, ENBC, BEmOC, and CEmOC. This lack of training shows that the goal of providing high quality healthcare through competent health professionals, as written in the National Strategic Sector Plan for Health, 2011-2030, is still far from being reached. The results of programmatic training and clinical training will be discussed in this report, as they are the competencies most directly related to the area of MNCH. Of those who have been trained, however, we see that there is a small number of those who feel proficient in the topics trained upon, conversely, in several categories, there is no one claiming to feel proficient in that skill. For example, in the category of Clean and Safe Delivery, not one person feels proficient in the first subcategory: Basic aspects of labor and delivery. Likewise, no one feels proficient in any of the Stages of Labor. There is also no one that claims to be proficient in any of the categories related to adolescent health. As these

are core competencies of MNCH, it would be beneficial to offer follow up trainings to those who already feel competent, in order for them to further strengthen their knowledge in these areas with almost equal division between not feeling competent and feeling competent in all of the areas. In most areas across the board, less than half state that they feel competent in the areas trained upon, and of course as mentioned above, the grand majority has not undergone training on most of the skills surveyed. If we look at specific skills, we find that of those who participated in FP trainings, the majority of participants rated themselves as having had sufficient training, but not yet competent in that area (average of 36%), with the highest percent of participants feeling not competent in putting in IUDs, and the highest level of competency felt in contraceptive injections. It makes sense that the majority of participants have participated in clinical trainings related to Clean and Safe Delivery, as this indicator has by far the most clinical competencies related to it. However, the fact that there is such a high percentage of participants in the trainings of the first sub-category: Basic aspects of labor and delivery, who do not feel competent, and that there is no one who feels proficient in this competency, is worrisome, as this is the most basic core knowledge related to this category. In regards to newborn care, only an average of 11.3% of the participants feel competent in this area, but in the area of dealing with babies born with asphyxia, only 6.2% of participants felt competent to do this aspect of their work successfully. Also noteable is that no one who has been trained feels proficient in any subject related to BEmONC., and more partcipants felt incompetent than competent in all of the areas. However, it is important to remember that this data needs to be interpreted carefully, because this data does not identify how many healthworkers, especially doctors and nurses, work in the specific areas identified above, and therefore need specific trainings. The Ministry of Health‘s Human Resources Directorate and the Municipal Health Services need to work together with the INS in order to identify healthcare workers who work in the different specific areas, and consequentally design trainings for them when necessary. Another goal is that trainings help to reduce the maternal, newborn and infant mortality, that according to TLDHS 2009-10, were respectively 557/100,000, 45/1,000 and 64/1,000. With this in mind, trainings should be prioritized according to those who will most directly help to decrease mortality. 2.

Detailed discussion of individual competencies

Results from this study show that the majority of health personnel, including doctors, nurses and midwives, have not yet gone through a complete clinical training. For those who have been trained in all 5 clinical competencies expounded upon earlier in this report, more than half have stated that they received sufficient theoretical and basic skills training, but are not yet able to implement the science and skills taught in these trainings. This problem needs to be investigated and an intervention plan developed in order to guarantee that all health personnel receiving training gain enough competence to be able to implement the theory and practice taught to them.

It is hoped that the introduction of a more focused clinical supervision system introduced by INS with support from USAID‘s Reinforce Project will help training participants to implement the lessons that they received during their clinical competencies trainings. The MOH, Municipal Health Services and INS need to work together to organize trainings to health personnel who show insufficient mastery of skills and also to those who have not yet been fully trained. In this vein also the organization of follow up after training (FUAT) and introduction to clinical supervision methods will be important in order to accompany and help training participants go beyond sufficient knowledge to be able to competently apply that knowledge, and for those who are already deemed competent, support them to attain professional proficiency. Those already deemed to be proficient should be tested, and if sufficiently skilled should be recruited as trainers in order to support both trainings and clinical supervision. The percentage of healthworkers that have already participated in a programmatic training is shown in Figure 2 below. As the graph depicts, the majority (over 2/3) of healthworkers have not yet participated in a programmatic training, and amongst the four categories, very few healthworkers have received training in adolescent reproductive health (3.2% only). Nutrition is the topic that has been attended by the most healthworkers, at 28.5%. Figure 2. Percentage of healthworkers that have already participated in a programmatic training.

The results from the TNA about training in individual clinical competencies such as FP, CSD, ENBC, BEmONC, and ARH are shown in the below Figure 3. From this graphic we can see that very few participants responded that they have already undergone clinical training in: FP (24,2%), ENBC (17,2%), CSD (28,5 %), BEmONC (14%) and CEmONC (8,1%). The highest percentage is in CSD and the least is in CEmONC (less than 10%), which is needed only at the referral hospital level. Figure 3. Percentage of participants who have attended clinical trainings by topic.

