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					            REGIONAL CENTRE FOR QUALITY OF HEALTH CARE

                                 IN COLLABORATION WITH

                 MINISTRY OF HEALTH AND SOCIAL WELFARE, TANZANIA




    REPORT ON FOLLOW UP OF SERVICE PROVIDERS TRAINED IN
                 QUALITY FAMILY PLANNING




     VENUE: Kibaha, Kisarawe and Mkuranga Districts, Coast Region, Tanzania

       DATE: 2nd - 12th November , 2009




COMPILED BY:
Dr. Anthony Okkoth - Consultant
Mr.Maurice Hiza – Consultant
Mary-Ani Lema-Consultant
Mrs. Grace Chuwa – Regional Family Planning Trainer, Coast Region, Tanzania
Contents                                                                                                           Page Number
i    Abbreviation ..................................................................... Error! Bookmark not defined.3
       1.0 Background to the follow-up .................................................................................... 5
       2.0 Methodology used for follow- up ............................................................................. 7
(ii) cknowledgements...........................................................................................................4

    3.0      ASSESMENT OF THE PERFORMANCE OF THE LEARNERS ........................................ 8
       3.1 Report on the status of the quality of care provided in the unit where the former
       trainees work. ................................................................................................................. 8
       3.2 Report on the extent to which the trainees have been able to execute their work
       plans .............................................................................................................................. 12
       3.3 Report on identified best practices observed: ....................................................... 13
    4.0 DEETERMINE THE EXTENT TO WHICH TRAINEES HAVE BEEN ABLE TO ADDRESS
    THEIR PEFORMANCE GAPS ............................................................................................... 13
       4.1      Gaps Identified During Follow Up ....................................................................... 13
       4.2      Extent to which the trainees have been able to address these gaps. ................ 14
       4.4      Gaps that would be best addresses by formal training ...................................... 14
       4.4      Suggestions from the learners on how the training can be improved to further
                improve the capacity to strengthen quality of family planning care in their units
                when they return home ...................................................................................... 15
       4.5       List of training needs of learners with regard to strengtherning them in being
                able to provide quality care ................................................................................ 15
    5.0 PROVIDE SUPPORT FROM THE LEEARNERS TO STRENTHEN THEIR CAPACITY TO
    FURTHER IMPROVE THE QUALITHY OF FAMILY PLANING CARE IN THEIR UNITS ............. 16
    5.1: Continuing Medical Education (CME) Training .......................................................... 16
       Goals ............................................................................................................................. 16
       Objectives...................................................................................................................... 16
       Rationale For The Topics Chosen .................................................................................. 16
    5.2 The CME training process: .......................................................................................... 16
       5.2.1        Course Core Content ....................................................................................... 17
       5.2.2        Findings of the CME training:...................... Error! Bookmark not defined.13
    6.0      APPENDAGES .......................................................................................................... 18
                      Appendix A:            List of Participants / Consultants / Facilitators
                      Appendix B:            Schedule for Continued Medical Education (CME): Nov. 11 &
                      12th, 2009
                      Appendix C:            Table 1- Pre and Post test results for February and Nov 2009.
                      Appendix D:            Pre and Post test questionnaires and Answer key
                      Appendix E:            Work Plans



                                                                                                                                            2
(i)Abbreviations

CO                 Clinical Officer
CME                Continuing Medical Education
FP                  Family Planning
MOH & SW           Ministry of Health and Social Welfare
NM                 Nurse Midwife
RCHS               Reproductive and Child Health Section
ZRCHco             Zonal Reproductive and Child Health Coordinator
RRCHco             Regional Reproductive and Child Health
RCHco              Reproductive and Child Health Coordinator
CPAC               Comprehensive Post Abortion Care
RHMT               Regional Health Management Team
CHMT               Council Health Management Team
HMT                Hospital Management Team
RMO                Regional Medical Officer
RNO                Regional Nursing Officer
AMO                Assistant Medical Officer
OJT                On the Job Training
IUCD               Intrauterine Contraceptive Device
MSD                Medical Store Department
HMIS               Health Management Information System
FS                 Facilitative supervision
IPC                Infection Prevention and control
NO                 Nursing Officer
SCO                Senior Clinical Officer
ZTC                 Zonal Training Centre
USAID              United States Agency for International Development
RCQHC              Regional Centre for Quality of Health Care




                                                                        3
(ii) Acknowledgement

Consultants who facilitated the Follow up of Service Providers from Kisarawe and Mkuranga
Districs of Coast region, Tanzania who were trained in Quality Family Planning would like
to acknowledge the management and staff of Regional Centre for Quality of Health Care
(RCQHC), based in Kampala, Uganda for conceptualizing and organizing the follow –up
exercise assessing the extent to which trainees have applied the knowledge and skills
gained during the training and provide them with necessary technical support (input/
updates) and and thus further strengthern the capacity of front line service providers in
effective management of family planning clients for high quality of care

 In addition, the team of consultants would like to acknowledge the Ministry of Health
and Siocial Welfare (MOHSW), Tanzania specifically the Family Planning Unit of the
Reproductvie Child Health Section (RCHS) under the Directorate of Preventive Health
Services of the Ministry of Health and Social Welfare for working tirelessly in collaboration
with the RCQHC officials to plan, prepare, coordinate and facilitate the follow up exerccise.

 Both RCQHC and the RCHS of the MOHSW are also acknowledged for provision of follow
up tools materials, moral and technical support during the actual implementation of the
field work follow up at trainees worksites.

The team would also like to express its sincere gratitude to USAID East Africa for funding
the training through RCQHC and USAID Tanzania Mission for provision of concurance
permisiion

Special thanks go to he following individuals:
            Dr. Kidza Yvone Mugerwa – Maternal, Neonatal and RH advisor from
               RCQHC, Kampala, Uganda for coordinating the whole process from
               planning, preparation and monitoring of the follow up.

              Dr Okoth Ndira Anthony - Obstetric and Gynaecology specialist from
               Kampala Ugand for providing guidance to the National level Facilitators
               during the actual follow up exercise

              Dr. Neema Rusibamayila - Assistant Director- RCHS of the MOHSW for
               provision guidance and moral support to the follow up team during
               planning and actual field work
.
We also appreciate the contribution of Coast Regional Health Management Team (RHMT)
and Council Health Management Teams (CHMTs) of Kisarawe and Mkuranga Districts for
guidance and moral support

Last but not the least, we thank the participants of the Qualiy Family Planning training for
their diligence, interest to learn and readiness to share their experiences during the two
days training.




                                                                                               4
1.0 Background to the follow-up

The Regional Centre for Quality of Health Care is currently involved in a multi-year project
that aims at developing quality of care skills, supervision and monitoring in Family Planning
services in East Africa.

 In November 2007, RCQHC convened a group of regional FP experts in Nairobi to design a
training course that would introduce FP supervisors to issues of quality of care such as
elements of quality, designing quality monitoring quality, leadership for quality FP, and
being a facilitative supervisor. The course has been given in 4 East and central African
countries in cooperation with the respective country ministries of health and or the
national associations of obstetrics and gynecologists.

In February 2009 RCQHC in collaboration with the Ministry of Health and Social Welfare
trained 20 frontline family planning service providers from Kisarawe and Mkuranga
districts in Tanzania.

The training was intended to strengthen the capacity of health workers to design, deliver
and manage quality family planning services. In the immediate post training evaluation,
trainees demonstrated marked improvement in knowledge of the subject. Trainees also
identified a number of performance gaps that they purposed to address on return to their
health facilities.

The training was very important for Tanzania, because Family Planning momentum in
Tanzania has slowed consideraly since 1999. Whilst modern methods prevalence increased
from 6.6 % to 13.3 % in 1999, the annual increase in prevalence dropped to 0.2 parcentage
per year, with prevalence reaching only 26.4 % in 2004 – 2005.

The annual percentage increase in modern method use dropped by half from 1.5
percentage points per year ( from 1992 to 1999) to 0.6 points (from 1999 to 2004-2005)
A current family planning objective identified in the Tanzania Ministry of Health and Social
Welfare’s National Road Map Strategic Plan to Accelerate Reduction of Maternal and
Newborn Deaths in Tanzania( One Plan) 20-06 – 2015 is to increase Contraceptive
Prevalence Rate from the current 20 % to 60 % by the year 2015

A number of factors appear to account to Tanzania’s loss of momentum.
These include waning of the program’s visibility and subsequently resources,
decentralizing responsibility of delivery of basic health services ( including Family Planning)
to the district council level, integrating the family planning program into a broader
Reproductive and Child Health Section (RCHS) and the subsequent integration of the RCHS
into a broader health- sector program, shifting donor funding from targeted geographic
programs or commodities to the basket, and launching the Poverty Reduction Strategy
Program, in which there is only one indicator for Family Planning.
These resulted to iadequate quality of family planning services provided to the needy
clients




                                                                                              5
With limited resources, the fundamental elements that needed to be supported to sustain
a thriving family planning program, including the important issue of improving the quality
of family planning services through properly organized training, on quality family planning
services.

