Ministry of Health and Social Welfare
National In-Service Education Strategy
December 2008
TABLE OF CONTENTS
List of Acronyms
Acknowledgements
1. Summary
5
2. Background
6
3. Vision
6
4. Goal
6
5. Purpose
6
6. Rationale
7
7. Strategy for Improving Health Care
8
8. Situation Analysis
 Concept and context of in-service education
 Situations affecting quality of service in Liberia
 How RNs, CMs, PAs practice VS how they are trained to practice.
 Changes that affect practice
 Efforts to cope with changes
 Essential conditions that affect implementation of in-service program.
 SWOT analysis.
9. Present Capacity for in service training for implementation of the BPHS.
 Maternal and Newborn health care.
 Child Health
 Reproductive and Adolescen Health Care.
 Communicable and Tropical Diseases.
 Mental Health
 Emergency Care.
 Trainers
 Training Centers
10. Detailed program description
 In-service Unit
 In-service Advisory Committee
 Training Consultant
 Master Trainers
 Trainers
Training Center
Monitoring Supervision and Revision of Curriculum
Commodities
Outcomes
11. Recommendation
12. Preparation for roll out
13. Scheduling
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14
18
22
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24
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14. Implementation
15. Two year time line
29
32
Attachments
37
1.
2.
3.
4.
5.
6.
7.
8.
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41
43
45
46
59
60
61
Advisory Committee TOR
Master Trainer Job Description
Trainer Job Description
Training Consultant Job Description
List of Training Equipment
Criteria for setting up an in-service training center
In-service Capacity
References
3
LIST OF ACRONYMS
ACT
ANC
ARI
BLSS
BPHS
CDC
CHT
CM
CMO
DHS
EMONC
EU
FDH
FP
HBLSS
HIV/AIDS
IMCI
IMR
IUD
LURD
MMR
MOH&SW
NACP
NGO
OIC
PA
PEP
PHC
PMI
PMTCT
RN
SGBV
SOW
TM
TOR
TTMs
UNFPA
UNICEF
USAID
VCT
WHO
Artemisinin-Based Combination Therapy
Antenatal Clinic/care
Acute Respiratory Infection
Basic Life Saving Skills
Basic Package of Health Services
Community Development Committee
County Health Team
Certified Midwife
Chief Medical Officer
Demographic Health Survey
Emergency Obstetrical and Neonatal/Newborn Care
European Union
Family Health Division
Family Planning
Home-Based Life Saving Skills
Human Immune Virus/Immune Deficiency Syndrome
Integrated Management of Childhood Illnesses
Infant Mortality Rate
Intra-uterine Device
Liberia United for Reconciliation and Democracy
Maternal Mortality Rate
Ministry of Health and Social Welfare
National Aids Control Program
Non Government Organization
Officer in Charge
Physician’s Assistant
Post exposure Prophylaxis
Primary Health Care
President’s Malaria Initiative
Prevention of Mother To Child Transmission
Registered Nurse
Sexual and Gender Based Violence
Scope of Work
Traditional Midwives
Terms of Reference
Trained Traditional Midwives
United Nations Fund for Population Activities
United Nation Children’s Fund
United States Agency for International Development.
Voluntary Counseling and Testing (for HIV/AIDS)
World Health Organization
4
1. PROGRAM SUMMARY
This In service Program is a capacity building initiative conceived by the Ministry of
Health and Social Welfare in support of rebuilding basic health services in Liberia.
Specifically the program will:1) train and retrain all relevant cadres of mid level
health care providers, to deliver comprehensive primary and secondary health care2)
establish within the MOH&SW, relevant training institutions and licensing authorities
the institutional capability to continue appropriate in service training
The training program will be task oriented and competency based in response to
MOH&SW’s need for mid level health care delivery personnel fully qualified and
competent to assume broadened responsibilities for delivering a balance of Curative/
preventive/promotive personal, family and community services. The curriculum will
embody the components of the Basic Package of health Service (BPHS)
The in service program identifies the present capacity for training for implementation
of the BPHS and outlines a detailed plan to build and expand this capacity to produce
an integrated comprehensive program for adequate implementation of the BPHS and
institutionalization of in service training in Liberia. The document outlines a detailed
,draft, prioritized schedule for roll out of the in service program, with detailed time
plan for two years and tentative projections for five years. Equipment list and start up
tips requested by BASICS and the In Service Unit are attached to this document.
At the end of this program the following conditions will prevail:1)approximately 1880
mid level health care providers will be trained and retrained through this in service
program to implement the BPHS;2)the content of the in-service program will be fully
integrated into relevant basic curricula 3) the MOH&SW will have the institutional
capacity to continue in-service education4)Licensing authorities will be cooperating
with MOH&SW in maintaining skills level of professionals by mandating continuing
education courses as eligibility for renewing license.
5
2. BACKGROUND
The ravages of two decades of armed conflict leading to the depletion of social ser
vices have brought Liberia’s health care delivery system to severe devastation.
Registered Nurses (RN), Certified Midwives (CM), Licensed Practical Nurses (LPN)
and Physician’s Assistants (PA) provide a wide range of health care services at
hospitals, clinics, health centers and communities independently. As the number of
Liberian physician’s dwindled over the years from over 600 to just over 50, the
burden on these frontline service providers to offer quality comprehensive services
has concomitantly increased while their numbers have drastically decreased. 1 Mid
level health care providers have therefore been obliged to meet the needs of their ever
expanding roles without the benefit of regular refresher, in-service or post graduate
courses. They have been doing this under severe hardship conditions. Shortage of
staff, lack of necessary equipment and supplies and other resources also contribute to
the deterioration of skills and practice.
With the advent of peace the MOH&SW has embarked on an ambitious and daunting
task of rebuilding the health care delivery system. A priority intervention is human
resources capacity building at all levels of the system The MOH&SW has developed
a Basic Package of Health Services which forms the basis for capacity building(inservice education) for health workers at service delivery points. .
3. VISION
The maintenance of a health care delivery system adequately staffed with
appropriately trained mid level service providers offering a comprehensive
mix/balance of curative, preventive and promotive services, as specified by the BPHS.
Mid level health care providers will be capable of training and supervising community
health care providers to compliment their services.
4. GOAL
The goal of the national in service program is to improve the health of the Liberian
population by developing the competence of mid level health care providers.
1
The need for in-service education was previously identified by a USAID assessment team in 1998.
See Rebuilding Liberia’s Health Sector: Analysis, Strategies and Recommendations, Barbara Hughes,
C. Kirk Lazell, Alan Malina, Mary Mertens, Dr. Paul E. Mertens, Dr. David Ofori-Adjei, June 1998.
6
5. PURPOSE
The purpose of this in service program is to improve the skills of frontline health care
service providers (RNs, CM, PAs) to give high quality comprehensive health care
based on the BPHS established by the MOH&SW.
The purpose of this five year in service plan is to develop and set forth a detailed two
year schedule for in service training and a continued three year projection. This effort
will be the cornerstone to enable the MOH&SW to implement the BPHS, improve
health services and expand appropriate coverage of health services particularly in
rural areas. It is designed to help MOH&SW develop the cadres of non-physician
health care providers in primary and secondary health care settings. They will be
equipped to deliver curative, preventive and promotive health care services to the
Liberian population specifically in rural areas where health care delivery is lacking or
grossly inadequate. Emphasis will be placed on midwifery and maternal and newborn
care skills to serve mothers and children, the population at greatest risk.
This in service program will serve many purposes:
 Upgrade and strengthen the skills of mid level health care providers to enable
them to offer the BPHS in an optimum manner.
 Establish within the country the institutional capability to upgrade the skills of
mid level service providers through in service training.
 Establish and maintain standards of care and make optimum use of resources.
 Equip mid level health care providers to overcome weaknesses or deficiencies
in training.
 Enable mid level health care providers to adapt their work performance to
changes in the health status and profile of the population.
6. RATIONALE
At present the rural poor in Liberia are underserved in health care. Mothers
and children are the groups suffering the greatest morbidity and mortality. The
government of Liberia has therefore prioritized maternal and newborn care as
the number one priority intervention strategy for the improvement of health in
Liberia. Accordingly the training of midwifes and in service training of mid
level and community health care providers in LSS is of high priority with the
MOH&SW.Training in all six areas of the BPHS will be done for mid level
frontline service providers.
The project aims at fulfilling a dual need. On the one hand, mid level health
personnel will be trained and retrained to implement the BPHS.
Simultaneously training institutions and the MOH&SW will be strengthened
to have the capacity to continue basic and in service training at the end of this
program.
This in service program will be implemented over a five year period and will
accomplish the following:
 Train and retrain all RNs in all aspects of the BPHS
 Train and retrain CMs in all areas of the BPHS
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Train and retrain all Pas in all aspects of the BPHS
Train a cadre of master trainers for in service education
Train a cadre of trainers for in service education.