For a futher breakdown of participants in clinical trainings, please see Appendix Tables. Although the majority of healthworkers have not yet participated in clinical trainings, we can further examine the results to see that from the ones who did, less than half feel competent in the sub-skills of the various topics. For example, when looking at clinical trainings about FP, we see the following breakdown of participants who selfreport as competent upon completion of the training course: Figure 4. Percentage of FP training participants that feel competent, by method:

In another example, the following is a breakdown of the components of CSD, by sub-topic, according to the percentage of participants who feel competent after participating in the referred training: The first sub-topic is basic aspects of labor and delivery: As shown in Figure 4, a little over half of the participants in all skills trainings do not yet feel competent in their abilities to work in this area. Figure 5: Percentage of CSD training Participants who do NOT feel competent in the basic aspects of labor and delivery

Figure 6 shows a summary of feelings of competency by all participants in other sub-topics of CSD, including first, second, third and fourth stages of labor, as well as newborn care and care of newborns with asphyxia. The skill that is mastered the least by participants is babies born with asphyxia, with only 25% of those trained feeling comfortable in working in this area. If this figure is looked at coupled with the fact that so many healthworkers have not yet received this training, it shows that only a very low percentage of people surveyed (less than 7%) would be able to help a newborn with this condition.

Figure 5. Percentage of CSD participants that feel competent in first, second, third and fourth stages of labor, newborn care and care of newborn with asphyxia

It should be noted that the other competencies have a similar trend – less than half of the participants feel like they are competent in the skills in which they were already trained, and in general, those competencies that are related to more emergency or problematic situations are those in which participants feel the least competent. This could have severe consequences for the maternal and infant mortality rate. For a complete list of tables see appendix.

B. Results from the institutional analysis As stated in the TNA Framework section of this report, this study explored the institutional assessment framework involving 4 competencies; (1) Management and administrative systems; (2) Infrastructure, equipment and supply; (3) Administrative procedures and management; and (4) Trainer qualifications. In preparation of conducting this TNA, researchers identified 3 institutions with the technical ability to complete this assessment, but only the INS fulfilled the criteria required by law to be a training center, while the other two are licensed to only provide healthcare services. In the area ―Management and System Administration‖, INS fulfilled eight out of the twelve criteria necessary. There are two competencies that are clearly not the responsibility of INS, and therefore do not exist at the INS, which are Secretariat, and Head of Management and Direction of Maternal NewBorn Child Health (MNCH) which is not covered under the Decree law 9/2011, which regulates the INS. In the area ―Infrastructure, Equipment and Supplies‖ INS only fulfilled 39 of the 66 written requisites. This shows that although INS already has infrastructure and basic equipment, they need to further improve in order to provide high quality training and to earn accreditation. In the area ―Administrative Procedures and Management System‖ INS has fulfilled 28 out of the 34 written criterias. This shows a positive result but needs to be improved in a manner that ensures its alignment with Decree law 9/2011 which regulates the INS.

In the area ―Qualification of Officials/Trainers‖, the INS fulfills all of the 17 written prerequisites. This shows that the INS already has a good process for preparing trainers, especially in the area of Maternal and Child Health. This level needs to be maintained in order to guarantee a high quality of clinical training on Maternal and Child Health for all health personnel, as stated in the INS official mandate. For a list of supplementary tables, please see the Appendix.

Chapter IV: Recommendations and Conclusions

A.

Recommendations 1.

It is recommended that the INS uses the results of this TNA in order to develop a training plan for healthworkers that have not yet received programmatic and clinical training. This plan should prioritize trainings based on relevance to individuals’ workplace duties, as well as ensure that each health center has at least one person trained in and feeling competent/proficient in each component of each topic.

2.

It is recommended that the INS re-organizes its programmatic and clinical training for those personnel that have not yet received sufficient training

3.

It is recommended that the INS work together with the Maternal and Child Health Deparment, the Human Resources Directorate, and the Municipal Health Services in order to implement the FUAT and introduce a system of clinical supervision, whereby a clinical supervisor accompanies and helps those participants who are still in need of further training after the training.

4.

It is recommended that the INS coordinate with the Ministry of Health in order to improve its infrastructure, equipment and distribution in order to improve and strengthen the INS as a training institute

5.

It is recommended that the INS continues to implement TNA before preparing a healthworker training plan.