In this regard the need to reposition family planning as a priority in the national
development agenda to focus resources and priority back to the national family planning
program and strengthern the quality of care provided to clients

In response to the request, a training on family planning quality of care was organized by
the Reproductive and Child Health Section of the Ministry of Health Tanzania in
collaboration with the Regional Centre for Quality of Health Care based in Kampala,
Uganda. The training was conducted at Tanzania Episcopal Centre (TEC), Kurasini, in Dar-
es-salaam from 23rd February - 4th March , 2009

The overall purpose of the the February – March, 2009 training was to build the capacity
of front line family planning service providers to empower and equip them with updated
knowledge and skills for effective provision of quality family planning services to the
needy people in their respective service delivery points.

This was part of the efforts to accelerate the reduction of maternal, newborn and child
morbidity and mortality through inreased accessibility and utilization of quality family
planning services in the country

During the Februry – March 2009 training, participants were exposed to theoretical
knowledge on contraceptive technology and practical skills on effective management of
FP clients including the elements of Quality of Care in Family Planning

The first phase of the training of the training was devoted for theoretical training where
participants were exposed to updates on contraceptive technology and the appropriate
ways of managing clients while providing natural, barrier, oral, IUDs, Implants, sterilization
and injectable family planning methods.
This inludes the key issues in creating demand for FP methods use (education and
counselling), organizing family planning services (establishing and maintaining
rapport,maximizing accesss and quality of care, infection prevention / control and record
keeping), managing clients for short–acting, long- acting and permanent FP methods use
(anatomy and physiology of reproduvtive system, history taking, physical examination,
explaining FP methods to clients, giving instructions on how to use FP methods, and
managing side effects)

At the end of the Februry – March 2009 training, trainees prepared their application plans
that reflected a need for follow-up to ascertain the extent, progress and obstacles in the
implementation of their respective plans,; as well as providing them with necessary
technical back ups.


                                                                                             6
The follow up was intended to reinforce the new skills and solve problems in the
implementation of high Quality Family Planning clinical procedures and help service
providers apply what they have learned to improve their routine clinic responsibilities.

The information collected during the follow-up exercise will be used by RCQHC to make
necessary revisions on the FPQOC curriculum to enable participants in the future to
benefit fully from training in quality of care.

The Specific objectives of the follow up activity are to

   a) To assess the performance of traineed service providers from Mkuranga and
      Kisarawe districts on the job after training
   b) Determine the extent to which trainees have been able to address their
      performance gaps since the training.
   c) Identify any other gaps in performance that are best addressed by training
   d) Provide support to the learners to strengthen their capacity to further apply their
      knowledge and skills to improve quality of family planning care and to train others.
   e) Gather and document information on the performance of service providers and the
      conditions that influence performance, in order to improve the implementation of
      FP practices


2.0 Methodology used for follow- up
2,1: Field visits
             Observation of trainees at work
             Exit interviews
             Facility audit

2.2: CME training
    This was to address the identified gaps and further strengthern trainees’ capability in
    providing high quality family planning services to clients
               Goal and objectives of CME training
               Deliverables
               Major contents of the CME training
               PIA and trainees workplans




                                                                                           7
3.0     ASSESMENT OF THE PERFORMANCE OF THE LEARNERS


3.1 Report on the status of the quality of care provided in the unit where the
former trainees work.
A total of 17 out of 20 participants trained on effective provision of Quality Family Planning
services were followed up by the consultants (observers) in a period of 8 days. This exceeded the
stipulated 5 days of follow up due to the extensive distances between the evaluated Health Units.
Providers were not warned in advance of the visits.

Aspects of evaluation included time of opening of the unit and utilization of the unit facilities.
Particular attention was paid to the actual handling of the clients by the providers.

This involved silent observation of the provider in the process of counseling of clients and
administering of the preferred method of the client. Data was collected using a closed and open
ended questionnaire.

The overall time of observation and exit interview for each client lasted 15 to 30 minutes.
An observer assessed the facility through a questionnaire addressed to the in charge of the Health
Unit.

All the clients served were aging between 19 and 44 years (within the Child Bearing Age),
Majority of them were at 28 years of age . This prove the importance of promoting quality
of care in FP clinics to address the unmet need for family planning among young women in
Tanzania which is still high (22% DHS 2004/5)

Majority of clients seen by trainees during follow-up were continuing clients were 63.6%
while new clients were 36.4%, This indicates a good continuity of satsfied clients to quality
service offered by trainees
On family Planning status of clients upon arrival, 100 % of clients observed during the
follow up were current users of family planning method. This indicates that many of the
clients attended by trainees are satisfied continuous users of family planning services,
having satisfied continuous users of family planning methods / services is one of the
indicators of improved quality of care at facility level.

100% of sservice providers visited during the follow-up were observed to have asking open
ended questions that facilitates clients’ free expression of ideas.

Clients satsfaction results from treating clients with respect. For this reason trainees were
assessed to see how they treat FP clients who attend for services, In 100% cases observed
during the follow up exercise, the provider treated the client with respect.This indicates that
service providers have positive attitude to their clients during service provision
100% of cases observed during the follow up the trained service providers serve clients in
private this contribute to clients’ satisfaction in family planning
In 90% of cases the provider asked the client if she had concerns about any method.



                                                                                                     8
This indicates a good application of knowledge on key masseges to be addressed during
client- provider interaction session to each client on each visit.

However, during the follow up, in 68.2% of clients seen, the provider did not use visual
aids while counseling the client. This indicates a serious gap that need to be addressed in
future training
 50% of cases which were observed, provider did not use the client’s records. This gap need
to be addressed in future training to ensure continuity of care and proper handling of clients
privious history, including how they were managed.

Among the factors that can promote quality of care in family planning services is to
maintain clients confidentialty.

The findings revealed that the provider assured the client of confidentiality in 63.6% of
cases but did not in 36.4% of cases. This indicates a need to put more empahasis on the
need to ensure clints’ confidentiality during future training.
 Trainnes were observed to have weakness in linking clients’ reproductive goal with the
guidance to be given to help clients to make informed choice of method. Many clients who
wanted to rest for more than five to ten years before the next pregnancy and even those who
did not want to conceive again, all ended by receiving short acting FP methods

Timing of the next child was not discussed in 86.4% of cases observed, This also
contributed to the problem/syndrome of many of the clients seen to end up in receiving
short acting FP methods (Depo Provera Syndrome)

Dicussing on current pregnancy status when taking clients’ medical, social and
gynaecological history is among the most important elements that enable service providers
to determine clients health status, needs and plan for proper management for individual
cliets, because pregnancy is one of the conditions that make clients not to be eligible to
most of the Family Planning methods. Findings indicates that current pregnancy status was
not discussed in 68.2% of cases seen

Likewise, history of pregnancy complications was not discussed in 81.8% of cases seen
during the follow up. This will assist interraction during counselling sesssion. This is a
knowledge decay that need to be taken care in the furure.

Recent studies revealed that among the hindrance factors to utilization of family planning
services in Tanzania is restriction by male partners. However, the results shows that
partners attitude about family planning was not discussed in 86.4 % of cases seen during the
follow up

Tanzania is moving forward to foster integration of Family Planning and HIV prevention
services. And family planning service provision avenue is one of the potential service
delivery areas that can be utilized to foster the integration.

Counselling clients for safer sex,which is one of the measures to prevent the spread of STI /
HIV, can not be successful without discussing with clients on the issue of spouses having
multiple or single sex partner. During follow up, in 86.1 % of the cases seen, providers did
not discuss with clients on the issue of spouses having multiple or single sex partner



                                                                                             9
Likewise, in 36.4 % of the cases seen during follow up, providers did not discuss on
STI/HIV/AIDS with clients; and in 59.1 % of the cases seen, providers did not explain the
history, signs and symptoms of STIs,

This indicate a serious gap on FP/ HIV service integration that need to be addressed through
a tailored training programme on FP/ HIV integration

Mojority of clients preferred Depo Provera, a method which does not protect against STI /
HIV. Clints who prefer Depo Provera as their method of contraception need to be
counselled for dual protection and dual methods. The importance of counselling such
clients for dual protection need to be emphasized in the future training including in the
CME curriculum.
 Provider should explain to client that Family planning method does not protect the client
from aquiring STIs and HIV/AIDS. Condom should be used consistently and correctly as
dual nprotection to prevent both pregnancy and STIs/HIV.