The MOH&SW will increase its capacity and institutional capabilities to
conduct in service training programs without further external assistance
Integrate the in-service curricular into basic health training curricula.
7. STRATEGIES FOR IMPROVING HEALTH CARE
The in service program will utilize three strategic approaches for improving health
care:
 Training all mid level health care providers to implement the BPHS.
 Strong supportive supervision of mid level health care providers by the county
health team and trainers: Trainers will do follow up supervision of participants
with the CHT. This will begin the process of institutionalization and
decentralization of the in service program. At least two CHT members will be
trained as trainers. A standardized assessment tool (checklist) based on the
BPHS will be used for supervision by trainers and supervisors. Supervisory
staff will be trained in the more positive techniques of supervision.
 Use of job aids: The program will specifically promote the use of procedure
and policy manuals as job aids. All service delivery points/units will be
equipped with these manuals The manuals will be in the form of box files
carefully arranged to allow individual policies to be easily identified and
removed and replaced when updated. The in service unit will be responsible
for developing and keeping these manuals updated and current.
8. SITUATION ANALYSIS
Concept and context of in-service training
The body of knowledge and skills that characterizes each health care profession is
dynamic, ever expanding and changing as new information is evolving and made
available through research, proven and best practices Research findings and
technological advancement impact diagnostic and therapeutic modalities at a rapid
pace. Socio-cultural change, environmental conditions (impacting nutrition, health
and disease profile) dictates priorities in health care which informs the content of in
service programs. To stay abreast of these changing conditions, continuous in service
programs is an imperative and should be a routine of every health care system. In
some jurisdictions in service programs are carefully stipulated, strongly mandated and
stringently regulated and enforced
Situations affecting quality of service delivery in Liberia.
In Liberia many factors affect the ability of service providers to practice their skills
optimally:
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Chronic and severe shortage of staff: requiring service providers to use short
cuts to handle overwhelming work loads
Lack of a comprehensive health team: requiring service providers to perform
tasks for which they do not have the proper or formal training and skills
Poor physical facilities: prohibiting or down grading the practice of some
procedures.
Lack of equipment: requiring improvisation leading to blunting and loss of
skills
Change in administration.
Poor basic training due to deterioration of asic training schools and hospitals
and clinics as clinical training areas.
Aging of staff
Lack of supportive supervision to reinforce learning and enforce standards and
high quality
Lack of reference materials and procedure manuals to guide practice.
Lack of reviews and frequent skills checks to determine and maintain quality
of practice.
Lack of an adequate health information system(HIS)which monitors and
provides continuous feed back on service delivery performance and results
Over the past two decades of conflict and post conflict all of the above issues have
been prevalent and the infrastructure for skills building in health has all but
disappeared. The training institutions endured severe destructions in physical
structures, furniture and equipment and loss of qualified staff that fled the country in
the wake of the violence. Some schools have been functioning in recent years without
adequate physical facilities, equipment and staff. In addition hospitals clinics and
community services that serve as centers for clinical/practical and field learning
experience have not been restored to adequate functional levels and therefore do not
afford opportunities for adequate practice. These institutions, both academic and
professional, therefore, produce graduates that have not attained optimum skills for
high level performance.
Mid level professionals who qualified before the conflict have not had regular in
service training to upgrade their skills. More importantly they have been denied
opportunities to practice their skills appropriately due to destruction of physical
facilities and lack of equipment and supplies including drugs As students use facilities
for practical learning experience, these practitioners serve as their preceptors and role
models providing them with less than satisfactory examples of practice.
The training of health care providers is now being given priority by the MOH&SW.
At present there is dire shortage of health manpower in general and particular among
doctors, which puts a strain on mid level health care providers. The physician’s
assistant is the surrogate physician whose present function is mainly ambulatory and
curative. It is necessary to retrain the PA to care for mothers and newborns and
assume leadership of the PHC mid-level team which will provide a balance of
preventive, promotive and curative health services.
The registered nurse is trained to perform general nursing duties but also delivers
maternal and newborn care with very little training in this most critical area. The
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registered nurse needs further training to sharpen general nursing skills and develop
maternal and newborn care skills
The certified midwife is trained specifically for maternal and newborn care but
functions (and will continue to do so) as a generalist and will require further training
to offer the comprehensive care that will be required of her for the foreseeable future.
Changes that affect practice
Over the years of conflict important developments/changes have taken place in health
care. Notably the pandemic of HIV/AIDS has revolutionized health care in many
ways. Disease profiles have changed negatively due to worsening hardship conditions
such as food insecurity, poor sanitation, lack of clean water, displacement and lack of
adequate shelter. The effect of these conditions is demonstrated in the comparison of
the results of the recent DHS (2007) with past DHS.
DHS 1999
DHS 2007
Maternal Mortality
Maternal Mortality
578/100,000
994/100,000
Infant Mortality
Infant Mortality
117/1000
71/1000
Child Mortality
Child Mortality
198/1000
110/1000
60% of population under 20 years of 60% of population under 20 years of
age
age
Contraceptive prevalence rate
Contraceptive prevalence rate
4%
Adolescence pregnancy
Adolescence pregnancy
10%
High
Fertility
Fertility
6.2
5.2
Efforts to Cope With Changes
A variety of in service training has been offered by NGOs and bilateral organizations
that support MOH&SW facilities/services. Many of these courses have not been
formalized. There has been insufficient attempt to arrive at skills and task analyses for
standardization and uniformity in in- service training for the country. This in- service
program is an attempt to achieve this. The MOH&SW has endorsed several programs
for training mid level care providers e.g., PMTCT, IMCI and BLSS. Two training
centers have been set up for BLSS training and three others are proposed to be
established around the country within a probable two year period. Basic Life Saving
Skills addresses the maternal and newborn component of the BPHS. The Child Health
component of the BPHS will incorporate IMCI, while the Communicable Diseases
component will incorporate VCT and PMTCT and Malaria case management.
Although the BPHS forms the basis for this in service program several strategies, and
mandates will contribute to the content and approaches used in this program. The
MOH&SW’s Health Policy and Plan, The Road Map for Reduction of Maternal and
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Newborn Morbidity are Mortality and the Child Survival Strategy will all impact the
in service program
The Health Plan uses a decentralized approach to provide for:
 A comprehensive health care delivery system through out the country
 Strengthening and expanding maternal and child health services throughout
the country.
 Replacing and renovating old and inadequate facilities particularly in rural
area.
 Strengthen measures for the prevention and control of communicable diseases.
These include vector control, provision of basic sanitation facilities and clean
water supply, and early detection and treatment of diseases.
 Train personnel at all levels and orient health human resources development
towards meeting the needs of communities.
The underlying strategy of the current health plan is that PHC is undertaken
not as an activity of MOH&SW but as an integrated element of the general
approach to development at the community level. County and district health
teams are encouraged to promote and support this strategy.
The Road Map for Maternal and Neonatal Health sets forth a format for
improving Maternal and Newborn Care over the next ten years.
The Child Survival Strategy seeks to achieve optimum child health by
promoting prevention and treatment of conditions that contribute to child
morbidity and mortality. Priority is given to participation of community,
family and females.
Essential Conditions for Successful Implementation
Some Essential Conditions for successful implementation of a national in service
program are:
 Ministry of Health & Social Welfare must make the program mandatory and
insist that all supporting agencies cooperate.
 The in service unit should collaborate with NGOs and donors offering vertical
programs to achieve standardization by integrating all programs into the
general in service program.
 All stakeholders should be made to appreciate the difficulties in scheduling
due to shortage of staff and be willing to make sacrifices to comply with
training schedules.
 In service trainers should be deployed full time to train and assist in follow up
and supervision of participants in collaboration with the county health teams..
 MOH&SW should standardize allowances for workshops and ensure that all
agencies comply. These standards should be used for the in service program.
 There must be a system for scheduling that ensures that the program achieves
its targets in compliance with the time line.
 The time line should be reviewed and revised frequently to accommodate
changing circumstances e.g. attrition of trainers and master trainers.
 The in-service unit must work with basic training programs to ensure
that the in-service curriculum is integrated into all basic curricula by mid
2009 and all graduates from June 2010 will have the skills necessary for
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implementing the BPHS and therefore will not be offered the in-service
course.
Facilities, supplies and equipment must be available at service delivery points
to enable workers to practice their skills (implement the BPHS) at a
satisfactory standard and minimize the need for frequent refresher training.
Basic health services will be supported by the widespread use of auxiliaries,
because professional staff will continue to be in short supply and it is
inefficient and uneconomical to use professionals for some simple routine
tasks.
The existing proposed organization of health services facilities and personnel is to
enable optimum implementation of the basic package of health services.
The MOH&SW is presently developing a strategy for implementing community
based services on a voluntary basis. Mid level health care providers will be trained
and expected to supervise, train and establish strong links with community health
volunteers.