B. Conclusion

The health system in Timor-Leste has greatly improved since its gaining of independence in 2002. A major factor in ensuring the quality of this health system is the capacity of its healthcare workers. In order for Timor-Leste to achieve its goals related to maternal, newborn and child health, especially those related to infant and maternal mortality, it is imperative that all healthcare workers be trained on and feel comfortable in carrying out the basic competencies related to this sector, and that all health centers have sufficient numbers of workers who are competent in dealing with all aspects of emergency and crisis care. This training needs assessment has provided the blueprint of how to map out a way for this goal to slowly and systematically become a reality. The annual administration of further TNAs will be able to track progress based on this initial baseline, as well as be flexible enough to accommodate new techniques and health knowledge that will certainly shape trainings in the future. The next step would be the development of a long term training plan, with the priorities adjusted for the information gleened in this report, and the

assurance of a solid evaluation system in place to help track the efficiency of the trainings on a more formative basis.

REFERENCES •

.......(2011), Asuhan Persalinana Bersih dan Aman, Panduan peserta, UNICEF, Ministerio da Saúde, Dili, Timor-Leste.

•

.......(2011), Asuhan Persalinana Bersih dan Aman, Buku Acuan, UNICEF, Ministerio da Saúde, Dili, Timor-Leste.

•

.......(2010), Essential Newborn Care Coures, Participants Book, UNICEF, Ministry of Health, Dili, Timor-Leste.

•

......(2014), Managing Newborn Problems, a guide for doctors, nurses and midwifes, UNICEF, Ministry of Health, Dili, Timor-Leste.

•

........(2014), Caring for the Newborn at Home, a training course for community health workers, UNICEF, Ministerio da Saúde, Dili, Timor-Leste.

•

Lembaga Administrasi Negara Indonesia (LAN) 2003, Manual Analisis Kebutuhan Diklat Aparatur Negara.

•

MoH, (2015), National Strategy on Reproductive, Maternal, Newborn, Child and Adolescent Health 2015-2019, MoH, UNICEF, UNFPA, Timor-Leste.

•

UNFPA, (2009), Adolescent Sexual and Reproductive Health Toolkit for Humanitarian Settings, Save the Children, USA.

•

……….(2007), Manual Training Needs Assessment, *asesu loron 20 Augusto 2016+.Available at: www. http://www.statpac.com/surveys/sampling.htm,

……….., (2015), Manual of Integrated Management of Childhood Illness, Ministry of Health, Timor-Leste., P. ……..(2013), Legislação Geral da Função Pública de Timor-Leste, Um Guia Explicativo.

APPENDICES I.

Distribution of participants in management trainings

Annex Table 1: Participation in management trainings: total

Annex Table 2: Participation in management trainings by workplace: No

Health facility

IMCI

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Yes Covalima CHC 2 Suai RH 9 Tilomar CHC 3 Lalawa HP 1 Foholulik HP 0 Maucatar CHC 1 Ogues HP 1 Haas Ain HP 0 Suai Vila CHC 5 Beco HP 1 Labarai HP 0 Gala HP 0 Zumalai CHC 3 Bulu HP 0 Beilaku HP 0 Fatumea CHC 0 Alas Tehan HP 0

No 6 44 4 2 3 5 3 2 13 5 2 2 8 2 2 4 3

Σ

8 53 7 3 3 6 4 2 18 6 2 2 11 2 2 4 3

DTPS

Yes 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 2 0

No 8 53 7 3 3 6 4 2 17 6 2 2 11 2 2 2 3

Σ

8 53 7 3 3 6 4 2 18 6 2 2 11 2 2 4 3

Community Mobilization Yes 1 1 0 0 1 0 0 0 2 0 0 0 1 0 0 0 0

No 7 52 7 3 2 6 4 2 16 6 2 2 10 2 2 4 3

Σ

8 53 7 3 3 6 4 2 18 6 2 2 11 2 2 4 3

18 19 20 21 22 23 24 25 26 27

Fatululik CHC Fohorem CHC Dato Rua HP Dato Tolu HP Laktos HP Vera Crus CHC Comoro CHC Quarantina Fronteira Salele Matai Treatment Post Sanfuk Treatment Post Total %

1 2 0 0 1 1 4 0

4 2 1 1 0 19 9 1

5 4 1 1 1 20 13 1

0 0 0 0 0 0 0 0

5 4 1 1 1 20 13 1

5 4 1 1 1 20 13 1

1 1 0 0 0 0 0 1

4 3 1 1 1 20 13 0

5 4 1 1 1 20 13 1

0

2

2

0

2

2

0

2

2

0

2

2

0

2

2

0

2

2

35 151 186 3 183 186 9 177 18.8 81.2 100 1.6 98.4 100 4.8 95.2

186 100

Regarding the place of work of participants who have already received management trainings in integrated management of

childhood illnesses (IMCI), district team problem solving (DTPS) and Community Mobilization (CM), the above table show

that the majority of participants work at the Reference Hospital in Suai, followed by those who work at the Community Hea Center in Vera Cruz. Annex Table 3: Participation in management trainings by profession: No