Client choice is one of the important elements that consitute quality of care in family
planning. Despite the acute shortage of contraceptive commodities facing the country,
service providers were expectected to strive to provide clients with their method of choice.
During the follow up in 50 % of the cases seen clients received their prefered method of
choice. This indicate a good adherance to principles and competent in skills of informed
choice counselling.

However, in up to 70 % of the cases seen during the follow up, providers did not ask to
determine clients’ reasons for method selection, the fact that could have revealed other
barriers to family planning method use such as spousal communication, decision power in
the family and gender equalities in decision making

During this follow-up only 30% of providers determine clients reason for method selection
while 70% did not. It reveals that there is knowledge decay since the previous training or
the provider did not put knowledge into practice.

Stock-outs of contraceptive commodities is one of the critical bottlenecks that can
negatively affect the move to improve quality of family planning services provided to the
needy people however during the follow- up some of the health facilities had stock-outs of
contraceptive commodities. Among the methods which were out of stock were Implanon,
Depo Provera anf Progestin Only Pills. Consequently there was no method mix, hence
many clients did not receive their methods of choice.

During followup 60% of the providers served clients did not check their blood pressure
before administering FP methods. According to Bruce’s elements of quality care Tecnical
competence of a provider is inclusive. Hence Quality FP servise is seen when all vital
signs of clients including body weight is known before administering of FP methods. This
provides a baseline of vital signs to compare before and after administering FP methods.
Some of the reasons observed at the3 sites as reported by the providers were the shotage of
sphigymomanometer in FP section.




                                                                                           10
Screening clients for FP method use is an important element in provision of high quality
family planning services.This step is important for ruling out contraindications for FP
method us, by ensuring clients’ eligibility to contraceptive methods use

Smoke produces chemical known as nicotinic acid chemical that can interfere with
absobortion of some drugs/ FP Methods like oral pills. Therefore there is a need to be
included in the future training
Breast feeding is among the short term methods of family planning only when three citeria
are bbeing followed by the client: fully or nearly fully breast feeding fully exlusively day
and night 6-12 times per day intervals shold not be longer than 4 hours during the day and
6 hours during bthe night, menses has not yet resumed and the infant is under 6 months of
age. This information can guide the provider in counselling for method mix.

Asking about chronic health problems is very crusual as some client might be using drugs
that can interract with the method and lower its potency. Like COC and POP with
rifampicin for TB ,phenytoin for anticonvulsunt, carbmazepine, barbiturates,topramate and
excarbazepine

For Quality FP service provision, provider should enquire client about the regularities of
menstral cycle because some of FP method like oral pills can be used as treatment for
regulating menstral cycle also pregnancy complications as this will assist in points to
discuss during counselling session as time to rest before getting next pregnancy.Like PAC
patients need to space for next pregnancy by six months to decrese the risks of low birth
weight , premature birth and maternal anaemia

Provider should know about clients pregnancy complications as this will assist in points to
discuss during counselling session as time to rest before getting next pregnancy.Like PAC
patients need to space for next pregnancy by six months to decrease the risks of low birth
weight , premature birth and maternal anaemia

For Quality FP service provision, provider should enquire client about the regularities of
menstral cycle because some of FP method like oral pills can be used as treatment for
regulating menstral cycle.

Acurate information should be given to every client (100%) because it is among their
rights. This will assist client to cope with situations like minor side effects and how to cope
with them.

The provider assured the client of confidentiality in 63.6% of cases but did not in 36.4% of
cases seen. Confidentiality is among the clients rights in Quality FP care. This should be
empasized in the future training.
100% of providers followed were skilled in technology, however some of clinics especially
hard to reach sites, lack skilled providers to provide method mix. There is a need to develop
special training material to equip lower cadres with knowledge and skills relating to family
planning.

55.5% of the providers did not show client self examination of breast.
Insructing clients how to self examine their breast is very beneficial to clients as it is one
way of detecting breast cancer problems for early management.



                                                                                                 11
The shorter the time is consummed by clients in FP clinic the more satisfaction is acquired.
This should be encouraged
82.7% clients were revising the clinic showing that they were satisfied with the services.
The challenge is to advocate for more new clients and maitain those already on methods to
continue wth FP methods use.It also raises providers’ job satisfaction

The facility should have all method mix. Providers should have contraceptive updates to
reduce skills decay to provide quality FP services.
70% of the reason for the visit was continuing methods and new clients changed in.
indicates clients satisfaction

Oral pills and Injectables observed to be the methods received by clients. Quality FP
services should have methods mix at facility level for clients to nmake choice. This reveals
a great challenge to the program especially at this time of FP repositioning


For Quality FP services client should state preferred method in order to avoid provider bias
to FP method. Some times provider lack skills on certain method then when client request
do not get. This should be noted by managers so that providers should be equiped with
skills in all FP methods at the facility.

50% of clients served received method they preferred while 50% received methods that
were available. At time sites are faced with problems of erratic supply of contraceptive
commoditie. Sometimes clients’ right can be altered to sellect among the available method
remporarilly until the method of preferrence is available
This is a challenge to the program need urgent action at this crucial time of the prosess of
repositioning FP


1. 3.2 The extent to which the trainees have been able to execute their work plans

Although there were some few gaps in performance which were observed during the
follow up, but all the visited trainees were observed to have positive improvement in their
perfomance.They all managed to apply their action plans at their work sites after the
training.
In many ares of performance that were observed during the follow up, majority of the
trainees proved to have exellent performance, particulary in the area of creating and
maintaining positive client/ provider interaction, adequate and acurate information given
to clients and practical performance of Family Planning clinical skills tasks.
Most of the trainees who were visited during the follow up reported that the workshop
was very useful, timely and beneficial to service providers
With regards to usefulness of the information provided to trainees during the workshop,
15 out of 17 visited participants (89%) responded that the information is very useful. Some
of the trainees visited said that the update were provided timely as they had no any
refresher training on family planning for many years.

Some of the trainees reported that even other service providers in their respective health
service delivery points also found the FP Quality of care training to be very useful.



                                                                                          12
Other trainees commented that most of the contents taught during the Quality FP training
are not included in their pre-service curriculum , while others posed the following
comments:
I gained correct information that built my confidence in providing quality FP services to my
clients, I received useful reference materials like the managing clients with side effects, I
gained additional skills on effective client / provider interaction.

A trained service provider from Maneromango Health Centre, in Kisarawe District for
example, commented that: ......”Most of the update information on quality family planning
we received are useful in addressing clients rights during service provision”.

Twelve (13) out of 17 contacted participants (67%) reported that they have ecuted their old
workplans and that they were able to apply the updates on the new version of the WHO
Elligibility Criteria for FP method use whe starting new acceptors of various family
planning methods.

3.3 Report on identified best practices observed:
      Good provider –client interaction
      Some of the providers were asking open ended questions and encouraged their
       clients to have free expression of ideals
      Explanations of effect and side effects of methods were given correctly
      Clients verbalized that they were satisfied with services provided
      Client waiting time was reasonably short.
      Sharing of knowledge among the their fellow Service providers at the site level
       observed
      Transferring of knowledge acquisition into skills.
      Client confidentiality was assured during service provision



4.0    THE EXTENT TO WHICH TRAINEES HAVE BEEN ABLE TO
       ADDRESS THEIR PEFORMANCE GAPS

4.1Gaps Identified During Follow Up
Despite the positive growth of knowledge and skills among the visited trainees, there were
few gap areas which was also observed in trainees performance at worksites. The weak ares
which needed to be adressed straight away and rectify the weakness, in a Continuous
Medical Training (CME), were:

   1. Inadequate linking of clients RH goal with advantages of Long Acting and
      Permanent Methods

   2. Lack of emphasis on Dual Protection and Dual Method

   3. Inadequate efforts to foster the integration of family planning with other
      RH services
                      -FP / STI/ HIV/AIDS



                                                                                          13
                      -Post partum Family Planning
                      -Post abortion Family Planning
                      - Family Planning in child health / immunization services