Groups at Community Level
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Community Development Committee (CDC): the main vehicle for development
of PHC at community level is the CDC or a similar group. The CDCs are
comprised of local leaders and should represent a cross section of the community.
It is essential that a significant percentage of the membership be women. These
committees should provide the managerial structure for PHC at the community
level. The functions of the CDC should include planning and management of
maternal and child health, water and sanitation, family planning and the treatment
of simple, particularly communicable diseases. One of the major objectives of
PHC is to reduce high morbidity and mortality among mothers and children. It is
therefore necessary to include activities such as nutritional surveillance of children
who are not brought to clinics, promotion of nutrition in homes, antenatal
screening, supervision of deliveries, management of diarrhea in children,
immunizations, zinc and vitamin A therapy and prophylaxis and emergency
treatment of malaria.CDCs should therefore actively encourage participation of
women.
The other main areas of emphasis are creating awareness of health problems and
availability of care.
Community Based Service Provider is responsible for:
Promotion of sanitation and clean water.
Surveillance of epidemics
Treatment of diarrhea, malaria, worms, anemia etc.
Health Education.
Family Planning
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Trained Traditional Midwife.: is responsible for:
Deliveries
Referral of high risk and difficult cases
Treatment of anemia
Advise to take children to under five clinics
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Monitor child development through growth charts
Health Promotion
The international PHC movement stresses the importance of community
participation, management and financing. The Liberia government does not
support payment of salaries to community health workers. Communities are
encouraged to find ways of compensating these workers. In the case of TTMs this
is already being done.
Methods of Continuing Education
As the program develops a variety of methods of continuing education
methods will be used:
COURSES
Courses comprise packages of learning events planned to enable health
workers to develop specific competences. These events include lectures, class
presentation by participants, laboratory exercises, role play, individual projects
etc.
Meetings
These are single learning events to inform staff of pertinent developments in
heath care, an important and outstanding case study, a looming epidemic or a
new drug or therapy.
Supportive Supervision
This is a very strong method of continuing education. Some institutions use
supervisors as continuing education/in service staff that offer preceptorship
training along with supervision of staff members.
MANUALS
Policy and procedure manuals can be used as job aids and teaching tools.
SWOT ANALYSIS
STRENGTHS
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Basic health care package developed and being implemented.
Life Savings Skills training in process
Integrated management of Childhood Illnesses training established and
ongoing.
Voluntary Counseling and Testing (VCT) training established and
ongoing.
Prevention of Mother to Child Transmission (PMTCT) training established
and on going.
Modules and other training materials available
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Qualified staff(many trainers)
Donor support
Administrative support
Political will
WEAKNESSES
 Lack of career structure for health workers
 Inadequate incentives for health workers
 Weak health system
 Weak data base for previous in-service training
 Uneven distribution of qualified staff
 The Ministry of Health and Social Welfare rely on NGOs and donor
agencies to support its facilities and services and does not exercise control
over the in service training they offer.
OPPORTUNITIES
 Donor support.
 Political will
 Voluntary commitment.
 Increase in budget.
THREATS
 Shortage of staff.
 Lack of cooperation and resistance from stakeholders who support
facilities. Already they are complaining of difficulty in releasing staff for
training due to shortage. They continue to resist.
 Existence of vertical training programs that will duplicate MOH&SW’s
Program.
 Resistance to change.
 Donor fatigue
 Weak health system
9. PRESENT CAPACITY FOR IN SERVICE TRAINING FOR
THE BPHS IN LIBERIA
MATERNAL AND CHILD HEALTH
Working towards achieving the UN Millennium Development Goals #4 and # 5 the
MOH&SW has endorsed and adopted two programs developed by the American
College of Nurse-Midwives (ACNM). Both Basic Life Saving Skills (BLSS) for mid
level health care providers in facilities and Home Based Life Saving Skills (HBLSS)
for community health care providers, families and communities have been
successfully implemented.
BLSS is a facility based two week intensive education program for midwives, nurses
and physicians (which builds on midwifery and obstetrical/gynecological skills) to
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provide quality care for women and infants during pregnancy, child birth and early
postpartum. The training enables maternal/newborn health care providers to respond
in a timely, effective and appropriate manner to obstetrical and newborn emergenciesessential in reducing maternal and newborn mortality and morbidity. BLSS training
also strengthens skills in maternal and newborn care, infection prevention, and
problem solving integrating HIV/AIDS education throughout the program. The use of
the partograph for tracing the progress of labor and recognizing the need for
intervention in a timely is the hallmark of intrapartum care.
Two training centers have been set up at Phebe Hospital and Redemption Hospital
specifically for BLSS to support the intensive clinical training that is required. The
Phebe Hospital center accommodates eight students and Redemption accommodates
sixteen.. Currently the program has trained 10 trainers, 249 service providers and 6
master trainers will be trained in December. The trainers and prospective master
trainers occupy other (some quite senior and demanding) positions in health service
making their availability for BLSS precarious and occasional. Rapid attrition among
this group should be anticipated and handled.
.
Home Based Life Saving Skills(HBLSS) is designed to improve the quality of care by
traditional midwives, utilizing a cascading method of training to empower family and
community members to recognize complications associated with pregnancy,
childbirth and postpartum and make early referrals to save lives.
HBLSS is a family focused training and community mobilization program to reduce
maternal and neonatal mortality by:
 Decreasing delays in problem solving
 Decreasing delays in reaching referral centers
 Supporting birth preparedness and complication readiness
HBLSS is a training for community care providers (TMs) and is therefore not a
component of this in service program for mid level health workers. It is, however,
highly recommended to be implemented simultaneously with BLSS for the proven
synergistic effect. When HBLSS is implemented in the catchment communities of
clinics and hospitals where BLSS is practiced the number of referrals to them is
increased. This has been markedly demonstrated at PHEBE hospital.
CHILD HEALTH
The IMCI curriculum developed by UNICEF is being used for training mid level
health care providers since 2006. To date 194 mid level service providers from all
counties have been trained. Twenty four doctors and mid level health workers have
been trained as trainers. Some have never functioned as trainers and since there is no
organized rotation of trainers some have not had the opportunity to practice their
skills even if they would like to. This course addresses the child health component of
the BPHS as it offers a mix of curative, preventive and promotive child health care
information.
REPRODUCTIVE and ADOLESCENT HEALTH
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Many attempts are being made to offer training in various aspects of reproductive
health. Many Family Planning (FP) modules are available including the IPPF module.
Family Planning is also offered in Registered Nursing and Midwifery curricula. The
methods include hormonal contraceptives by pill and injection and male and female
condoms for dual protection as a barrier method against STIs and pregnancy.
Intrauterine Device (IUD) insertion and removal is also taught in those curricula but
the skill is not mastered. The BLSS course also includes the theory of IUD insertion,
removal and management.
There is a module on Gender Based Violence (GBV) including rape management and
Post Exposure Prophylaxis (PEP) prepared by WHO for the MOH&SW.It is intended
for the training of service providers but it is not being used for this purpose on a
regular basis. Information on past training activities is not yet available.
A yet to be used training module on Adolescent Sexuality has been developed by
BASICS.
COMMUNICABLE DISEASES
There are a number of training courses that have been offered to mid level service
providers in some aspects of communicable diseases.
A module which addresses tuberculosis, malaria HIV/AIDS and some endemic
diseases which frequently reach epidemic proportions has been developed by
BASICS. The BPHS requires skills in VCT, PMTCT, Treatment of Opportunistic
Infections associated with HIV/AIDS. These are included in a number of courses
given by NACP: There is a ten (10) day course for VCT, fourteen (14) day for
PMTCT, five(5) days for opportunistic infections and syndromic management of
STIs, and five(5) days combined Refresher.
The malaria program through MENTOR Initiatives has trained most mid level health
care providers in the new protocols for treatment of malaria. With funding from the
President’s Malaria Initiative (PMI) Mentor Initiatives plans to offer training to CMs
in managing malaria in pregnancy. The plan is to train one hundred and twenty five
CMs yearly for three years.
MENTAL HEALTH
The post war history of Liberia makes mental health a high priority. It is also a
severely underserved area of health care. Although mental health is offered in theory
in the basic curriculum for registered nurses, there is very little opportunity for
practice as mental health services are not offered at most facilities. A mental health
module has been prepared by BASICS.
EMERGENCY
A first rough draft of an emergency health care module has been prepared by
BASICS.
TRAINING CENTERS
Two training centers have been set up for BLSS. The Phebe hospital training center
accommodates 8 participants for clinical training and 15 in the classroom. The
Redemption hospital training center accommodates 16 participants for clinical
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training and 20 in the classroom. These centers are set up specifically for BLSS and
are not available for other use.