1 2 3 4 5 6 7 8 9

Profession

General doctor Nurse S1 Nurse D3 Nurse D1 Midwife S2 Midwife S1 Midwife D3 Midwife D1 Nurse SPK Total

IMCI

Yes 2 0 3 4 0 1 6 10 9 35

No 53 8 22 6 1 1 22 12 26 151

Σ

DTPS

Yes 55 0 8 0 25 0 10 1 1 0 2 0 28 0 22 1 35 1 186 3

No 55 8 25 9 1 2 28 21 34 183

Σ

Community Mobilization

Yes 55 1 8 0 25 0 10 2 1 0 2 0 28 2 22 0 35 4 186 9

No 54 8 25 8 1 2 26 22 31 177

Σ

55 8 25 10 1 2 28 22 35 186

When looking at the different types of health professions held by the participants, the data in the above table 3 shows that 81

% of medical professionals that participated in the survey, including doctors, nurses and midwives, has not yet received IMC training. In the same table it is revealed that 96% of the doctors, 84% of the nurses and 70% of the midwives have not yet

participated in this IMCI training. Clearly this shows that those in the profession that have benefitted the most from IMCI

training are the midwives, compared to the nurses and doctors, even though they only represent 32% (total of 17 persons) ou of a total of 53 midwives. But if we look at the DTPS and MK training, almost no doctors, nurses or midwives have yet

attended. Interestingly, those with a degree of D1 show a much higher probability of having been through this training, whic could infer that D1 training itself has a IMCI training component in it, and could also explain the higher percentage of midwives who have already participated in this training. Annex Figure 1: Participants in IMCI training, by profession:

Midwives

Nurses

Doctors

16%

4%

32%

68% 84% 96 Participated in IMCI traininig

have participated

participated in ICMI training

have not participated



II.

Distribution of participants in programmatic trainings:

Annex Table 4: Participation in programmatic trainings (VCCM, MLM, ARH, and Nutrition) by topic:

Option Yes No Total

No. Part. VCC M 54 132 186

%

No. Part. MLM 23 163 186

29.0 71.0 100

% 12.4 87.6 100

No. Part. % ARH 6 3.2 180 96.8 186 100

No. Part. Nutrition 53 133 186

% 28.5 71.5 100

Annex Table 5: Participation in Programmatic Trainings by Profession: No Profession 1

General doctor

2 3

Nurse S1 Nurse D3

Yes 11

VCCM No Σ 44 55

ML Yes NoM Σ 3 52 55

ARH Yes No Σ 1 54 55

Nutrition Yes No Σ 16 39 55

0 9

8 16

0 5

0 0

1 11

8 25

8 20

8 25

8 25

8 25

7 14

8 25

4 5 6 7 8 9

Nurse D1 Midwife S2 Midwife S1 Midwife D3 Midwife D1 Nurse SPK Total

5

5

10

4

6

10

1

9

10

3

7

10

1

0

1

0

1

1

0

1

1

0

1

1

2

0

2

0

2

2

0

2

2

0

2

2

8

20

28

5

23

28

0

28

28

7

21

28

3

19

22

0

22

22

0

22

22

5

17

22

15

20

35

6

29

35

4

31

35

10

25

35

54

132

186 23

133

186

163 186 6

180 186 53

This table shows a clear difference between types of programmatic training frequency amongst all 3 categories of professions. 29% of health professionals have been trained in VCCM and 28% have been trained in nutrition. However, only 12% have been trained in mid-level management, and only 3% have been trained in Adolescent Reproductive Health. It is interesting to note that all of the university-level midwives have been trained in VCCM, while none of the university-level nurses have. A breakdown by professions on VCCM and Nutrition programmatic trainings is below: Annex Figure 2: Participation in Programmatic VCCM Trainings by Profession:

Nurses Midwives

Doctors

20% 80%

37%

have particip ated have not particip ated

63%

Have partici pated Have not partici pated

Have particip ated 30% 70%

Annex Figure 3: Participation in Programmatic Nutrition Trainings by Profession:

Have not particip ated

Midwives Doctors Nurses

15%

23%

29% 77% 71% 3.2

Participated Have not participated

Participated

Have participated

Have not participated

Have not participated

Clearly there has been a large discrepancy in nutrition trainings, with nurses having a much weaker background in nutrition, and midwives much more likely to be trained in this programmatic component.

III.