   4. Inadequate knowledge on how to complete the Reporting and Requisition
      (Rand R) forms used for ordering FP commodities

   5. Inadequate knowledge on how to apply the principles of Performance
      Improvement Approach (PIA) to solve the existing performance
      problems and influence other co-workers at facility level to participate
      fully in the improved quality of care provided to clients


4.2 All the trainees have been able to address their performance gaps by
executing their respective action plans.
Majority of the trainees visited during the follow up 16 out of 17 (94 %) were able to
implement their work plan at their respective work sites.
They reported that they managed to get most of the necessary resources needed for effective
application of knowledge and skills gained from the training. Most of them were able to
secure consumable supplies like chlorine, gloves, syringes and contraceptive supplies.
They also admitted that supervisors were very helpful to them and they were provided with
adequate enabling environment for effective provision of Quality Family Planning Services
which included reorganizing FP clinics to ensure privacy and confidentiality during
counseling and examination sessions


4.3 List the gaps that would be best addressed by formal training
Despite the fact that most of trainees performance problems were adequately addressed and
solved during the follow up and through the CME training which was administered as part
of the follow up, yet there were some gaps which need to be addressed by formal
competency based training. These were
                The insertion /removal of implants
                The insertion and removal of IUDs
                Surgical contraception
                Integration of family planning and other related Reproductive Health
                   services:
                            Integration of Family Planning and HIV/AIDS services
                            Integration of Family Planning and Post partum services
                            Integration of family planning and Post abortion services
                            Integration of family planning and Child Health/
                                Immunization services
                            Integration of family planning and Gender Based Violence




                                                                                        14
4.4 Suggestions from the learners on how the training can be improved
to further improve the capacity to strengthen quality of family planning
care in their units when they return to worksites
During the follow-up, trainees were asked to suggest on how best can the training be
improved to further improve their capacity to strengthern quality of family planning care
in their health units when they return to their respective worksites:

    Majority of participants suggested that the training should include more practical
     skills to make it a Competence Based Training (CBT)

    Participants expressed a need for constant follow up by trainers to provide them
     with further technical support and supportive supervision by supervisors who are
     knowledgable and skilled in Family Plannning

    They also suggested that they need to be provided with necessary working
     equipment and clinical supplies

    Others suggested that contraceptive commodities should constantly be made
     available to ensure a full range of method mix


4.5 List of training needs of learners with regard to strengtherning them in being
able to provide quality care

       Majority of the visited trainees observed to have serious gaps in performing some
       critical competency based family planning clinical procedures which need to be
       addressed through a well structured competance based training

       Most pf the visited trainees observed to have gaps of knowledge and skills in the
       fdollowing ares which can best be addressed by organizing a tailored competency
       based training that will expose them to practival experince :
                     IUD insertion and removal
                        Implants insertion and removal
                     Infection Prevention and Control
                     Dual Protection and Dual Methods
                     Record Keeping and Data management
                     Linking clients reproductive goal and choice of appropriate
                        method
                     Effective planning and application of Performance Improvement
                        Approach (PIA)




                                                                                          15
5.0 PROVIDE SUPPORT FROM THE LEEARNERS TO STRENTHEN THEIR
CAPACITY TO FURTHER IMPROVE THE QUALITHY OF FAMILY PLANING CARE
IN THEIR UNITS


5.1: Continuing Medical Education (CME) Training

A two days Continuing Medical Education training was organized to further build the
capacity to trainees


Goals of the CME
Objectives By the end of this workshop the participants should be able to:

      Share experience on the process of applying knowledge gained from the training in
       real practice at worksites
      Identify the level of achievements that has been reached by trainees in utilizing
       their respective application plans
      Document gaps which hindered trainees performance
      Recognize best practices that resulted from the training on Quality Family Planning
      Provide technical inputs to improve trainees performance
      Guide trainees to prepare a six months application plan which serve as a way
       forward


Rationale for the Topics Chosen
The CME meeting was organized to address gaps observed from trainees during follow-up
at their worksites. Gaps were mainly observed in the following critical areas of providers’
performance:
     Identifying Client’ reproductive goal versus type of FP method
     Dual protection/dual method for STI/ HIV prevention among FP clients
     Integration of FP with other RH services(FP/HIV;FP/Postpartum; FP/ Post Abortion)
     Effective filling in of the Report and Requisition (Rand R) forms, record keeping,
        analysis and utilization of service data
     Application of Performance Improvement Approach (PIA), including effective
        sharing of knowledge and skills with co-workers effective ways of solving their
        performance problems


5.2 The CME training process:
The needs for CME were identified through:
    Observations from the field during follow-up
    Analysis of the follow-up questionnaire
    The previous application plans
    Participants’ views
    Pre and post questionnaire


                                                                                         16
A two days training was organized to address the performance gaps wch neede immediate
attention to rectify the weakness
A tailored curriculum was designed and used to solve trainees’ performance problem
which needed a refresher exposure to some of technical issues The gap areas addressed
by the curriculum were:
     Identifying Client’ reproductive goal versus type of FP method
     Dual protection/dual method for STI/ HIV prevention among FP clients
     Integration of FP with other RH services(FP/HIV;FP/Postpartum; FP/ Post Abortion)
     Effective filling in of the Report and Requisition (Rand R) forms, record keeping,
        analysis and utilization of service data
     Application of Performance Improvement Approach (PIA), including effective
        sharing of knowledge and skills with co-workers effective ways of solving their
        performance problems
Sessions started by exposing trainees to a pre- training knowledge test where a
questionnaire was used to to assess the knowledge and skills gap since the previous
RCQRH training done on 23rd February to 4th March 2009 and before the initiation of the
current two days training.
There after an over view of the training was discussed whereby goal and objectives of the
CME was clearly elaborated
There after presentations were made to refresh trainees’ knowledge on the above
selected topics
At the end of the two days CME training, a post training knowledge test was again
administered, using the same questionnaire to measure the extent of knowledge gain
after exposure to the CME training

5.2.1 Course Core Content
Topics discussed reflected the gaps observed from the most of the trainees at site levels.
They included:
Session 1: Introduction to CME training
Session 2: Pre knowledge test
Session 3: Review of the previous action plans
Session 4: Follow-up results from the field
Session 5: Identifying Client’ reproductive goal versus type of FP method
Session 6: Dual protection/dual method
Session 7: Integration of FP with other RH services
Session 8: Record keeping
Session 9: PIA –Fostering integration of services in FP
Session 10: Post knowledge test
Session 11: Develop work plan for the next 6 months




                                                                                        17
         All the participants who attended the CME training 17 out of 20 (85%)service
          providers trained on quality FP in April 2009 were updated on key issues related to
          effective provision of quality family planning services
         Active participation observed and all participants commented that the CME
          training answered most of their performance problems
         Participants reported some achievements in the implementation of the previous
          action plans
         Pre and post knowledge assessment revealed that there was an improvement of
          knowledge acquisition because all scored above 50%. The highest score in pre
          knowledge was 66 % while the lowest score 40%. In post knowledge the highest
          score was 80% and the lowest was 57% hence the knowledge gained was 35%
         All participants developed individual six months work plans



6.0       APPENDAGES

Appendix A:      List of Participants / Consultants / Facilitators
Appendix B:      Schedule for Continued Medical Education (CME): Nov. 11 & 12 th, 2009
Appendix C:      Table 1- Pre and Post test results for February and November 2009.
Appendix D:      Pre and Post test questionnaires and Answer key
Appendix F:      Work Plans




                                                                                           18
                                        5. Appendages:

      Appendix A: List of Participants / Consultants / Facilitators who attended a two days
                                           CME training


S/N       Name                         Designation    Health Facility        Contact
1         Eveline Mathew               PHN            Vianzi                 0786372378
2         Batuli Yahaya                PHN            Mwanambaya             0754905309
3         Grace Zephania               DRCHCO         Mkuranga               0754407145
4         Naza Mkabara                 PHN            Kibaha/Mkoani          0787101911
5         Shebu S. Mambo               PHN            Kisarawe/Homboa        0712275227
6         Mariama Elias                PHN            Kisarawe Mzenga        0782169371
7         Editha Mkinga                NM             Kisiju H/C             0786319936
8         Hoka Masudi                  PHN `B’        Magawa Disp            0784-396920
9         Hawa Kinyogeli               PHN B          Masaki H/C             0784220503
10        Joyce Mselu                  PHN B          Mkiu Disp              0786939037
11        Gloria Majiyapwani           PHN            Mkuranga D.H           0754654769
12        Rose Machange                NM             Kisarawe D.H           0787878486
13        Sikudhani Saidi              NM             Masanganya DISP        0787-358229
14        Mwanahamisa Mgomba           PHN B          Maneromango H/C        0787121708
15        Felister. Kemi               PHNO           Kisarawe/ Hosp         0783454472
16        Marietha Killonzo            NM             Chole Disp             0782415433
17        Magreth Muro                 EN             Vikindu Disp.          0755856341