TRAINERS
A large number of trainers have been trained for specific vertical programs and their
services utilized when funds are available to offer the courses. Many of these trainers
occupy demanding, senior and full time positions and their availability is not
guaranteed
10. Detailed Project Description
This program addresses two basic constraints of the MOH&SW:
 The lack of appropriately trained mid level health workers to properly
implement the basic package of health services.
 The lack of institutionalized capability to train and retrain (update) the
necessary cadres of health workers
In pursuit of millennium goals4) to reduce infant mortality, 5) to improve maternal
health and 6) to combat infectious disease such as HIV/AID, tuberculosis, malaria etc.
robust implementation of the BPHS will be promoted primarily through the in service
training of front line service providers and improved basic training.
Organogram
In-Service Education Staffing
Director of Human Resource
Training
Assistant Director
Senior Trainer
Assistant Director
Administration
Regional Master Trainers
2
2
2
2
2
County Level Trainers
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
17
11 Master Trainers
45 Trainers
IN-SERVICE UNIT
An in service unit within the MOH&SW will implement the in service program. The
office is headed by a Director of Human Resources/Traininjg. Two assistants have
been assigned making a total staffing of three. One assistant will assume mainly
administrative duties, while the other will assume technical responsibilities as senior
master trainer
IN SERVICE ADVISORY COMMITTEE
An In-service Education Advisory Committee has been set up to advise the in service
unit in all aspects of its work.
The in service committee is chaired by the MOH&SW. Its membership includes
MOH&SW, Representatives of international organizations such as WHO, UNICEF,
UNFPA USAID, EU, NGOs /implementing partners of major donors, representatives
of training institutions and professional boards. the committee will provide a
collegiate forum for discussion and decision making on issues concerning in-service
education. The committee will serve to keep stakeholders informed and involved in
the in service program as this could be a factor in their cooperation with scheduling
and releasing their staff for training which is anticipated to be a great constraint in a
system where shortage of staff is so acute. Terms of reference for this committee are
attached.2
The work plan defines the roles of the mid level health cadres and need for retraining
initiatives as part of the BPHS implementation process. All cadres will participate in
organizing community outreach. All cadres will be prepared to give comprehensive
health care based on the six components of the BPHS. The CM will function as the
maternal and newborn specialist and also as a generalist. The PA and RN will be
trained to function comprehensively and as manager of the health team at clinic level
in preventive/promotive/curative health care and general public health. Selected CMs
in particular and RNs and PAs if necessary will be trained as trainers of traditional
midwives and other community based workers. Selected RNs and Pas will be trained
as master trainers and trainers for the mid level provider in service program. All mid
level service providers will be trained as supervisors of community health volunteers.
County health teams will be oriented to the content of the in service program and the
supervisory tools used to monitor the implementation of the BPHS.Two members of
each county health team will be trained as trainers for the program and will function
as trainers and supervisors The program will train all Pas CMs, RNs and LPNs in
service in .Liberia.
2
The full terms of reference for the Advisory Committee is attachment 1.
18
One of the priorities of the MOH&SW is LSS training of mid level health care
providers and traditional midwives. The two training centers established and in
operation for BLSS training of mid level providers will be used to continue that
training as a priority until all cadres are trained. The imminent training of master
trainers for BLSS should speed up this training. The MOH&SW is desirous of
establishing three more centers. The sites have not yet been selected. The RBHS
project provides for the establishment of seven EMONC centers in hospitals. Ideally
and conveniently the training centers should be established at these sites.
The IMCI course will include EPI. It meets the requirements for Child Health training
and will be continued at an increased pace until all mid level health care providers are
trained.
The remaining four components of the BPHS will be combined in one course and will
be offered to mid level providers who have already taken the BLSS and IMCI
courses.
TRAINING CENTERS
The integrated in service training will be based at the five regional training centers
throughout the country. Two training centers will be set up initially and others will be
phased in. Attached is the criteria for selecting a training center. BASICS has checked
on an abandoned building on the Phebe hospital compound. It is ideal for a training
center but needs repairs after being vandalized during the war. The building is owned
by the Lutheran church. The church is willing to enter a deal for the use of the
building in lieu of paying for repairs. Architectural drawings and cost estimates for
repairs are attached.
Ideally in service training should be given on the job site to limit the amount of time
an employee spends off the job for in service training The program will work towards
attaining this ideal. A first step will be the training of at least two members of each
county health team as trainers. Issues that necessitate the use of training centers are:
 The lack of suitable conditions for training at most duty stations
 The need to train for all levels of service delivery.
Five training centers will be set up in five regions. The criteria for establishment of
training centers are attached. Where possible every effort will be made to establish
BLSS training centers at some of the EMONC centers proposed in the RBHS project
TRAINING CONSULTANT
A training consultant will be engaged to train in country staff as master trainers and
trainers. Two members of each county health team will be trained as trainers. The
consultant’s scope of work will include working with basic training programs to
integrate the in-service curriculum into these programs. This should be accomplished
by the third quarter of 2009 and by June 2010 all graduates from the basic programs
should have the in-service program with no need for upgrading their skills through the
in-service program. This consultant will be recalled annually (or at a frequency to be
19
determined) for redesign activities. A job description for the training consultant is
attached.3
MASTER TRAINERS
Eleven master trainers will be trained. Selection criteria and job description are
attached. The trainers should be registered nurses and PAs who have the qualification,
interest, motivation and experience to function as trainers. They should be health care
providers who are clinically active within the health care delivery system as OICs or
clinical instructors who will have opportunities to continually practice their skills and
will be available to train more trainers and fill in for trainers when the need arises.
Senior officers with demanding schedules should not be selected for these positions.
One assistant from the in-service training unit and two people for each of five regional
centers will be trained. This makes a total of eleven master trainers. The Job
Description for Master Trainer is attached.4
TRAINERS
The master trainers will train three people from each of fifteen counties as trainers to
man the training centers. Trainers will be carefully selected by MOH&SW based on
education, experience and ability to teach. They will work intensively with the
consultant and master trainers to complete the development of course structure
(teaching content and methodology, identification and preparation of training
materials, work books, manuals and design of practical exercises). The course
planning will extend to the level of individual lesson plans. In the first year 15 trainers
will be trained. In year two another 30trainers will be trained. Subsequently, trainers
will be trained as necessary to man the training centers and cope with attrition. Upon
completion of training the trainers will be assigned to their training sites where they
will teach under the supervision of a master trainer. Trainers who are not occupied
with training will conduct supportive supervision to monitor and follow participants
to reinforce learning and glean information for the health information system and for
operations research to inform the curriculum review and revision process. They will
conduct supportive supervisory follow up with members of the county health team.
MONITORING, SUPERVISION and REVISION of CURRICULUM
The training process will be carefully monitored for quality control by the master
trainers who will supervise and continue the development of trainers. A data base for
the in-service program will be set up
Inter-cycle periods will be utilized for program assessment, curriculum adjustment
and retraining of trainers (reinforcement). It is projected that a cycle of
(TBD)participants will be completed every(TBD)months. This will yield (TBD)
participants inclusive of supervisory staff each year. All mid level health care
providers will be trained by the end of 2012.The curriculum designer, master trainers
and trainers will then review the training process, assess the performance of
participants and design refresher courses to begin 2012/2013.
3
4
The Job Description for the Training Consultant is attachment 4.
The Job Description for Master Trainer is attachment 2.
20
COMMODITIES
The commodities proposed for this program consist of training materials and
equipment, reference books and manuals for clinics and hospital wards, supplies for
the training centers, vehicles to provide transportation for trainers to do supervision
and for participants field training experience.
a)Teaching Equipment and Supplies
Equipment and supplies to be procured for this program include projectors, reference
materials and other instructional equipment.
Attachment ------provides a list of program equipment and materials.
Attachment-------Provides a list of office equipment and supplies.
b) Vehicles.
Five vehicles are proposed, one for each training center.
c) Workshops/Seminars.
Workshops/seminars will be planned to develop curricula, retrain health workers,
orient MOH&SW personnel, orient community leaders and evaluate the program.
Outcome
By the end of the program enrollment and graduation figures should show that:
 The in service training of mid level health professionals is institutionalized
 The in-service curriculum is integrated into basic curriculum for RNs, PAs and
CMs. This should be accomplished by year1 and by the end of year 2 all
graduates from these basic schools should have all the skills required for
implementing the BPHS.
 Curriculum for in service training will be fully developed and in place.
 A permanent in service training faculty will be in place
 MOH will have the capability to develop national in service training curricula
and teaching materials.
 Retraining will have been provided to existing PAs, RNs and CMs including
CHT members and continuing education will be institutionalized in
MOH&SW and decentralized to the counties..
11. Recommendations

The MOH&SW training unit conducts a training inventory to glean
information on training that has already taken place to determine who has been
trained. This list will be compared to the list of mid level health workers
working in the country to determine how many people still need to be trained
and in which components of the BPHS. This information is being sought. Two
hundred and forty nine participants have had BLSS training and the list of
names and locations is available. One hundred and ninety four participants
have had IMCI training. There is a list of names of participants who have been
trained in the new malaria treatment protocols. The list is available.5
5
A form was developed by the Consultant and distributed to NGOs supporting MOH&SW facilities for
distribution to collect information on In-service training already done by their staff. County Health
Teams are also using the form to collect information from the counties.