Distribution of Participants in Clinical Trainings

Annex Table 5: Participation in Clinical Trainings, Totals:

Option

Yes No Total

No. Part % Family Planning 45 24.2 141 75.8 186 100

No. Part % ENBC

No. P % CSD

32 154 186

53 133 186

17.2 82.8 100

No. Part % BEmOC

28.5 26 71.5 160 100 186

14.0 86.0 100

No. Part CEmOC

%

15 171 186

8.1 91.9 100

Appendix Table 6: Participation in Clinical Trainings (FP, ENBC and CSD) by Workplace:

No

Health Facility

1

Covalima CHC

FP Yes 1

Σ

2 3

Suai RH Tilomar CHC

9 2

44 5

53 7

11 0

42 7

53 7

17 4

36 3

53 7

4 5

Lalawa HP Foholulik HP

2 1

1 2

3 3

0 1

3 2

3 3

2 1

1 2

3 3

No 7

Σ

8

ENBC Yes No 1 7

8

CSD Yes 2

Σ No 6

8

6

Maucatar CHC

1

5

6

0

6

6

0

6

6

7 8

Ogues HP Haas Ain HP

2 0

2 2

4 2

1 0

3 2

4 2

1 0

3 2

4 2

9

Suai Vila CHC

6

12

18

5

13

18

7

11

18

10 11

Beco HP Labarai HP

1 0

5 2

6 2

0 0

6 2

6 2

2 1

4 1

6 2

12 13

Gala HP Zumalai CHC

1 1

1 10

2 11

0 1

2 10

2 11

0 3

2 8

2 11

14 15

Bulu HP Beilaku HP

0 1

2 1

2 2

0 0

2 2

2 2

0 0

2 2

2 2

16

Fatumea CHC

0

4

4

0

4

4

1

3

4

17

Alas Tehan HP

0

3

3

0

3

3

0

3

3

18

Fatululik CHC

1

4

5

0

5

5

2

3

5

19

Fohorem CHC

1

3

4

1

3

4

1

3

4

20

Dato Rua HP

0

1

1

0

1

1

0

1

1

21

Dato Tolu HP

0

1

1

0

1

1

1

0

1

22

Laktos HP

0

1

1

0

1

1

0

1

1

23

Vera Cruz CHC

7

13

20

5

15

20

4

16

20

24

Comoro CHC

7

6

13

6

7

13

4

9

13

25

Border Quarantine Salele

0

1

1

0

1

1

0

1

1

26

Matai Treatment 1 Post

1

2

0

2

2

0

2

2

27

Sanfuk Treatment Post

0

2

2

0

2

2

0

2

2

Total

45

141

186

32

154

186 53

%

24.2

75.8

100

17.2

82.8 100 28.5

133 186 71.5 100

Appendix Table 7: Participation in Clinical Trainings (BEmOC and CEmOC) by workplace:

No

Health Facility

BemOC Yes

Total

CEmOC

No

Yes

1

Covalima CHC

0

8

8

0

No 8

2

Suai RH

10

43

53

10

43

Total

8 53

3

Tilomar CHC

1

6

7

1

6

7

4

Lalawa HP

0

3

3

0

3

3

5

Foholulik HP

0

3

3

0

3

3

6

Maucatar CHC

0

6

6

0

6

6

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Ogues HP Haas Ain HP Suai Vila CHC Beco HP Labarai HP Gala HP Zumalai CHC Bulu HP Beilaku HP Fatumea CHC Alas Tehan HP Fatululik CHC Fohorem CHC Dato Rua HP Dato Tolu HP Laktos HP Vera Cruz CHC Comoro CHC Border Quarantine Salele Matai Treatment Post Sanuk Treatment Post Total %

0 0 4 0 0 0 2 0 0 1 0 0 1 0 0 0 3 4 0 0 0 26 14

4 2 14 6 2 2 9 2 2 3 3 5 3 1 1 1 17 9 1 2 2 160 86

4 2 18 6 2 2 11 2 2 4 3 5 4 1 1 1 20 13 1 2 2 186 100

4 2 17 6 2 2 11 2 2 3 3 5 4 1 1 1 19 12 1 2 2 171 91.9

4 2 18 6 2 2 11 2 2 4 3 5 4 1 1 1 20 13 1 2 2 186 100

0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 0 0 0 15 8.1

From these two tables above one can see that 4/5 (36 out of 45) of all health facilities surveyed has at least one person trained in family planning, and that the worst case in terms of distribution of clinical trainings is Comprehensive Emergency Obstetric and Newborn Care, with only 21 out of the 45 workplaces surveyed not having anyone trained in this component. A look at the figure below shows the comparison: Annex Figure 4: Number of health facilities with at least one staff trained in clinical competencies, out of 45 total facilities:

