Strengthening evidence-based Family Planning services in pre-service medical education

31 March 2018
I. Background and Justification
Traditionally, most efforts to strengthen the health care practices in the public health system in India have focused on in-service training. However, medical colleges are role models for large numbers of medical and nursing students, their practices determine the actual practices in primary care system. 
At the same time, the practices at medical colleges are not always evidence based and are often outdated. They may not align with national and international guidance, especially in maternal care and family planning, for example, evidence based practices in labour care are not often practised, and medical eligibility criteria of family planning, respectful maternity care etc. are not followed, which affects lifelong attitudes and practice of medical students as doctors. Efforts to rectify these during in-service training are often not successful. 
Experiences of training programs on in-service doctors and nurses have revealed that providers are less likely to change their practices if they are to the contrary of what they have learnt in medical colleges. When pre-service and in-service training are closely coordinated, and both teach and reinforce evidence-based scientific knowledge and clinical skills, significant quality of care and cost-effectiveness benefits can be achieved. 
The skills of medical students in FP are very low, which results in a situation that a MBBS doctor is not able to properly counsel for and provide even the reversible FP methods. While those who postgraduate in obstetrics and gynecology, obtain skills in family planning, other doctors (those who practice as non-specialist doctors in the field, or postgraduate in other fields) do not acquire these skills. However, they do encounter young mothers and fathers and thus have missed opportunities to counsel for and provide family planning services.  This is largely due to outdated teaching methods, and insufficient focus on skill based training. 
There are some programmes to improve the pre-service classroom training, however, unless clinical sites follow the same standards simultaneously or before the classroom sessions, students will get frustrated that the clinical care they are asked to provide is not the same they are taught. 
Faculty of medical colleges are often part of technical guidance committees, and various expert committees that determine the service delivery guidelines. Hence, improving the knowledge of faculty on evidence-based maternal and reproductive health care, would eventually lead to implementation of evidence based and better quality practices not only in medical colleges, but will have an indirect influence on larger public health system. 
According to a recent estimate by ministry of health, 20% of all deliveries of public health system were handled by medical colleges. Therefore, in order to initiate the process on strengthening evidence-based RH care and FP skills in pre-service medical education, UNFPA proposes covering medical colleges in Maharashtra and Rajasthan.   
II. Objectives
1. To improve the quality of care and adherence of evidence-based standard clinical practices in medical colleges, focusing on maternal care and family planning
2. To improve the quality of teaching provided to medical students, so that builds greater skills for family planning and respectful maternity care and sensitivity towards reproductive rights 
III. Strategic Interventions
Formative stage: 
1. Baseline assessment of quality of care and quality of teaching for family planning skills in medical colleges: Adherence to evidence-based care, especially evidence based maternal care, reproductive rights, medical eligibility criteria of contraceptives, etc.
2. Reviewing the curriculum and advocacy meetings with Medical Council of India (MCI) and with state universities of medical sciences: The curriculum of MCI will be reviewed and suggestions will be provided for necessary changes in terms of incorporation of FP skills / rights based services. 
3. Form a project guidance group and setting standards of care: 
The implementing partner will identify the collaborating agencies and form a small group of 4-5 institutions / experts in the field (e.g. from FOGSI/ IMA, top level medical institutions, experts from public health), who will meet periodically and guide the intervention   
Standards of evidence based RH care will be identified and outlined, based on guidance from WHO, Ministry of health and other resources.  This will be done through an expert group, who will review the current situation and prepare a compendium of important guidelines, and a brief summary of standards. 
Implementation stage:
4. Implementing the standards of clinical practice:
Capacity building seminars of medical faculty on evidence based maternal care and family planning - to be conducted by expert group (1 training workshop per state, then onsite workshop in each medical college) 
Disseminate the guidance materials: the compendium of evidence based protocols and guidance materials will be provided. Some protocols will be displayed in labour rooms/ OPD/ family planning counseling sites. 
On-site support to selected medical colleges to identify other actions that are needed to develop solutions to root causes. On-site support (approx. 3-4 times a year) will be necessary, because sensitizing/ training of 1-2 faculty members in a medical college that has 30-40 persons involved in providing services will not bring about the desired change.