          Facilitators and Consultants
S/N       Name                         Designation    Contacts
1         Dr. Anthon Okoth             Consultant     +256-772645556
2         Maurice Hiza                 Consultant     +255754308223
3         Mary-Ani Lema                Consultant     +255-754-695573
4         Grace Chuwa                  FP Trainer     +255-754301384



                                                                                              19
   Appendix B: Schedule for Continued Medical Education (CME): Nov. 11 & 12 th, 2009

                       Day One November 11, 2009
 Time                  Activity                                           Responsible
 8.30 -8.45 am         Welcome and registration                           Chuwa
 8.45 - 9.30           Session 1: Pre knowledge test                      Lema & Chuwa
 9.30- 10.00           Session 2: Overview of CME Meeting                 Hiza
 10.00- 10.30          Nutritional Break
 10.30- 11.30          Session 3: Review of action plans                  Lema
 11.30-12.00           Session 4: Follow-up results from the field        Dr Okoth
 12.00–1.00 noon       Session 5: Identifying Client’ reproductive goal   Chuwa
                       vs type of FP method
 1.00 -2.00 pm         Nutritional Break                                  All
 2.00pm - 3.00         Session 6: Dual protection/dual method             Chuwa
 3.00-4.30 pm          Session 7: Integration of FP with other RH         Lema
                       services
 4.30 -4. 15 pm        Nutritional Break
4.15- 5. 00 pm         Day one Process review                             Chuwa
 5. 00 pm              Closure
                       Day two November 11, 2009
 8.30 -9.00 am         Recap                                              Hiza
 9.00-10.00 am         Session 8: Record keeping                          Chuwa
 10.00 -11.00 am       Session 9: PIA –Fostering integration of           Hiza
                       services in FP
 11.00- 11.30          Nutritional Break                                  All
 11.30- 12.15          Session 10 Post knowledge test                     Hiza
 12.15- 1.00           Session 11: Develop work plan for the next 6       Lema & Chuwa
                       months and presentation
 1.00-2.00 pm          Nutritional Break
 2.00-3.00 pm          Presentations of Work plans                        Chuwa
 3.00 -3.15pm          Participants views on the follow-up activity
                       and trainings
 3.15pm - 4.00 pm      Feedback of individual performance                 All
 4.00 pm               Official Closure                                   Hiza
 4.00 5.00 pm          Facilitator/consultants’ consensus meeting         All




                                                                                         20
APPENDIX C

                             Table 1

Summary of Pre and Post knowledge test in February and November
            Training (Results and the percentages gained).

                Training on Feb 2009                     Training on Nov. 2009
                                               %                          %
SN.   Participants           Pre       Post    Gained      Pre    Post    Gained
                            Test %     Test%             Test% Test%
 1    Batuli Yahaya           43        84       41        48       72      24
 2    E. Mtesigwa             45        69       24
 3    Editha Mkinga           58        77       19        65         68   03
 4    Eveline. Mathew         47        68       21        63         69   06
 5    Felister Kiemi          37        81       44        60         78   18
 6    Gloria                  48        84       36        49         73   24
      Majiyapwani
 7    Grace Zephania          62        74       12
 8    Hawa Kinyogoli          55        80       25        59         57   -2
 9    Hoka Masudi             42        82       40        54         72   18
10    Irene Mhando            55        79       24
11    Joyce Nselu             44        81       37        58         72   14
12    Magreth Muro            54        66       12        66         80   14
13    Mariana Elias           37        84       47        42         71   29
14    Marietha Killonzo       42        76       34        40         75   35
15    Mwanaarabu              49        82       33
      Sharifu
16    Mwanahamisi             55        80       25        59         67   08
      Mgomba
17    Naza Mkabara            57        90       33        63         66   03
18    Rose Machange           57        76       19        60         73   13
19    Shebu Mambo             57        85       28        40         66   26
20    Sikudhani Saidi         51        78       27        49         67   18
N.B: 3 Out Of 20 Participants did not attend the follow-up activity


                                                                                   21
Trends In Pre and Post test results February 2009




Trends In Pre and Post test results November 2009




                                                    22
APPENDIX D:

Pre / Post CME training knowledge test questionnaire – Answer key


Instructions:
      1. You are required to write your ID number on top of each sheet of paper
      2. Choose the most appropriate answer and write (T) for True or (F) for False.
      3. There may be more than one correct answers in one question
      4. Respond to all statements in each question

1) On Dual Protection
     Is not accomplished solely through condom distribution.T
     May be accomplished through correct and consistent use of the male and
       female condom only. T
     May be accomplished through avoidance of all types of penetrative sex F
     May be accomplished through use of contraceptive plus mutual monogamy
       among uninfected partners T
     In general, the chance of producing an unintended pregnancy per each
     unprotected coital episode is much higher than the risk of transmitting a
       bacterial cervical infection.F

2) On fertility awareness methods
     In the standard days method users avoid unprotected intercourse by using a
       condom or abstaining on days 8 to 19 of the cycle.T
     In the two day method - When the woman detects cervical secretions, the
       couple avoids unprotected sex on that day and until the woman has had two
       days in a row of the thinner less sticky secretions T
     Standard days method is more than 95% effective with correct use, and more
       than 88% with typical use among all women.F
     The “fertile window” during the woman’s menstrual cycle consists of several
        days before ovulation and a few hours after.F
     In the cycle bead, the bright red bead for a woman with a 28 day cycle is the
        day of ovulation.F

3) On lactational amenorrhoea
     The three criteria that are essential to the effective use of LAM are -the
        baby is less than six months old, Menses have not returned and the baby is
       fully or nearly fully breast fed day and night. T
     The three criteria that are essential to the effective use of LAM are -the
        baby is less than six months old, Menses have not returned and the vast
       majority of feeds given to infant day and night are breastfeeds.F
     Exclusive breastfeeding is not necessary for LAM to be effective.F
     For LAM to be successful the optimal pattern is for the baby to be nursed
       as frequently and as long as the infant wants the interval between night


                                                                                       23
     feed should be at least 3 hours.T
    LAM is rendered less effective if vitamins, water, juice, or ritualistic feeds
     are given infrequently in addition to breastfeeds. T

4) On implants
     Jadelle has two rods, effective for five years.T
     Implanon: one rod, effective for three years. T
     Norplant: six capsules, labeled for five years of use, but large studies have
       found it effective for seven years. F
     Implants are one of the most effective and long-lasting methods, with five
       pregnancies per 10,000 women using implants over the first year.T

5) On Female Sterilization
     Spousal consent is mandatory.F
     In mobile outreach VSC programs, counseling and follow up should be the
       same as at fixed sites. T
     May be done within 7 days after a first trimester abortion.T
     Does not have to be performed in an operating theatre.F
     Is associated with a decreased risk of ovarian cancer. T


6) On vasectomy
     Failures as high as 3-5% have been reported.T
     WHO recommends that the couple use alternative contraception for three
       weeks after the procedure. T
     During vasectomy severing the vas deferens may result in blockage of flow of
       prostatic secretions into the penile urethra.T

7) Quality Family planning care

      Increases women’s desire to adopt family planning T
      results in clients having children by choice and by chance F
      Can results in increased demand for services. T
      Means that a service provider should tell clients what method is best for them and
       warn them about all side effects. F
      Includes counselling clients about all methods available include their side effects,
       advantages and disadvantages. F

8) On Benefits of family planning:

      Approximately one million out of 11 million deaths per year of children younger
       than five years could be averted by increasing the birth intervals to at least 24
       months. T
      In 2003, if there had not been any contraceptive use, approximately 813,000
       children in sub-Saharan Africa would have been newly infected with HIV. T




                                                                                           24
      Pregnancy intervals of less than six months (15-month birth intervals) are
       associated with 50% increased risk of maternal death. F
      Lowering the pregnancy rate among HIV-infected women by at least 5.6%, has the
       same impact as providing nevirapine for PMTCT. T
      If fertility declines by just 5/1000 in a given decade, a poverty reduction of 6.3%
       occurred is expected to occur 10 years later. T