21







The MOH&SW training unit conduct a survey among INGOs and LNGOs to
find out their in-service training capacity, plans,/schedules and funding if any.
This survey is in process. At least ten vertical training programs have been
identified. Most are funded through the Global Fund and the President’s
Malaria Initiative (PMI).Vertical programs are usually donor driven with
funding dedicated to meeting specific milestones stipulating cadres, numbers,
and length of course etc.All programs draw from the same pool of service
providers. There is also a local organization that is often engaged by INGOs to
offer training in one of four courses that overlap with components of the
BPHS.6
Now that the validation process has identified the gaps and overlaps, the in
service unit should adjust the modules during the workshop in Gbarnga on
December 14th to 21st, 2008 This can be done by extracting material from the
vertical programs to include in the integrated program.
The in-service unit should meet with the implementers of vertical programs to
discuss and arrive at agreement/compromise for the integration of vertical
programs into the national in-service program.
The training unit should send a representative to the monthly NGO
coordination meeting at SC-UK to inform the group about the unit and its
SOW and TOR.7
The MOH&SW training unit should acquire the following documents:1) all
basic curriculum, manuals and modules used in the country; 2)all in service
curriculum, manuals and modules used in the country 3) all post graduate
curriculum, manuals and modules used in the country.
A master calendar with all in service training planned for the calendar year
must be developed and posted in the unit.
Physical space should be allocated and furnished to accommodate the unit
12. Preparation for Rollout
Prepare a budget with current costs and a ten percent contingency. Consult with
people who have experience in planning and implementing training. Make sure
all goods and services are included in the budget. Have others double check
before the budget is submitted.
1) Accelerate IMCI and BLSS: The BLSS training at two sites will accommodate 24
participants. The IMCI will accommodate 30 students. Two cycles per month for 2
months will train 96 for BLSS and 120 for IMCI making a total output of 216 for 2
months. The 2 training components will not be modified, and so can be easily
accelerated while plans are put in place for the integrated in-service program.
2) Recruit Consultant: A scope of work should be developed immediately for the
consultant who should be on board in early February, 2009. The consultant should
work with the Peace Corps Volunteer to fine tune the curriculum, administer the TOT
and supervise trainers to teach for at least one session. Ideally all staff of the in6
The consultant has collected as much of this information as she is aware of. A chart is attached. The
In-service Unit should double check.
7
The consultant attended the NGO coordinating committee meeting on December 6th, 2008 to inform
the body of the National In-service Plans. The In-service Unit should follow up.
22
service unit should take the TOT course. The consultant should have at least one week
in country before the TOT starts.
3) Select Master Trainers: Identify Master Trainers and set the date for training as
soon as the availability of the consultant is arranged.
4) Select Trainers: The number of trainers selected could be limited to two training
sites to begin. This will give Master Trainers the opportunity to train Trainers for
other training sites as the program is rolled out.
5) Set up Training Center: Aim to start off with two or three training centers. Use the
criteria and supply list. Be prepared to rent a vehicle for transportation until a vehicle
is procured. This may take longer than anticipated. If the Lutheran facility at Phebe is
selected, make arrangements for renovation ASAP. Be prepared to rent space until the
renovations are complete. It will be necessary to procure furniture. This could be
ordered locally to cut costs. Other supplies such as linen and kitchen utensils should
be procured in a timely manner. Make arrangements for catering and be prepared to
pay a portion of the cost in advance.
6) Order training materials: Order should be placed ASAP. Reproduce six months
supply of training modules for participants.
7) Work with FHD to establish additional training centers for BLSS. Ideally these
should be located at hospitals earmarked as EMONC centers.
8) Orientation workshop for Training Center Staff: Make sure to conduct orientation
workshop for training center staff (hospital, clinic and community).Appropriate
training center staff should be included among the first group for training as service
providers, to enable them to function adequately as preceptors for participant trainees.
9) Advance notice to participants: Responsible authorities should be given the longest
advance notice possible to release their staff for training. Time may be needed to
temporarily relocate or hire staff.
13. Scheduling
The in service schedule is a dynamic initiative that will need to be adjusted to address
change in circumstances. However it is very important that every effort be made to
attain training targets.
BASIC TRAINING GRADUATES 2009
No. of graduates
Name of School
PA
RN
CM
RN/CM
Zorzo (midwife)
40
Zwedru
40
Phebe
30
15
5
Cuttington
57
Ganta Methodist
29
TNIMA
42
81
58
23
Mother Patern
Smythe
Total
42
46
40
283
153
5
The schedule takes into consideration the following factors:
 There are approximately 1880 mid level health care providers who will be
eligible for training. Approximately 1399 are in active service and 478 are
expected to graduate from basic training schools in 2009.The in service
curriculum will be fully integrated into basic curricula by mid 2009.Beginning
2010 all graduates from basic programs will be expected to have the skills
imparted in the in service program. A training consultant will assist with
integrating the in service curriculum into basic programs.
 A maximum of not more than 100 participants will be drawn from service
delivery at any given time.
 The IMCI and BLSS training will not be modified.
 IMCI and BLSS training will be accelerated while preparations are in process
for implementing the integrated in-service curriculum.
 At least 2 more training sites will be established for BLSS
 The integrated in service curriculum will be 4 weeks in length.
 There will be intervals between training cycles for planning, monitoring and
supervision, curriculum review and revision.
 In-service trainers will be expected to do all service delivery training as
participants.
24
Training Plan
IMCI
Total trained: 194. Total to be trained: 1686
2009
1 Training Center
30 class size
12 Sessions (2 sessions each, February, March, April,
May, July and September, one class in December)
390
2010
1 Training Center
30 class size
12 Sessions (2 sessions per month for 6 months when the
integrated curriculum is not being given).
360
2011
1 Training Center
30 class size
12 Sessions (2 sessions per month for 6 months when the
integrated curriculum is not being given).
360
2012
1 Training Center
30 class size
16 Sessions (2 sessions per month for 8 months when the
integrated curriculum is not being given).
480
A second training site may be used for IMCI to speed up the training and increase the
output. Since between IMCI and BLSS at no time do the total participants in training
exceed 70, a second training center for IMCI will not extend the total amount of
participants off their jobs to more than 100.
25
Training Plan
Integrated Curriculum
Total to be trained: 1880
2009
2 Training Centers
30 class size
4 Sessions (June, August, October & November)
240
2010
5 Training Center
20 class size
6 Sessions
600
2011
5 Training Centers
20 class size
6 Sessions
600
2012
5 Training Center
20 class size
4 Sessions
400
26
Training Plan
BLSS
Total already trained 265. Total to be trained 1615.
2009
2 Training Centers
24 class size (2 centers)
12 Sessions
288
2010
3 Training Center
32 class size (in 3 centers)
12 Sessions
384
2011
4 Training Centers
40 class size (in 4 centers)
12 Sessions
480
2012
4 Training Center
40 class size (in 4 centers)
12 Sessions
480
27
14. IMPLEMENTATION
YEAR 1
First Quarter











Curriculum design and training consultant recruited and fielded
Accelerate the roll out of BLSS
Accelerate the roll out of IMCI
Develop training materials
Selection of master trainers
Selection of trainers
Order and receive equipment and supplies for training centers.
Order and receive office equipment.
Order and receive clinic equipment
Train master trainers.
Train Trainers
Second Quarter
 Train Trainers
 Start training service providers
 Deploy participants
 Orient MOH&SW staff.