45 40 35 30 25 20 15 10 5 0

36

34 27

Family Planning

26

ENBC

CSD

24

BEmONC

CEmONC

Appendix Table 8: Participation in Clinical Trainings by Profession:

No 1 2 3 4 5 6 7 8 9

Profession Family Planning General Doctor Nurse S1 Nurse D3 Nurse D1 Midwife S2 Midwife S1 Midwife D3 Midwife D1 Nurse SPK Total

ENBC

CSD

BEmOC

CEmOC

Yes No 2 53

Σ 55

Yes 5

No 50

Σ 55

Yes No 21 34

Σ 55

Yes 0

No 55

Σ 55

Yes 1

No 54

Σ 55

0 1 2 1

8 24 8 0

8 25 10 1

0 1 0 0

8 24 10 1

8 25 10 1

0 0 0 1

8 25 10 0

8 25 10 1

0 0 1 0

8 25 9 1

8 25 10 1

0 0 0 0

8 25 10 1

8 25 10 1

2

0

2

1

1

2

1

1

2

1

1

2

0

2

2

15

13

28

10

18

28

11

17

28

8

20

28

3

25

28

17

5

22

15

7

22

16

6

22

16

6

22

11

11

22

5

30

35

0

35

35

3

32

35

0

35

35

0

35

35

45

141 186 32

154 186 53

133 186 26

160 186 15

171 186

From this table we can see that: 1. There are no nurses with a university level degree (S1 or S2) that have been trained in ANY of the clinical competencies listed in the above table. 2. No nurses at all have been trained in either BEmOC or CEmOC. 3. Midwives have by far received the most amount of Family Planning (66%) and ENBC (49%) training, compared to doctors (4% and 9% respectively), and nurses (10% and 1% respectively). 4. Midwives in general have received the most CSD training (55%) compared to doctors (38%) and nurses (4%). IV.

Self-perception of competency in clinical training areas:

Annex Table 9: Self-perception of competency in the clinical training area of family planning:

Level of competency

Benefits of Family Planning

Reproductive System and its Function

Family Planning Counselling

Fertility Based Awareness Method

Intrauterine

F

%

F

%

F

%

F

%

F

%

142

76.3

146

78.5

143

76.9

148

79.6

148

79.6

Yes, not sufficient 9

4.8

6

3.2

4

2.2

7

3.8

8

3.8

Yes, sufficient but 23 not competent

12.4

22

11.8

16

8.6

19

10.8

18

10.2

Yes, competent

12

6.5

12

6.5

23

12.4

11

5.9

11

5.9

Yes, proficient

0

0

0

0

0

0

1

0.5

1

0.5

Total

186

100

186

100

186

100

186

100

186

100

None

Device (IUD)

Annex Table 10: Self-perception of competency in skills related to Clean and Safe Delivery

Level of competency

Clinical decision making

Mother and Newborn Care

Prevention of Infection

Mother and Newborn Referral

F

%

F

%

F

%

F

%

None

133

71.5

133

71.5

129

69.4

129

69.4

Yes, not sufficient

4

2.2

0

0

2

1.2

0

0

Yes, sufficient but not competent

25

13.4

27

14.5

28

15.1

32

17.2

Yes, competent

24

12.9

26

14

27

14.5

25

12.9

Yes, proficient

0

0

0

0

0

0

0

0

Total

186

100

186

100

186

100

186

100

Annex Table 11: Self-perception of competency in skills related to Essential Newborn Care: Level of Competency None

Universal Precaution (PI) F % 148 79.6

Newborn care F % 149 90.1

Fever in newborns F % 149 80.1

Yes, not sufficient

4

2.2

2

1.1

2

1.1

Yes; sufficient but not competent Yes, competent

18

9.7

20

10.8

20

10.8

15

8.1

14

7.5

15

8.1

Yes, proficient

1

1

0.5

0

0

186

100

186

100

Total

186

0.5 100

Annex Table 12: Self-perception of competency in skills related to Basic Emergency Obstetric Care (BEmOC):

LevelLevel of of competenc competency y

Introduction toto Introduction essential essential maternal and maternal and child care child care F 157

None Yes, not Nonesufficien t

Yes, competent Yes,

Yes, proficient competent

Total

Yes, proficient

158

84.9

160

86.0

57

84.4

157

84.4

%

F

%

5155

2.7 84.4

5

2.7

17

9.1

7

3.8

0

0

F

%

F

%

F

%

F

157 8

84.44.3

1585

2.7 84.9

8 160

4.3 86

5 57

4.3

5

2.7

8

4.3

7.5

15

8.1

3.8

8

Yes, not sufficient 8 Yes; Yes, sufficient sufficientbut but not not competent competent