9) On Family Planning and Maternal mortality:
     The lifetime risk of death from pregnancy-related complications in sub-Saharan
       Africa is 1 in 16. T
     Health risks of pregnancy-related complications are far greater than any risk of
       contraceptive use. T
     Of global maternal mortality, 13% is caused by unsafe abortion. T
     In 2000, about 90% of global abortion-related mortality could have been averted if
       women wishing to postpone or limit further childbearing had used effective
       contraception. T
     Pregnancy intervals of less that six months are associated with 70% elevated risk of
       third trimester bleeding, 70% increased of premature rupture of membranes. T

10) Meeting clients reproductive goal:
A mothr of 3 children come to RH FP clinic with three months old twins, she has been
breast her babies only without additional food stuff. She is looking for family planning
method because she does not want to have more children soon. What optional methods
are suitable to her ?
     Condoms only is good for her
     Implanon
     Injectable-DMPA T
     IUCD T
     Minilaparotomy
     Vasectomy
     Condom as dual protection T


11) Awoman has delivered last night in your health facility. On descharge I will consider
the following:
     BCG vaccine to her newborn T
     No need of family planning methods because she will not have sexual intercourse
        soon
     Provide her with methods you think are suit for her
     Counsel client for family planning methods of choice T

12) One day during morning report in Gynae ward you find a school girl who had
   a spontanously abortion last night and the Dr is about to discharge her home.
    What action are you going to take before her discharge:
     Ask her why she conducted abortion
     Tell her abortion is a criminal case to be reported



                                                                                        25
       Counsel her for family planning informed choice and provide method T
       Tell her to mention someone who made her pregnant
       There is no need of counselling her for family planning as she is an adolescent


13) The following are among the best tools for client satisfactions:
     Ask provider whether clients are satisfied
     Use suggestion box and to be opened weekly by service providers
     Use suggestion box and to be opened monthly by the Health board members T
     Use questionnaires for client exit
     Ask clients to verbalize at the health facility waiting bay


14. Quality Improvement approach can be defined as a pprocess of:
     Identifying service providers who are coming late
     Identifying performance gaps T
     Identifying causes of gaps T
     Developing action plans with interventions to address gaps T
     Monitoring progress of action plans T

15. Among the major consideration on Infection Prevention and Control include:
     Hand washing before and after procedure is not very necessary in all family
      planning procedures.
     Re-sterilization of sterile pack after seven days T
     Re-sterilization of sterile pack after one month
     You can use of sterile pack within ten days after sterilization
     Time decontamination of equipment takes 10 minutes T


16. The following are tools for clients’ record keeping at family planning unit:
     OPD register book
     MTUHA book number 2 and 8 T
     MTUHA number 6
     MTUHA number 6
     Report and Request family planning methods on monthly basis T


17. A good reproductive health manager will do the following:
     Keep data in locked cupboard and keep keys on her/his own
     Compile monthly report from HMIS registers T
     There is no need of sharing information concerning data as no one is interested
     Analyze, interpret and utilize for improvement of services T
     Write report and submit timely to at all levels starting from the facility T
     According to Integrated Logistic Management System there is no need of using
        R& R any more.



                                                                                          26
APPENDIX F : Trainees Work Plan

FACILITY NAME MKURANGA DISTRICT: BY GRACE ZEPHANIA


SN       Problem area                  Activities                       Indicators              Resources
                                (What need to be done)              (What do I expect        (What do I need
                                                                          to see)             to support me)
1.   Inadequate knowledge       To sensitize staff at facility Increased number of client        Time
     on integration of FP       on the importance of           clients use FP methods            Funds
     and other RCH services     integration of FP and other during postpartum and post           Humans
     to the health providers    RCH services to the health     abortion                            resources
                                providers                                                        Posters of FP
                                                                                                 Leaflets of FP

2.                              To make sure availability       Reporting & requesting on          Time
     Shortage of tools for      of Tools for ordering FP        time                               Funds
     ordering FP                drugs and equipment at the      Availability of drugs and          R&R forms
     commodities and            health facility                 equipment of FP
     equipment at facility
     and district level

3.                              To make knowledge on            Increase number of client   Funds
                                application of document         use due protection          Transport
     Inadequate knowledge       protection to health                                        Adequate condoms
     and skills on              providers at Mkuranga           Reduce number of            Human resource
     application of dual        District                        unwanted pregnancies at
     protection to FP clients   To provide service to the       Mkuranga district
     at Mkuranga RCH            community
     clinic



FACILITY NAME: KISARAWE DISTRICT BY: FELISTER. W. KIEMI


SN       Problem area                 Activities                   Indicators             Resources           B
                                (What need to be done)           (What do I expect      (What do I need     (Tim
                                                                     to see)               to support
                                                                                          me)
1.   Inadequate family          To ensure R&R forms          All health facility has           Time      By Jan
     planning commodities       are filled and collected     collected R&R form                Funds
                                monthly                      monthly                           ILS
                                                             All facility has FP                request
                                To check ILS form every      commodities                        forms
                                quarter before sent to
                                msd to identify if FP
                                commodities ordered




                                                                                               27
2.                            To make sure                  High number of                     Maker      By De
     Inadequate family        availability of Tools for     postpartum an FP                    pens       2009
     planning integration     ordering FP drugs and         acceptance                         Time
     and other RCH services   equipment at the facility                                        RCH
                                                                                                staff
                                                                                               Lesson
                                                                                                plan

3.                            To provide knowledge to       Use of condoms will be      Condoms            As soo
                              all staff working in          higher reducing of          Staff              Novem
     Inadequate knowledge     RCH on dual protection        unwanted                    Time lesson plan   to 201
     and skills on            and its application           Protection of STIs
     application of dual      during FP counseling          infection
     protection




        FACILITY NAME: KISARAWE HOSPITAL: BY ROSE MACHANGE

SN       Problem area                 Activities                    Indicators       Resources               By w
                                (What need to be done)           (What do I expect (What do I need         (Time
                                                                      to see)         to support
                                                                                     me)
1.   Inadequate family        To introduce RCH staff on        High number of post       -Maker -        By Decem
     planning integration     integration of FPO services      natal and abortion        pens
     and other RCH services                                    care acceptance will      -Time
                                                               raised                    -RCH staff
                                                                                         -Lesson
                                                                                         plan

2.   Poor knowledge of dual   To introduce knowledge to        High number of             Lady           By Decem
     protection on FP         health provider services         uses condoms               pepeta         2009-201
     method                   about dual protection on FP                                 Condomss
                              method                                                      Maker pen
                                                                                          Reflent
3.   Inadequate knowledge     To sensitization of              Increase number of     Time               As soon b
     and skills on            community client about long      client uses            Reflex             Novembe
     application of dual      methods mini lap, IUCD                                  Paper              2010
     protection               implants




FACILITY NAME: MZENGA HEALTH


S    Problem area              Activities                     Indicators                  Resources
N                        (What need to be done)             (What do I expect          (What do I need
                                                                to see)              to support me)



                                                                                               28
1.   Service providers       -Give feedback report on        -Quality FP services          -Feedback report
     lack knowledge and      what Acquired in the            -Increased number of          -Time schedule
     skills on FP Quality    training to Facility in         FP clients                    -Lesson plan Handout
     services                charge and staff
                             -Organize sessions through
                             On the Job Training
2.                           Sensitize clients on the
     Low number of FP        importance of using family      Increased # of FP users Lesson plan
     clients                 planning during outreach                                IEC materials
                             services and at OPD                                     Posters
3.   PAC clients are         Conduct counseling              Increased # of CPAC     FP service provider tool it for
     not aware of family     sessions to PAC clients and     client using FP methods counseling
     planning services       provide methods after
                             informed choice




FACILITY NAME: VIANZI DISPENSARY BY: EVELINE MATHEW

SN       Problem area                 Activities                     Indicators                   Resources
                                (What need to be done)            (What do I expect           (What do I need
                                                                        to see)               to support me)
1.     Lack of integration    I establish initiate that        Increase the no. of FP        Skilled                   Im
       of family planning     services by recurrence other     use                                                     y
       with other RCHC        clients whose recurrent
       Service                others attended at another       # of unwanted
                              services such as : Postnatal     pregnancy are
                                                               decreased
2.     Poor record            Daily data recording daily       Availability of different    Day to day book            B
       keeping delay          monitoring and activity and      of type of FP methods        ( MTUHA)                   D
       monitoring and         evaluation of FP activities      continuity of FP                                        2
       evaluation of          data collection utilization      member                       R & R form
       family planning        and report                                                    Book 2
       activities                                                                           Book 10
3      Lack of knowledge      Conduct sessions on ASRH         -Decreased number of         -Skilled Trainers on       Ja
       about Adolescent       adolescent/youth social          Youth /adolescent            adolescent Reproductive    2
       Reproductive           groups and at schools            infected with STIs           health
       Health among                                            including HIV/AIDS           -IEC/Health learning
       youth and                                               -Number of                   materials
       adolescents                                             Adolescents/youth            -Stationeries
                                                               coming to RH/ FP             - Lunch allowances/half
                                                               clinics for services         per diem
                                                               -Reduced # of                -Venue charges,
                                                               unwanted pregnancies         Transport and fuel and
                                                                                            Communication