5. Incorporation of new contraceptives,  evidence based maternal and FP care and reproductive rights into CME sessions and conferences: In partnership with professional associations,  following interventions will be delivered:
CME (Continuous Medical Education) sessions will be supported in these locations / medical colleges, where sessions on FP updates (focusing on new & reversible contraceptives), evidence based maternal care guidelines, reproductive rights will be held. (Total 14 workshops over 3 years)  
Short term training courses for medical students / interns on FP: Short duration certificate programs (weekend courses) might be considered on reversible & new contraceptives (incorporating issues of reproductive rights) for selected states during the course of this intervention.  Part of the cost might be recovered from trainees as nominal fee. Approx. 10-12 training courses.
These interventions will be delivered in selected locations (cities) where medical colleges which are part of this this intervention are located. 
6. Implementing the standards of teaching of students:
Consensus on core competencies in family planning for medical students 
Identifying opportunities for building FP skills 
Capacity building seminars for medical faculty on skill based FP training 
Implementation of skills based RH learning (simulated training) 
Advocacy with textbook writers 
Modifications in practical examinations 
7. Periodic visits to monitor changes in practices: Periodic visits will take place to monitor progress in changes in clinical practice and teaching, and iterative corrections through providing feedback, and support them to implement changes, beginning with “low hanging fruits”. 
8. Evaluation of program and dissemination of results for scaling up
An end-line assessment will be done to assess the changes in practices 
Dissemination of results will be done through presentations in consultations and workshops as needed (such as innovation summits held for National Health Mission) and through dissemination workshop. Results will also be disseminated to state medical universities on regular basis. 
IV. Geographic coverage
Maharashtra – 4-5 medical colleges  
Rajasthan – 6 medical colleges 
Another state (depending on interest expressed) – 5-6 medical colleges
Target population: 
80 medical teachers  across 16 medical colleges and 
2400 medical students
160000 women delivering in these medical colleges
96000 women receiving outpatient consultation on family planning
V. Duration Three years (April 2018-Mar 2021)
Project budget is to submitted for following periods: Apr – Dec 2018, Jan -Dec 2019, Jan-Dec 2020, Jan-Mar 2021
VI. Key output  and outcome indicators
Output indicators
1. Number of faculty members in selected medical colleges trained in evidence-based standard clinical practices, focusing on maternal care and family planning (Target: 80 Faculty of medical colleges)
2. % lectures for undergraduates in obstetrics and gynaecology in selected medical colleges where interactive teaching methods / simulation methods were used (Target: 40%)
3. Number of fresh medical graduate students trained in evidence based standard clinical practices, focusing on maternal care and family planning (Target: 800 medical students)
Outcome indicators
1. % medical colleges that follow at least 3 crucial evidence based practices during labour care routinely (Target: 60%)
2. % fresh medical graduates who can correctly assess the eligibility of a client about 3 reversible methods of family planning (oral pills, injectables, copper-T) (Target: 60%) 
3. % fresh medical graduates who can correctly counsel a client about at least 3 reversible family planning methods, and demonstrate insertion of IUD on a model (Target: 60%) 
4. % medical colleges where standard screening checklists for contraceptives are used routinely (e.g. for PPIUCD insertion, injectables) (Target: 50%)
5. % medical colleges where OPDs have sufficient privacy and confidentiality during counseling (Target: 40%)
6. % recently delivered women in postpartum wards who perceive that they were treated with respect and dignity during labour and delivery (Target: 60%) 
Expected impact of the project
Increased alignment of national health priorities and medical teaching of reproductive health care  
Having providers who have the necessary skills to immediately begin providing services upon graduation, and resultant improved RH service delivery
Readiness in the State medical universities to make changes in the curriculum and examination system which is more aligned to objectives of the project (more competence among students for rights, and evidence based FP & RH skills)
VII. Prerequisites for implementing agency: 
The project requires dialogue and advocacy with department of medical education in states, medical council of India, professional associations and medical colleges. Hence the project will have to be led and implemented by senior management of the organization, who are able to travel to states and interact with senior medical college and medical department personnel. Senior level medical faculty of obstetrics and gynaecology departments who have experience of implementing evidence and rights-based practices in their set ups will have to be associated with the project for capacity building.   The agency should be comfortable in working with medical faculty of obstetrics and gynaecology, and have experience of monitoring and evaluation of programmes.  
It is desirable that the agency has experience of implementing projects in other states.  
For this project, two agencies with complementary expertise are welcome to submit a joint proposal.