 Start monitoring and follow up
Third Quarter
 Train service providers
 Do monitoring and follow up
 Orient MOH&SW
Fourth Quarter
 Train service providers
 Do monitoring and follow up
 Assist with developing procedure manual
YEAR TWO
First Quarter
 Train service providers
 Train trainers
 Curriculum consultant visit
 Review and revise curriculum
 Develop procedure manual
 Do monitoring and follow up
28
Second Quarter
 Train service providers
 Develop procedure manual
 Do monitoring and follow up
Third Quarter
 Train service providers
 Develop procedure manual
 Do monitoring and follow up
Fourth Quarter
 Train service providers
 Develop procedure manual
 Do monitoring and follow up
YEAR THREE
First Quarter
 Curriculum consultant visit
 Train service providers
 Do follow up and monitoring
 Review and revise curriculum
Second Quarter
 Train trainers
 Train service providers
 Do monitoring and follow up
 Develop procedure manual
Third Quarter
 Train service providers
 Develop procedure manual
 Do monitoring and supervision
 Orient MOH&SW staff
Fourth Quarter
 Train service providers
 Develop procedure manual
 Do monitoring and follow up
 Design retraining curriculum
 Develop retraining schedule
 Decentralize training
YEAR FOUR
29
First Quarter
 Train service providers
 Develop procedure manual
 Do follow up and monitoring
 Orient MOH&SW staff
Second Quarter
 Train service providers
 Do monitoring and follow up
 Develop procedure manual
Third Quarter
 Train service providers
 Develop procedure manual
 Do follow up and supervision
Fourth Quarter
 Train service providers
 Develop procedure manual
 Do follow up supervision
FIFTH YEAR
First Quarter
 Train service providers
 Do follow up and supervision
 Develop procedure manual
Second Quarter
 Train service providers
 Do follow up and supervision
 Develop procedure manual
Third Quarter
 Train service providers
 Develop procedure manual
 Do follow up supervision
Fourth Quarter
 Train service providers
 Develop procedure manual
 Do monitoring and supervision
30
31
15. Two Year Time Plan
2009
Target
Objective 1: To build MOH capacity to offer in-service training
Activities 1: Set up in-service education office
1.1.1
Recruit staff
1.1.1.1
Peace Corps Volunteers arrives
1.1.1.2
Select Trainers and Masters
1.1.1.3
Field curriculum design & training consultant
1.1.2
Develop training staff
1.1.2.1
Train Master Trainers
1.1.2.2
Train Trainers
1.1.2.3
Train Service providers
1.1.2.4
1.1.2.5
1.1.2.6
1.1.2.7
1.1.2.8
1.2.2.9
Train County Health Team
Train preceptors
Orient MOH staff
Orient hospital, clinic & community staff
Certification of participants
Integrate In-service curriculum into BASIC
curriculum
IMCI
BLSS
Integrate
d
J
F
2010
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
x
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Two Year Time Plan
2009
Target
Objective 2: To establish training centers
Activities 1:provide hostels accommodation
2.1.1
Establish hostel
2.1.1.1
Room and accommodation
2.1.1.2
Provide allowances
2.1.1.3
Provide classroom with adequate furniture
2.1.1.4
Establish training office
2.1.1.5
Provide transportation for field experience
J
F
2010
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
0
N
D
2
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
3
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
33
Two Year Time Plan
2009
Target
Objective 3: To provide training materials
Activities 1:Develop Curriculum
3.1.1
Continue Curriculum Development
3.1.1.1
Continue development curriculum
3.1.1.2
Continue development of modules
J
F
X
X
X
X
X
2010
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
O
S
O
34
N
D
Two Year Time Plan
2009
Target
Objective 4: To provide supportive supervision
Activities 1:Develop supervisory checklist
4.1.1
Revise and update the present draft
4.1.1.1
Develop procedure manuals
4.1.1.2
Train supervisors
a. Orientation to supervisory checklist
b.
4.1.1.3
Assign trainers and supervisors
J
F
2010
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
N
D
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
35
Tow Year Time Plan
2009
Target
J
F
2010
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
J
A
S
O
Objective 5: To develop Database
Activities 1:
5.1.1
5.1.1.1
5.1.1.2
5.1.1.3
5.1.1.4
5.1.1.5
5.1.1.6
36
N
D
ATTACHMENTS
37
Attachment #1
WORKING DRAFT OUTLINE
TERMS OF REFERENCE
In service education committee
38
BACKGROUND
Over the past two decades the Ministry of health and Social Welfare
(MOH&SW) has not sponsored a formal comprehensive in service program to
upgrade the skills of mid level service providers, who have been functioning in
expanded roles, necessitated by the by the shortage of other health care
professionals especially doctors.Mid level health care providers have been
obliged to meet the demands of their ever expanding roles without the benefit of
regular refresher, In service or post graduate courses. In addition to shortage of
staff, lack of equipment and supplies, poor physical structures contribute to the
deterioration of skills. Several in service education courses are being given to
address emergent needs. The MOH&SW developed the BPHS for which a
comprehensive in service plan is needed. This plan will incorporate many courses
that are already being implemented.
Purpose: To advice the Ministry of Health (In Service Education Unit) on all matters
relating to in service education.
OVERALL OBJECTIVE.
To provide guidance and support necessary for developing and maintaining a
comprehensive national in service program
To present a body of expertise that will provide technical assistance to the in- service
unit of the Ministry of Health to develop, monitor, review and approve in- service
education in Liberia
To ensure adequate In-service Education of all levels of service providers in Liberia.
OPERATING PRINCIPLES
The In Service Advisory Committee is a multisectoral/multidisciplinary body that will
offer technical assistance to the MOH&SW/In service Education Unit in coordinating
the In service program in Liberia. The committee will participate in making decisions
and recommendations that will apply to all sectors involved in offering health care
and in-service education in Liberia.
.RESPONSIBILITIES
The In service Advisory Committee will have the following responsibilities:
 To assist the In service Education department in appointing standing ad hoc and
sub committees to perform specific or specialized tasks
 To make and alter it’s Terms of Reference (by consensus)
 To appoint members, advisors, consultants as necessary
 To deliberate and make recommendations on in service issues presented to it by
the In service unit of MOH&SW
 To pass it’s recommendations to MOH&SW through the In service department for
consideration, approval and implementation
 To liaise with other technical committees in fostering a comprehensive and
integrated approach to In service Education
39
 To distribute minutes of meetings to other technical committees and relevant
entities
TERMS OF REFERENCE
The Terms of Reference for this technical committee shall be approved and adopted
by the CMOs office, and may be amended, repealed or modified as the committee
deems with the approval of the CMO or her delegate.
MANAGEMENT
The general management of this committee shall be vested in the Ministry of Health
and Social Welfare in service unit.
TERMS OF EXISTENCE
The Terms of Existence of this committee shall be perpetual unless reversed by the
CMO’s Office
STRUCTURE OF THE ADVISORY COMMITTEE
OFFICERS
1. The Chairperson shall be the assistant minister for preventive services or his/ her
designee
. 2. The deputy chairperson shall be the Director of the Family Health Division
3. The in-service unit shall be the secretariat.
SUBCOMMITTEES (standing or ad hoc)
The committee may create or appoint subcommittees as necessary to carry out special
functions or projects pertaining to in-service education.
The chairperson of all subcommittees shall be approved by the in service committee
chairperson. These subcommittees will report to the chairperson or his/her designee.
Ad Hoc subcommittees will be dissolved when no longer needed.
MEMBERSHIP
Membership will consist of relevant stakeholders
40
Attachment #2
JOB DESCRIPTION
NATIONAL IN SERVICE PROGRAM-MASTER
TRAINER
Responsible To:
The IN SERVICE COORDINATOR
Duty Station:
Ministry of Health and Social Welfare
Headquarters, Monrovia, Liberia
JOB DESCRIPTION
Position Title :
Duty Station :
Reports To :
Master Trainer
Monrovia
In Service Coordinator
Major Responsibilities:
Training of Trainers, Participant teaching, Course planning, Course
scheduling, student evaluation Curriculum design, review and revision.
 In collaboration with members of the in service education team,
designs and develops instruments for student teaching, evaluation
and certification.
 On behalf and in collaboration with other officers of the In service
unit reviews the credentials of all participant students for
acceptance in courses before approving their admission to training



Participates in preparing detailed work plans, evaluation reports, and quarterly and
annual reports.
Makes timely submission of work plans or reports.
Anticipate/identify major constraints and problems before they have serious
bearing on In service program and plans and recommend to relevant parties,
adjustments to program
SPECIFIC RESPONSIBILITIES
Teaching
 Train Trainers
 Plan training sessions for trainers
 Substitute for trainers when necessary
 Identifies the need for refresher training of trainers
 Identifies the need to increase the pool of trainers.
 Participates in updating in service curriculum.
41
 Identifies the need for additional in service courses.tifies the
Supervision and Evaluation
 Supervises trainers in all aspects of their work
 Assist in planning training schedules.
 Assist in identifying, establishing and monitoring best practices etc.
 Plan and coordinate participant/student activities.
 Ensure that all prescribed conditions for course implementation are being met
 At the beginning of the performance cycle, meets with staff in order to discuss and
agree on program plans, and monitor performance.
 Regularly meet with senior staff members individually and in groups to discuss
performance and program development and implementation,.
Other
 Other related technical duties as assigned by the IN service Coordinator.
Qualifications:








Registered Nurse, Physician’s Assistant
Ability to teach
Ability to travel extensively up country in Liberia
Knowledge of and work experience in Liberia or other developing countries
At least a Bachelor’s Degree
At least two years experience as a trainer.
At least five years professional experience.
Very good interpersonal skills
42
Attachment #3
JOB DESCRIPTION
NATIONAL IN SERVICE PROGRAM-TRAINER
Responsible To:
Master Trainers.