                                                                                                      29
FACILITY NAME: MAGAWA DISPENSARY                         BY : HOKA MASUDI


N      Problem area                  Activities                           Indicators                Resources
                               (What need to be done)                  (What do I expect        (What do I need
                                                                            to see)                to support me)
1.   Inadequate            Conduct feedback sessions on QI       -Increase the no. of FP         -Schedule,
     knowledge on FP       FP service knowledge acquisition      use.                           -Lesson plan
     among Co workers      in the training.                      -# of unwanted pregnancy       -Conducive
     at Dispensary                                               are decreased                  environment
                                                                                                -Handouts for Quality
                                                                                                Family Planning
2.   -Missed               Conduct health education to           -Number of sessions            -Lesson plan
     opportunities in      clients on importance of FP           conducted on continued         -IEC materials
     Family planning       services after delivery or abortion   education                      - Availability of FP
     post partum and       in OPD, and RCHS clinic               -Number of clients attended      method mix
     Post abortion                                               session
     clients                                                     -Number of new clients
                                                                 recruited on FP Methods
                                                                 After Delivery Or Abortion
3    Inadequate            Conduct session on the                -Number of SPVs attended       FP methods selected
     information given     importance of dual protection to      sessions                       by thee clients
     to FP clients on      SPVs at facility level through on     -Number of clients             -Condoms –
     dual protection       the job training                      provided with condoms as       female/male condoms
     after method of                                             dual protection method         -Penile model
     option                                                                                     -Register book
                                                                                                number 8 and RCHS
                                                                                                form # 5
                                                                                                -Posters and leaflets


FACILITY NAME: CHOLE DISPENSARY By : MARIETHA KILLONZO

S      Problem area               Activities                  Indicators                        Resources
N                           (What need to be done)        (What do I expect                    (What do I need
                                                                to see)                  to support me)
1    Missed for FP         -Conduct Health education -Number of Health       C
     opportunities in      sessions on FP services in education sessions                    -Clients
     child health clinic   child health clinic and in conducted                              - Health learning
     mothers               OPD                        - Number of FP clients                    materials
                                                      recruited from child                   - IEC
                                                      health clinic                           - Materials eg
                                                                                                posters and leaflets
2    Inappropriate FP      -Review on the use of R&R      - Number of sessions
     record keeping for    forms with District/           used to discuss on R&R                 -HMIS registers Bk 1,
     commodities           Regional RCH coordinators      with D/RR Co-                         4 ,8, & 10,
                           -Use R&R forms for             coordinators.                        - RCHS form
                           reporting and ordering of      - Utilization of R&R                 no. 5, R&R forms
                           monthly FP commodities         forms for reporting and
                                                          ordering of FP
                                                          commodities
3                                                                                               -Lesson plan
     Inadequate filling    Discuss with co- FP            - # of newly recruited &              - Schedule
     of clients card -     providers on the importance    revisit FP clients                       -Han d out HMIS #



                                                                                                   30
     RCH 5 & HMIS             of recording clients’         increased                                                R
     #8                       particulars on daily basis
                              using HMIS book # 8 &
                              RCHS form & 5

FACILITY NAME: VIKINDU DISPENSARY BY: MARGRETH MURO

SN       Problem area                          Activities                       Indicators              Resources
                                         (What need to be done)              (What do I expect       (What do I need
                                                                                  to see)             to support me)
1    Inadequate knowledge         Give feedback report on training        - Increased # of FP           -Lesson plan
     on Quality FP among          attended to co- workers                 clients and Clients           -Health learning
     health workers                                                       satisfaction                  materials



2    Poor floor pattern           -Discuss the problem with Facility      - Clear client floor in
     causing bottle neck in       in charge                               RCH clinic                Long term:
     RCH clinic                   - Conduct meeting with other SPVs                                 -Finance from CCH
                                  and chair person for health board                                 budget for improvin
                                  -Document suggestions and send                                    the clinic structure
                                  minutes to required authorities for                               -Construction mater
                                  improvement of the infra structure.                               -Human recourses
                                  -Rearrange the floor parten to
                                  improve the current situation as a
                                  short term.

3    -Inadequate knowledge        -Conduct continuing Health              -Increased number        -Schedule for healt
     on Quality FP among          education sessions on quality family    of FP clients            education sessions
     clients in the facility      planning services to OPD and RCH                             -Lesson plans
                                  clients




FACILITY NAME: MKOANI HEALTH CENTER KIBAHA BY : M. MKABALA


S      Problem area                 Activities                  Indicators              Resources                    By
N                             (What need to be done)             (What do I          (What do I need               (Tim
                                                                   expect          to support me)
                                                                   to see)
1    Inadequate               - Conduct session to         -Increased numberL                                     -Dec.
     integration of FP        other health providers on    of FP users at       -Schedule for different           ongoi
     into other RH            the importance of            facility level       sections
     services in the          integration of FP                                 -Lesson plan
     facility                 services into other RH                            -IEC and Health learning
                              services like : PMTCT,                            materials
                              VCT, PITCT




                                                                                                    31
2   Inadequate          -Conduct session to other   # of clients using     -Schedule for different         -Ja
    knowledge and       health providers and        condoms as dual          sections                        on
    skills on dual      clients on the importance   protection method      -Lesson plan
    protection in FP    of using condoms as a                              - Health learning materials
    services            backup methods with                                 - Availability of condoms
                        other FP methods

3   Lack of FP method   - Communicate with          # of clients using                                     -No
    mix especially      DRCHco on capacity          long acting          -Skilled service provider on       on
    long term in the    building to service         methods of           LTPM
    facility            providers.                  contraception         -Schedule for different
                        - Ordering long term FP                             sections
                        methods in ILS kits                                -Lesson plan
                        - Sensitizing community                          - Health learning materials
                        on the availability of                           - Availability of IUCD and
                        LTPM services eg IUCD                                implanon commodities
                        and Implanon



             FACILITY NAME: MKURANG : By GLORIA MAJIAPWANI


S     Problem area               Activities                       Indicators                Resources
N                          (What need to be done)              (What do I expect         (What do I need
                                                                     to see)            to support me)
1   Inadequate          Give feedback report on CME        -Increased awareness of        -Feedback report on
    knowledge on        training attended in DSM to       Quality FP among health         CME
    Quality FP among    co- workers                       workers                         -Health learning
    health workers                                        - Increased # of FP             materials
                                                          clients and Clients
                                                          satisfaction
2   -Inadequate         -Conduct continuing Health        -Increased number of FP        -Schedule for health
    knowledge on        education sessions on quality     clients                         education sessions
    Quality FP among    family planning services to                                       -Lesson plans
    clients in the      OPD and RCH clients                                                  -Health learning
    facility                                                                                   materials

3   -Lack of men        Conduct health education                                         -Schedule for health
    involvement in FP   sessions to community on the      -# of men in attending FP       education sessions
    services            importance of men involvement     clinic                          -Lesson plans
                        in FP services eg                 -# of men using FP                 -Health learning
                        accompanying their partners in    methods                              materials
                        FP clinics
                        -Change Clinic poster from
                        Maternal and Child health
                        Clinic (MCH) to clinic to
                         ( RCH) clinic showing en
                        involvement




