Appendix: The Country Situations Stimulating Development of the IUD/Genital Tract Infection Structured On-the-Job Training Program

The IUD/GTI structured OJT program in Zimbabwe was an outcome of the evaluation of an IUD/GTI group-based training program. In 1993, JHPIEGO assisted the ZNFPC to develop and conduct an IUD/GTI clinical skills training course for supervisors and service providers. The goal of the course was to improve the quality of IUD service provision. Service providers posted in ZNFPC FP clinics or MOH/CW health centers who were responsible for inserting IUDs would also become competent in screening and diagnosing common GTIs. In 1994, an evaluation of this integrated program showed only limited success. Some trained service providers had never initiated GTI screening services because of lack of space in their clinic or because their supervisors did not support the program. In other clinics, the caseload for IUD/GTI screening services was so low that trained providers quickly lost their skills because of lack of practice. Evaluators also found that trained providers did not pass their skills along to other staff. If the trained provider was on vacation or away from the clinic for a workshop, services stopped.

Results of this evaluation, when discussed with the relevant training officials in Zimbabwe, opened discussions about alternatives to the traditional group-based course. Group-based training may not always be the most appropriate or effective way to ensure application of new skills on the job, particularly for "rare event" skills such as GTI screening. Although during the initial group-based training course, trainers were able to ensure that participants learned the clinical skills required to initiate the IUD/GTI integrated service, the course was not successful in providing participants with the knowledge and skills necessary to integrate IUD/GTI services effectively into their work setting.

In Kenya, discussions about alternative approaches to group-based training began about the same time as in Zimbabwe. Two factors led to these discussions: 1) the high cost of providing inservice group-based training to the large numbers of nurses needed to increase access to FP and 2) the difficulties in assuring adequate caseload for clinical training. Prior to 1993 when the ECHN nursing school curriculum was revised to include FP, service providers (nurses) were required to attend a 6-week inservice FP course (the 6-week basic FP course) and receive certification before they were allowed to provide FP services including IUD insertion. Despite the revised curriculum, which in theory provided adequate FP training for nursing students, many students who have graduated from nursing school since 1993 have not been competent in IUD insertion even though they may have practiced providing non-clinical methods. The lack of competency in IUD insertion was caused by the lack of an IUD caseload in many sites (Brechin, Smith and Schaefer 1997).

Thus, the DPHC’s adherence to the requirement of certification in the 6-week basic FP course for all service providers meant that only a limited number of providers could be trained each year. In reality, only a few providers needed the entire 6-week basic FP course, and many service providers just needed to be trained in IUD insertion skills. The requirement that all providers be trained in this course meant that services at FP clinics were frequently disrupted because staff were off site attending this lengthy training course. And, because training capacity and funding for these group-based courses were inadequate, the lists of nurses waiting to be trained were long. Because staff in health centers were given priority to receive this training, hospital-based FP clinics with high IUD caseloads were often short-staffed for FP service providers. So, the attempt to maximize scarce training resources was not working effectively.

In addition, because participant selection, post-training deployment and delivery of training were all done by different entities, the individuals responsible for selection and deployment had little incentive to make responsible decisions because their decisions were "cost-free." In a study done in Kenya in 1994 (Schwarz and Guild 1994), followup data of service providers trained in the 6-week inservice FP course showed that only about half of them were still in a position to provide services two years post-training. Even though FP clinics may have staff on the waiting list for training, many staff who have received FP training are typically deployed to other wards/clinics in the hospital where they do not use their FP skills.

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