The IN SERVICE COORDINATOR and
Duty Station:
Ministry of Health and Social Welfare
Headquarters, Monrovia, Liberia
JOB DESCRIPTION
Position Title
Duty Station
Reports To
:
:
:
Trainer
.Major Responsibilities:
Participant teaching, Course planning, Course scheduling, student
evaluation Curriculum design, review and revision.
 In collaboration with members of the in service education team,
designs and develops instruments for student teaching, evaluation
and certification.
 On behalf and in collaboration with other officers of the In service
unit reviews the credentials of all participant students for
acceptance in courses before approving their admission to training



Participates in preparing detailed work plans, evaluation reports, and quarterly and
annual reports.
Makes timely submission of work plans or reports.
Anticipate/identify major constraints and problems before they have serious
bearing on In service program and plans and recommend to relevant parties,
adjustments to program
SPECIFIC RESPONSIBILITIES
Teaching
 Teaches assigned classes.
 Prepares lesson plans in collaboration with other trainers
Supervision and Evaluation.
 Oversee participant student performance ensuring that competence is attained in
the classroom and in practice .
 Assist in identifying, establishing and monitoring best practices etc.
43
 Plan and coordinate participant/student activities.
 Ensure that all prescribed conditions for course implementation are being met
 At the beginning of the performance cycle, meets with staff in order to discuss and
agree on program plans, and monitor performance.
 Regularly meet with senior staff members individually and in groups to discuss
performance and program development and implementation,.
Other
 Other related technical duties as assigned by the IN service Coordinator.
Qualifications:







Registered Nurse, Physician’s Assistant
Ability to teach
Ability to travel extensively upcountry in Liberia
Knowledge of and work experience in Liberia or other developing countries
At least a Bachelor’s Degree
At least five years experience in service provision and/or training
Very good interpersonal skills
44
Attachment #4
JOB DESCRIPTION
TITLE:
Training Consultant
Responsible to:
Chief of Party/Human Resource Director: Training Unit
Overall Responsibilities: Conducts training of master trainers and trainers.
Coordinates the integration of in-service curricula into basic training programs.
Professional Responsibilities.
1. Will conduct TOT workshops as necessary
2. Will collaborate with teaching staff of basic programs to integrate in service
curriculum into basic curricula.
3. Will supervise trainers to practice teach.
4. Will review curriculum and advice on revision.
5. Will advice on preparation of training material
Personal Responsibilities:
1. Will submit a work plan to contractor through the COP within one week of arrival
in country
2. Will submit a written report to contractor through the COP at the end of the
assignment.
Qualifications:
A masters degree in nursing/health education, curriculum or equivalent preferred.
Formal training and experience in conducting TOT required.
At least five years experience in curriculum design, health education or equivalent
required
Professional experience in working in a developing country required.
45
Attachment #5
List of Training Equipment for LSS
EQUIPMENT LISTS8
This list identifies the equipment needs at both the LSS Training Site and the
midwives places of work. It provides a suggested list of items used during LSS
training and/or by the LSS skilled provider. This information may be used to provide
each participant with the additional things necessary for her to perform LSS at the
service delivery point.
LSS Training Site Supplies and Equipment List Form (suggested)
TYPE
QUANTITY
NEED AVAILAB ORDE
ED
LE
R
PER
UNIT
COST
TOTAL
1. Videos:
a. Why did Mrs. X Die?
b. Birth in Squatting
Position
c. Infection Prevention
d. Delivery Self
Attachment
2. Models
a. Pelvis/fetus
Boney Pelvis
Placenta/Cord
Model
Cloth Pelvic
Model
b. Resuscitation
Infant CPR Model
Adult CPR Model
Additional Infant
Model
airways
8
List designed by ACNM and used for training at Phebe and Redemption. Other requirements and
criteria for establishing training center for BLSS is available.
46
c. Uterine Model9
LSS Training Site Supplies and Equipment List Form (suggested)
QUANTITY
TYPE
NEEDED
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
3. Laminated Charts:
a. Birth Anatomy
illustrated Charts
b. Wall Partograph in
English (nonpermanent
markers)
c. Infant Resuscitation
Flow
d. One to One Chart Set
e. Labor Squatting
Positions
f. Positions Labor Out of
Bed
g. Cervical Dilatation
Model
4. Equipment to practice delivery and active management third stage (used for other
procedures)
a. Cord/espisiotomy
scissors
b. Straight hemostat
clamps
c. Injections syringes
/Needles
d. Gauze squares / Lap
sponges
e. Sterile gloves
f.
Urinary Catheter: #12
French, straight
g. Nonsterile gloves
9
A bag with a drawing at the opening. The finished bags are about 7.5cm (5inches) long and
5cm(4inches) wide. They can be stuffed with foam or gauze. When the drawings are pulled it forms
the cervix. Made in country. American college of Nurse –Midwives. LSS Generic Equipment List.
47
h. Talcum powder for
gloves
i.
Fetoscopes or pinard
horns
j.
Clocks: delivery labor
LSS Training Site Supplies and Equipment List Form (suggested)
QUANTITY
COST
TYPE
NEEDED
AVAILA
BLE
ORDER
PER UNIT
TOTA
L
5. Equipment to practice episiotomy repair(will also use equipment to practice delivery
above)
a. Repair Model: Sponge
b. Suture/Thread
c. Suture needles
d. Needle holder
e. Tissue forceps
6. Equipment to practice newborn resuscitation, (may use from delivery and infection
prevention)
a. Infant ambu bags
b. Oxygen tubing
c. Small bowls
d. DeLee traps and tubing
e. Receiving blankets/cloths
f.
Country appropriate infant
head covers
g. Hand washing soap
h. Stethoscope
i.
Bulb syringes
7. Equipment to practice Infection Prevention
a. Long plastic, canvas, or
heavy cotton aprons
48
b. Shoe/foot covers: plastic
bags, boots, etc
c. Heaby-duty cleaning gloves
d. Cloth masks(if country
protocol)
e. Head covers(if country
protocol)
f. Eye protectors (glasses,
etc.)
g. Bottle bleach(chlorine)
h. At least 6 liter container
i. Laundry Soap
j. Brushes to clean
instruments
LSS Training Site Supplies and Equipment List Form (suggested)
QUANTITY
TYPE
NEEDED
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
8. Equipment to practice management of hemorrhage (plus infection prevention and
practice delivery)
a. IV normal saline
b. IV connecting tubing
c. IV Needles
d. Tape
e. Something for arm board
f.
Cotton balls
g. Alcohol, spirits, soap/water
h. Drinking cup, glass
i.
Tourniquet
j.
Injectable oxytocic
9. A/V Equipment
a. TV and VHS machine
b. Overhead projector
10. Other Equipment DEPENDING ON TOPICS CHOSEN FOR TRAINING
a. Vacuum Extractor
49
b. Vaginal Speculum, Small
c. Vaginal Speculum, Large
d.
e.
f.
g.
Sponge holding forceps
Urine Testing set
Sterilization equipment
Manual Vacuum
Aspiration(MVA) Kit
h. Uterine Tenaculum for
MVA
i. Magnifying Glass for MVA
j. Strainer for MVA
k. Scalpel with #20 blade
LSS Training Site Supplies and Equipment List Form (suggested)
QUANTITY
TYPE
NEEDED
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
11. Trainers Receive
a. Life-Saving Skills Manual
b. Life- Saving Skills clinical
guide
c. LSS Trainers Manual
d. Lab Coat
e. Name Tags
f.
LSS or White Ribbon Pins
g. Certificate
12. Forms Needed
a. Antenatal records
b. Partographs
c. Postpartum records
d. Training Schedule
e. TNA/Registration
50
f.
Training Report
g. Certificates
h. Final Evaluation
i.
Handouts: to be decided
LSS Training Site Supplies and Equipment List Form (suggested)
QUANTITY
TYPE
NEEDED
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
13. Other things used during training
a. Clock classroom
b. Whiteboard/blackboard
c. Whiteboard pens/chalk
d. Erasers for board above
e. Classroom with chairs and
tables to accommodate
trainers ad consultants
f. Sleep room for trainers /
trainees on call
g. Extension cord
h. Masking tape
i.
Scotch tape
j.
Rulers
k. Paper tablet, pencil, pen,
eraser for each participant
l.