% 84.4

Approaches toto Gender based for for women Infection Approaches Gender based Care Care Infection reduce violence (GBV) Prevention reduce violence women Prevention maternal and maternal and (GBV) child mortality child mortality rates F % F % F % F % rates

14

14

7

7

0

0

186

186

7.5

3.8

0

0

100

100

0

15

8

8.1

13

186

186

2.7

13

7.0

7

15

4.3

5

2.7

9

9

4.8

0

0

0

0

0

4.3

0

5

2.7 84.4

0

100

5 0

186

100

2.7

186

0

100

100

15

0

186

186

8.1

8.1 4.8 0

17

9.1

7

3.8

0

100

100

0

186

186

100

100

Annex Table 13: Self-perception of competency in skills related to Adolescent Reproductive Health: Level of competency

Importance of the focus on sexual adolescent and reproductive health

Adolescent sexuality and reproductive health in emergency situations

Necessary Human rights, knowledge of the ethical and legal subgroup of concentration adolescents who are at risk and need of special attention

F

%

F

%

F

%

F

%

None

184

98.9

184

98.9

184

98.9

185

99.5

Yes, not sufficient

1

0.5

1

0.5

1

0.5

0

0


1

0.5

1

0.5

0

0

0

0

Yes, competent

0

0

0

0

1

0.5

1

0.5

Yes, proficient

0

0

0

0

0

0

0

0

Total

186

100

186

100

186

100

186

100

Level of

Need for acceptable and appropriate

What you need to know about how to mobilize

How to reintegrate into the family or

competency

interventions for adolescents

parents and communities in the prevention of adolescent pregnancy

community

F

%

F

%

F

%

None

185

99.5

184

98.9

185

99.5

Yes, not sufficient

0

0

1

0.5

1

0.5


0

0

0

0

0

0

Yes, competent

1

0.5

1

0.5

0

0

Yes, proficient

0

0

0

0

0

0

Total

186

100

186

100

186

100

V.

Institutional Analysis

Annex Table 14: Management and Administrative Systems Service Performance No Service Performance

Description

1

Management Center

2

Secretariat

3

Implementing Agency Policy and Program

Institutional Leadership (DE, Director SSM, DE HR) Secretariat, Chief of Executive Director/ Repreentative delegation Representative delegation Department head Agency head Treasurer Head of financial management Directorate of Maternal and Newborn Child Health (MNCH) has programs and does socialization about SMI, SR, SA INS makes

4

5

Finances

Service system/ education/training

INS Yes

No

√

SSMC Yes No

HRS Yes

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√ √

√ √ √

No

√

√ √

√ √

√

√

√

√

Subtotal (12 standards)

curriculum/ modules/and training

8

2

5

5

7

3

Annex Table 15: Work performance: Infrastructure, Equipment and Supply No

Work performance

Description

Building and workspaces 1. Office for the director of training/educatio n coordinator 2. Conference or meeting room 3. Workspace for computers and IT 4. Library Infrastructure that 5. Storage facilities for supports the equipment, process 1 of education/ simulator, models training provision anatomy 6. Breakroom 7. Space for practice and simulation (competency on models) 8. Special area for bedside training 9. Space for practice with patients 10. Changing or locker room

INS Yes

SSMC No

√

Yes

HRS No

Yes

√

No

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

Sub Total: 10 standards 1.Rules adjusted according to the type of training

2

3

INS/ CHRD: Skills lab

Furniture and equipment for meetings and knowledge transfer

4

6

2

8

3

7

√

√

√

2. Area that accomodates at least six people

√

√

√

3. Simulation and practice schedule exists

√

√

√

4. Security system and keys exist for each room

√

√

√

5.There are training packages, equipment and references to support each training

√

√

√

Sub Total (5 standards)

2

5

2

3

0

1. White board (hung on wall or easel) 2. LCD projector 3. Computer

√

√

√

√

√

√

4. Display screen 5. Video/ DVD/ Blueray player 6. TV 7. Flipchart 8. External hard drive, CD/ DVD-RW for learning materials 9. Audio Set 10. Water dispenser 11. Temperature regulator/fan

√

√

√

√

√ √ √ √

√ √ √

3

√

√ √

√

√

√

√

√

√

√

√

√

√

√ √ √

4

5

6

Adequat e logistics

Availability of training/ SoC

SoC/ SoP adequate for provision of SMI, SR and SA work or training materials

Sub Total (11 standards) 1. Paper, cardboard, flipchart 2. Writing equipment for flipchart 3. Writing equipment for white board 4. Notebook, pens or pencils, folder set 5. Clips for flipchart Sub Total (5 standards)