                                                                                            32
FACILITY NAME: MASANGANYA DISPENSARY BY: SIKUDHANI SAID


S     Problem area                  Activities                   Indicators                           Resources
N                             (What need to be done)          (What do I expect                    (What do I need
                                                                    to see)                        to support me)
1                          -Conduct orientation sessions -Increased # of FP clients                -Schedule for health
    -Low number of FP      to SPVs at facility.          using FP methods post natal                education sessions
    method users           -Counsel postnatal and post   and post abortion                          -Lesson plans
    among Postpartum       abortion clients for FP                                                    -Health learning
    and Post abortion      method use                                                                    materials
    clients
2                          -Press order for R&R forms                                       Re
    -Lack of R&R           -Orient other SPVs on how to        -Availability of FP               Request for R&R letter
    forms at facility as   fill R&R forms properly             methods mix for client            R&R forms
    shown by                                                   informed choice
    inadequate supply
    of FP
3
    -Inadequate FP         -Conduct On the Job Training        - Reliable data
    record keeping in      on how to fill HMIS/MTUHA
    HMIS Bk 2, 4,          registers and forms HMIS Bk 2,
    RCH # 5 & 8            4, RCH # 5 & 8




               FACILITY NAME: HOMBOZA DISPENSARY BY:                         SHEBU MAMBO


S     Problem area                  Activities                         Indicators                      Resources
N                             (What need to be done)                (What do I expect               (What do I need
                                                                          to see)                  to support me)
1   Post partum and        Conduct client education on the     # of FP clients using FP                 -Schedule
    post abortion          importance of FP use after          methods after delivery and              -IEC/BCC
    mothers do not get     delivery and after post abortion    post abortion                             -Posters
    FP methods on          services.                                                                     -Clients
    discharge

2   Lack of R&R            Request R&R forms from              Availability of FP                -Request form/letter
    forms at facility      DRCHco                              commodities at facility           -Funds to photocopy R&
    level causing          Liaise with Facility in charge to   level                             forms
    shortage of FP         Photocopy R&R plain forms to
    Commodities            be used as a temporary measure
                           meanwhile waiting for
                           requested forms
3   Inadequate record      Conduct OJT on how to fill          Reliable data for facility         # of staff attended OJ
    keeping in HMIS        registers and forms as required     improvement of services                     sessions
    registers and RCH      to staff members at facility                                           # of sessions
    forms                  level




                                                                                                     33
          FACILITY NAME: ST. GASPAR XAVEL DISPENSARY                        BY: JOYCE MSELU

          Problem area                   Activities                        Indicators               Resources
SN                                 (What need to be done)                (What do I expect         (What do I need
                                                                             to see)                 to support me)
     Lack of method mix in     - Communicate with the authority        Availability of method          -Feedback
     the facility due to       leaders and give them the feedback     mix FP for clients options        report lesson
     religious beliefs (only   of the Quality FP training and the                                       plan
     BOM method accepted)      importance of using modern                                              -Handout
                               methods of FP




       Few number of FP        - Find out strategies of                                            -Health education
      clients due to lack of   communicating and convincing               # of FP clients            schedule
           method mix          with facility administrator and give   increased                     -Lesson plan
                               health education in OPD and RCH                                      -Clients for
                               clinic on the importance of FP                                        sensitization
                               services
     Lack of HMIS              -Pressing order of HMIS /MTUHA          # of FP Clients using         -MTUHA
     /MTUHA registers,         registers, RCH 5, R&R forms from       Modern                          registers, RCH 5,
     RCH 5, R&R forms for      the DRCHco                               Methods of FP               - R&R forms for
     FP                        -Orient other SPVs on the use of                                    FP
                               registers and forms using HMIS # 1

     FACILITY NAME: MANEROMANGO DISPENSARY BY:                          MWANAHAMII MGOMBA

     SN          Problem area                   Activities                       Indicators                Resources
                                          (What need to be done)              (What do I expect         (What do I need
                                                                                   to see)               to support me)
           Inadequate knowledge and      Give feedback report on         -Increased awareness of           -Feedback rep
           skills on Quality FP          CME training attended in       Quality FP among health            on CME
           among health workers          DSM to co- workers             workers                            -Health learni
                                                                        - Increased # of FP clients        materials
                                                                        and Clients satisfaction
           Low # of FP clients using     -Conduct counseling                                             -Lesson plan
           condom as dual protection     sessions for the group and     # clients using condoms as      -IEC materials
           method in FP services         individual on the              dual protection                -Posters
                                         effectiveness of using
                                         condoms as dual protection
                                         method
                                         -Orient other staff on how
                                         to counsel FP clients
           Erratic supply n of FP                                                                      -Request letter
           commodities and supplies      -Request R&R forms             Availability o FP              -Invoice forms
           due to lack of R&R forms      -Review with other service     commodities                    -Copies of R&R s
                                         providers on how to fill                                      DRCHco
                                         R&R forms




                                                                                                      34
FACILITY NAME: MWANAMBAYA DISPENSARY BY: BATULI YAHAYA


S     Problem area                   Activities                   Indicators               Resources
N                              (What need to be done)           (What do I expect (       (What do I need
                                                                    to see)                 to support me)

1    Inadequate           Give feedback report on CME        -Increased awareness of         -Feedback
     knowledge on         training attended in DSM to       Quality FP among health          report on CME    N
     Quality FP among     co- workers                       workers                          -Health
     health workers                                         - Increased # of FP clients      learning
                                                            and Clients satisfaction         materials

2    Inadequate           -Conduct counseling sessions                                     -Lesson plan
     knowledge on the     for the group and individual on   # clients using condoms as    -IEC materials
     use of condom as     the effectiveness of using        dual protection                -Posters
     dual protection      condoms as dual protection
     method in FP         method
     services             -Orient other staff on how to
                          counsel FP clients
3    Inadequate supply                                                                    -Request letter
     n of FP              -Request R&R forms                Availability o FP             -Invoice forms      Ja
     commodities          -Review with other service        commodities                   -Copies of R&R
                          providers on how to fill R&R                                    sent to DRCHco
                          forms



FACILITY NAME: MASAKI HEALTH CEMTER                          BY: HAWA KINYOGOLI


SN         Problem area                     Activities                    Indicators             Resources
                                      (What need to be done)            (What do I expect (     (What do I ne
                                                                            to see)              to support m

 1    Inadequate knowledge         -Conduct OJT sessions on Quality                            -Schedule
      and skills on FP services    FP services to facility staff    -# of Quality FP           -Lesson plan
      among facility staff                                          sessions                   -Hand out
                                                                                               -Posters


 2    Erratic supply n of FP       -Liaise with DRCHco concerning                              -Request letter
      commodities                  scarcity of R&R forms              Availability o FP        -Invoice forms
                                   -Request for supply of R&R         commodities              -Copies of R&R s
                                   forms                                                       to DRCHco
                                   -Review with other service
                                   providers on how to fill R&R
                                   forms




                                                                                              35
 3   Inadequate knowledge on       -Conduct counseling sessions for                                   -Lesson plan
     the use of condom as dual     the group and individual on the      # clients using condoms      -IEC materials
     protection method in FP       effectiveness of using condoms       as dual protection          -Posters
     services                      as dual protection method
                                   -Orient other staff on how to
                                   counsel FP clients

 4   Post natal and PAC            Counsel PP and PAC clients on        Increased # of FP             -Lesson plan
     patients discharged           the importance of using FP           clients using FP             -IEC materials
     without FP methods            methods after discharge              methods after PAC &         -Posters
                                                                        PP period



FACILITY NAME KISIJU DISPENSARY                 BY: EDITHA MKINGA

SN      Problem area                   Activities                       Indicators                        Resources
                                 (What need to be done)               (What do I expect                 (What do I n
                                                                          to see)                       to support m

 1   -Giving feedback to in      - Conduct feedback             -Quality FP service provision at         -Lesson plan
     charge and other            meeting                        facility evidenced by client -           -Schedule
     service providers at the    on what acquired in the        satisfaction                              -Health learn
     facility                    training with co-workers                                                   materials
                                                                                                          -Handouts w
                                                                                              -              updates
 2   -Low number of clients      Counsel Post partum and              -Increased # of Post
     accessing FP methods        Post abortion clients on the   partum and Post abortion clients        -Availability o
     after PP and PAC            importance of using family       discharged with FP Methods            method mix a
                                 planning methods before                                                       level
                                 being discharged home                                                  -HMIS form
                                                                                                         register num
 3   -Inadequate practices in    -Review session on the         -Proper and reliable service
     record keeping              importance of record           data at facility level for              -HMIS form #
                                 keeping with co workers        utilization                               register # 8
                                 -Demonstrate how to fill
                                 data in MTUHA register
                                 and forms
 4   Clients lack knowledge      - Conduct counseling           -# of clients using condoms as a         -Availability
     on the use of condoms       sessions with clients on the   back up method                             female &
                                 importance of using                                                         condoms
                                 condoms as dual protection
                                 method




                                                                                                   36

				
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