Flipcharts and markers
m. Transparencies and pens
n. Pencil sharpeners
o. Access to
photocopier/paper
p. Measuring tapes
51
LSS Midwife and/or Other Skilled Provider Supplies and Equipment List
(suggested)
QUANTITY
TYPE
NEEDED
Life-Saving Skills Manual
1
LSS Clinical Guide
1
1
Midwifery Reference Book
1. Hemostat/artery forceps
2
2. Cord/episiotomy scissors
1
3. Fetal scope
1
4. Blood pressure machine
1
5. Stethoscope
1
6. Bulb mucus syringe
2
7. Urinary Catheters
2
8. Rectal tubes
2
9. Delivery apron
1
10. Surgical latex gloves
12pr
11. Heavy duty cleaning gloves
1pr
12. Surgical towels
6
13. Lab sponges or gauze
6/1pkg
14. Injection syringes
100
15. Needles
16. Stainless steel containers
with lids
17. Kidney shaped/placenta
basin
18. Reflex hammer
19. Tape measure
20. Vaginal speculum, small
21. Vaginal speculum, med
22. Suture, absorbable
23. Suture Needles
24. Needles holders
100
2
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
2
1
1
1
1
20pks
12
1
52
25. Tissue/thumb forceps
26. Suture scissors
27. Sponge holding forceps
1
1
1
LSS Midwife and/or Other Skilled Provider Supplies and Equipment List
(suggested)
QUANTITY
TYPE
NEEDED
28. Airway, adult & infant
29. Urine testing set
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
1each
30. Towels
31. Baby Weight Scale
1
4
1
32. Adult Weight Scale
1
OTHER SUPPLIES AND INSTRUMENTS/EQUIPMENT DEPENDING ON NEEDS
33. Height Measure
34. Hemoglobin Measure
35. Intravenous Fluids
36. Intravenous Giving Sets
37. Oxytocics
38. Antibiotics
39. Sterilization Equipment
40. Vacuum Extractor
41. Manual Vacuum Aspiration
(MVA) Kit
42. Uterine Tenaculum for
MVA
43. Magnifying Glass for MVA
44. Strainer for MVA
45. Scalpel with #20 blade
53
GENERAL TRAINING EQUIPMENT AND SUPPLIES FOR EACH TRAINING
CENTER
QUANTITY
COST
NEEDED AVAILA
ORDER
PER UNIT
TOTA
TYPE
BLE
L
1. LCD Projector
2. Overhead Projector
3. Training CDs
4. Television
5. Stabilizer and Backup UPS
for Computer
6. Pelvic Models
7. Models for IUD Insertion
Demonstration
8. Other Training Models as
Identified
9. Training Manuals (Modules
for each student)
10. Desk for Computer
11. Printer
12. Photocopier
13. Generator
14. Generator Fuel
EQUIPMENT FOR EACH CLINIC.10
QUANTITY
TYPE
NEEDED
AVAILA
BLE
ORDER
COST
PER UNIT
TOTA
L
Injection Control Supplies
o Plastic Buckets
o Brushes
o Heavy Duty Gloves
o Soap
o Towels
Lockable Cabinets for VCT
Records
10
This is additional equipment
54
Small Libraries
Professional Books for each Clinic
Policy and Procedure Manual
Rape Management Manual
Local Drug Management Manual
TRANSPORTATION
QUANTITY
TYPE
NEEDED
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
20 Seater Bus (To transport
students to training sites: clinic,
hospital community)
Fuel
First Aid Kit
Driver
Maintenance Service
Registration
Insurance
EQUIPMENT FOR TRAINING CENTER OFFICE
QUANTITY
TYPE
NEEDED
AVAILA
BLE
COST
ORDER
PER UNIT
TOTA
L
Desk
Chairs
Laptop Computer
Printer
Photocopy
Perforator
Binding Machine
Box Files
Staple Machines
55
Paper Clips
File Cabinets
Adaptors
Paper
Ink for Copier & Printer
EQUIPMENT AND SUPPLIES FOR ONE CLINIC.11
TYPE
NEEDE
D
QUANTITY
AVAIL ORDER
ABLE
COST
PER UNIT TOTA
L
Delivery bed
Flip Chart, foldable, 70x100cm
Models for male and female
reproductive organs
Motorcycle, Yamaha AG100
Generator Set, diesel 5KVA
Blood Pressure Machine(aneroid)
with cuff
Stethoscope (double)
Pressure Cooker
Microscope, Olympus cx21
binocular, complete
Sterilizers steam, double rack
Large artery forceps for clamping
umbilical cord
Jug for cheatle forceps
Cheatle forceps, pick up and
transfer
Kidney dish – 8inch
Galipot (Small Bowl)
Instrument dishes with
cover(20x10x5cm)
Boilable nail brush
Microscope slide, plain 76x26mm
11
This is standard equipment
56
Blood lancets disposable
Bathroom Scale
Hunting torch or angle poised lamp
Stethoscope foetal, wood
(Fetuscope)
Table /Trolley for instruments
Table for sterilizer 105 x70cm
Stool (adjustable) for examiner
Lockable cabinet for drugs and
contraceptives
Pap smear slide carrier
Double bowl stand
Drums for autoclaving equipment
290mm diameter
Draw Sheets 90x180cm
Large Dressing Towels
Small Dressing Towels
Client gowns, different sizes
Hegars dilators sizes ¾ and 5/6 ea.
Uterine sound 320mm
Single toothed
Volsellum/tenaculum
Blunt nose scissors
SUPPLIES
FP Promotional Materials
FP methods pamphlets
Condoms
Lockable Cabinet for HIV/AIDS
VCT Records
57
Attachment #6
CRITERIA FOR SELECTION OF TRAINING SITES
LOCATION
A geographical location that offers a full demonstration of the three
levels(community, clinic and hospital) of service delivery contained in the BPHS. If
some levels are lacking or inadequate, the in-service training program will work with
facilities to fill these gaps and offer participants opportunities to be involved in
initiation/establishment of some services.
PARTICIPANT ACCOMMODATION
Accommodation for at least thirty participants.
Preparation of meals for participants
CLASSROOM FACILITIES
Adequate classroom space for thirty participants
Furniture
Storeroom
OTHER REQUIREMENTS TO BE ACQUIRED FOR TRAINING CENTERS
TRANSPORTATION
Vehicle to transport students to the sites of the various levels of service. An eighteen
to twenty seater vehicle is suggested
Driver
Maintenance
58
Running Cost
Fuel.
Attachment #7
In-service Capacity12
12
The In-service Unit will continue to follow up.
59
CLASS SIZE
TRAINERS
LENGTH OF
COURSE
MEDICAL SUPPLIES
MASTER
TRAINERS
COURSE MATERIALS
PATIENT LOAD
TRAINING SITE
Curriculum
Course
SPONSORS
USAID UNFPA
SERVICE
PROVIDERS
TRAINED
RN's CM's
LPN's
TOTAL OF
MID LEVEL
SERVICE
PROVIDERS
TRAINED
COMMENTS
PA'S
MATERNAL AND NEWBORN
BLSS
Phebe Hospital
BLSS
Redemption
Hospital
IMCI
Catholic
Hospital
Yes
10 modules
models
Textbooks
Essential drugs
120/m
10
10 2wks
8
Yes
10 modules
models
Textbooks
Essential drugs
200/m
10
10 2wks
15
249
CHILD HEALTH
Yes
EPI
7 Modules
24 11dys 30
5 Modules
194
5dys
REPRODUCTIVE AND ADOLESCENT HEALTH
Adolesent Health
1 Modules (BASICS)
IPPF Modules
Demonstration equipment
Pelvic models
IUD insertion equipment
Norplant insertion equipment
Family Planning
Safe
Motherhood
(FP)
2dys
FP clinic
4wks
Infection Control
(FP)
Post Abortion
Care
GBV
(Rape
Management)
Family Planning Association of Liberia
(FPAL)
2WKS
30
FPAL
No training materials submitted
5dys
FPAL
No training materials submitted
2WKS
FPAL
3 modules
1dy
MOH&SW
COMMUNICABLE DISEASES
General
Module(BASICS)
1dy
VCT
Modules from NACP
10dys 15
Global Fund
TOT
Modules from NACP
10dys
Global Fund
Modules from NACP
5dys
Global Fund
Modules from NACP
5dys
Global Fund
PMTCT
Modules from NACP
14dy
Global Fund
Refresher for
HIV/AIDS
Modules from NACP
5dys
Global Fund
Malaria
Modules from Malaria Control (ART)
Malaria
Modules from MENTOR Initiative (IPT)
Opportunistic
Diseases & ART
STI Syndromic
Treatment
7 5dys
5dys
1000+ TRAINED
375 clinics in 3 years (PMI)
TB
MENTAL HEALTH
Mental
Health
1 Modules
1wk
EMERGENCY
Emergency
Yes
No
Attachment #8
References:

Ministry of Health and Social Welfare,
60
Basic Package of Health and Social Welfare Services for Liberia, June 2008,
BASICS

Ministry of Health and Social Welfare,
National Health Policy and National Health Plan 2007

Ministry of Health and Social Welfare,
Liberia Demographics and Health Survey 2007

Ministry of Health and Social Welfare,
Liberia Demographic and Health Survey – Key Findings

Ministry of Health and Social Welfare,
Draft National Strategy for Child Survival in Liberia 2008 – 2011

F.R. Abbatt. A Mejia,
Continuing Education Health Workers
World Health Organization
61