8

3

9

2

4

√

√

√

√

√

√

√

√

√

√

√

√

√

√ √ 4

1

5

1. Clinical work guide

√

√

1. SoP/ Clinical 2. work guide Participant guidebook/manu al 3. Guidebook/manual for trainer

V √

V

0

5

7

0

√

√

V

√

√

√

√

4. Work or qualification guide

√

√

√


4

1. SoC/ SoP MNCH 2. SoC/ SoP for Reproductive health 3. SoC/ SoP for Adolescent health 4. SoC/ SoP for Newborn care 5. SoC/ SoP for BEmONC 6. SoC/ SoP for CEmONC 7. SoC/ SoP for Family Planning (updated contraceptive technology)

0

1

3

1

3

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

√

7

8

Access to and availability of literature and updated references

Organizatio n that wants to learn (about the program) or environmen t conducive to learning

8. SoC/ SoP for IMCI, Nutrition, LSS Sub Total (8 standards) 1. Minimum of 5 new literatures or references every year 2. Availability of Access to new information through the internet 3. Subscription to new editions or updates to the management or program manual Sub Total (3 standards)

Breakroom

6

√ 2

8

√ 0

√

√

√

√

√

2

1

0

√

√

√

0

3

8

√

1

2

1.Shared vision

√

√

√

2. Mental model

√

√

√

√

√

√

√

√

√

√

√

√

√

√

3. System of thinking 4. Mastery of subject matter 5. Learning team 6. Humanistic techniques/rol e model/adult learning Sub Total (6 standards) 1. Dimensions of room follow the criteria 2x2x3/ per person

9

√

2. Clean, comfortable and with privacy 3. Sufficient ventilation or there is equipment to measure the temperature

0

6

0

√

6

1

√

√

√

√

√

√

√

√

√

5

10

Toilet facilities

Sub Total (3 standards) 1. Dimensions follow standard criteria and are clean 2. There is running water or a place for putting water 3. Toilets with sufficient water and functioning Sub Total (3 standards) 1. Dimensions follow standard

2. Security/keys 3. Sufficient space to store things, and training equipment 4. Inventory and Schedule of things Storage room stored 5. Places and things are clearly labelled 6. Register of things going out and being returned Sub Total (6 standards)

11

0

3

0

3

3

√

√

√

√

√

√

√

√

√

3

0

3

0

3

√

√

√

√

√

√

√

√

√

√

√

√

√

√

0

0 √

√

6

0

√ √

6

0

4

2

Annex Table 16: Qualification of officials and trainers

No

Work performance

Description

INS Yes

Official 1. Has been trained 2. Competent for work and has the required abilities

SSMC No

Yes

HRS No

Yes

√

√

√

√

√

√

No

Qualification process for 1 Officials /trainers

3. Has completed qualification process as an official/educator/train er 4. Capable of fulfilling role 5. Is a valued official/educator/train er 6. Trains at grassroots level and also to civil servants/ participants Sub Total (6 standards)

Management of the implementing SoC/ training 2 process/ training of the implementing official/ educator/ trainer

1.There is documentation of work processes/education/ trainings 2. Every official/educator/ trainer can use the traiing modules/SoC/training 3. There are systems package and mechanisms for performance evaluation of work/training participants/trainers 4.Established mechanisms to give feedback to officials, participants, and trainers Sub Total (4 standards)

√

√

√

√

√

√

√

√

√

√

√

√

6

-

6

-

6

√

√

√

√

√

√

√

√

√

√

√

4

0

4

0

√

0

3

1

3

4

System and mechansm of documentation of work performance of officials/ teachers/ trainers

1. Evaluation forms filled out for officials/teachers/ trainers, that includes a section to give feedback from officials, participants 2. Mechanism and trainers established to evaluate data and feedback about officials’ work performances 3. System established to recognize and value officials’, teachers’ and trainers’ work 4. Involvement in every knowledge transfer activity/work performance improvement/ participants and trainers

Sub Total (4 standards) 1. Be aware of and maintain performance of civil servants’ work knowledge and abilities/ participants and trainers in the work place Activity plan 2. Access to scientific for health references and skills officials in the through media, office/ literature, courses, participants/ trainings, internships, trainers additional education, both in country and out of country 3. Access to learning through use of the computer, learning from assistance modules, medical sites and electronic journals, etc.

√

√

√

√

√

√

√

√

√

√

√

4

0

√

3

√

1

√

1

√

√

√

√

√

√

√

- 45 -

3


3

0

Grand Total (17 standards) Level of criteria based on the institution (A+B+C+D)

- 46 -

1

2

3