TRAINING OF NPCS IN MATERNAL
HEALTH AND LEADERSHIP IN TANZANIA
BY GODFREY MBARUKU
AND SENGA PEMBA
MAY 2012
BACKGROUND
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With a physician to population ratio of close
to 1:25,000 and further challenged by 8090% of medical doctors practicing in urban
areas the majority of the Tanzania population
has no access to care by a physician
However, there is potential of using the
existing mid-level cadres in the system to
provide essential services if their skills can
be upgraded through targeted short courses
or long courses
BACKGROUND CTD…
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AMOs and Nurse midwives for instance can
effectively be upgraded to provide CEMOC in
rural areas where Medical doctors are not
willing or ready to work
WHY TRAIN NPCS FOR CEMOC
SERVICES?

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WHO estimates that 1 in 10 pregnant women
in Tanzanian requires emergency maternal
health care so the need to have a trained
health worker in EMOC
We need to accelerate the attainment of
health related MDG especially MDG 4 and 5
THE ETATMBA PROJECT: TRAINING OF ADVANCED
LEADERS IN MATERNAL HEALTH

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To implement the ETATMBA Project, IHI in
collaboration with TTCIH set out to train Non
Physician Clinicians (NPCs) from
disadvantaged HC and District Hospitals in
CEMOC, anaesthesia and leadership and
thereafter assess its impact on Maternal and
Perinatal Mortality in their respective areas
We were guided by the training life cycle to
ensure success
EMOC TRAINING PROGRAMME: LIFE CYCLE
TIME
Phase 1 Training
conceptualization
Phase 2 Planning
the training
Phase3 Execution
of training
Phase 4 Termination
SELECTION AND RECRUITMENT OF
TRAINEES
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We opted for a small intake of about 12 -16 trainees per
batch
To be able to show an impact, a pair (AMO, NW) were
recruited from one health centre
The NPCs were selected from facilities that were remote
and hardly accessible during rainy season.
The Facilities given priority were Heath Centers (HCs)
that were already upgraded with theatres or were in the
process of being upgraded.
However, in certain disadvantaged districts there were
no such HCs and therefore the District hospital was
selected.
MAP OF TANZANIA
DURATION OF TRAINING
Duration of Training was 16 weeks undertaken
at the Tanzanian Training Centre and St. Francis
Referral Hospital in Ifakara.
AMOs: 10 weeks on CEMOC, 2 weeks on
Leadership and 4 weeks of internship.
Nurses: 10 weeks on Anesthesia, 2 weeks on
leadership and 4weeks on internship
The internship was done in their Regional
Hospitals
DAILY TIME TABLE FOR NPC TRAINING
1. 7.45 am - 9.00 am: Review of Emergency cases
managed by AMO within 24 hrs
2. 9.00 am-1.00 pm Major ward round
3. 3.00-5.00 pm: Lecture on EMOC topics including
Neonatal Resuscitation.
4. 5.00 pm-7:30 am: Night Duty for one AMO daily
including weekends and public holidays
WHAT TRAINING STRATEGY ARE WE USING?

We are training the AMOs and Nurse midwives
using a competence based education
approach
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Competence-based education is an approach
that is related to on-the-job performance and
has a close relationship between the
knowledge or skill required and on-the-job
application
TRAINING CURRICULUM FOR NPCS
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Two competence based training curricula are used (one for
AMOs in EMOC and another for Nurses in Anaesthesia)
The actual training duration is three months (12 weeks) full time
with an addition of one month (4weeks) for internship
The implementation of the curriculum requires the use of training
facilities at a training centre as well as opportunities to practice at
the hospital
Training materials addressing the various areas of CEMOC are
prepared in advance and availed to trainees
A schedule detailing the day to day topics is usually prepared to
standardise the teaching/learning process
A logbook to guide the training of skills is given to each trainee
TRAINING CURRICULUM CTD…
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All NPC (AMO and Nurses) underwent 10 dayLeadership course during which management
and leadership skills were taught by an expert
in this area.
See next slides for the leadership course!
LEADERSHIP: OBJECTIVE- LEARNING
OUTCOMES
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Provide leadership in key areas of maternal
health services
Conduct organizational capacity assessment
Manage change in a health facility
Improve quality of services
TOPICS IN LEADERSHIP AND
MANAGEMENT
Demonstrating
Personal
Qualities
Setting
Directions
Improving
Services
Working with
Others
Managing
Services
TRAINING METHOD
Develop research
proposals
Bring to this course
own experiences
Learning by
Doing
Benefit own
experience and
knowledge
Forum for sharing
information
LENGTH OF THE COURSE
• Introduction and Orientation
Day 1 • Personal Qualities
Day 2
Day 3
Day 4
Day 5
• Values
• Work improvement
• Team work and Change management
•
Evaluation and way forward
WHO ARE THE TRAINERS OF THE NPCS?

The trainers comprise of the following:
– Obstetricians local and international
– Anaesthetists/Anaesthetic Officers
– General Medical Officers working in OBGY
Department
– Nurse midwives working in the in maternity ward
– Leadership and Management experts
WHAT TEACHING METHODS DO WE USE?

A variety of teaching/learning methods are used including:
– Lectures discussions
– Involving the trainees in the actual doing through
practicing in the theatre as well as in the maternity and
surgical wards at the teaching hospital
– Encouraging trainees to conduct their own group
discussions and presentations and availing trainees the
opportunity for self study
– Use of Clinical Skills Lab for demonstrations and
simulations
– A team approach to learning is emphasised where
AMOs and Nurse Midwives learn together
TRAINING CURRICULUM: ASSESSMENT
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The assessment process is designed to promote the
highest possible standards of demonstrable achievement
within and beyond the scope and content of the curriculum.
To achieve this, assessment of the trainees involves the
following:
– Course work and individual assignments
– Class participation and group assignments
– Self assessment
– Monthly tests
– End of module assessment using written exams and
OSCE
INTERNSHIP
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The last 4 weeks of the course were on Internship
in their Regional Hospitals.
No Lectures were given at the hospitals.
AMOs managed the Maternity wards as well as
labour wards under our supervision and did
surgical procedures (C/S, vacuum etc) on
patients with indications.
The nurses administered anesthesia and did
neonatal resuscitation in the theatre
ACTUAL MODE OF INTERNSHIP
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Clinical meeting- attended daily by NPCs, all
senior hospital staff and supervisor
Lively discussion of all cases admitted during
the 24 hrs
Administrative problems discussed and
sorted out
Acts as a forum for continuing education and
leadership role in action
ACTUAL MODE OF INTERNSHIP CTD...
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Daily ward rounds in the maternity ward
Discussion on management of cases
Focus on correct use and interpretation of
the partogram
Demonstration of practical procedures
Applying skills and mentorship both in labour
ward and theatre
MATERNITY DATA DURING INTERNSHIP:AN
EXAMPLE OF S’WANGA HOSPITAL
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CESARAN SECTIONS 58
DELIVERIES
373
RUPTURED UTERUS
3
MATERNAL DEATHS
4 (DUE TO ECLAMPSIA,
RUPTURED UTERUS, ANAESTHETIC ACCIDENT).

AUDIT OF MATERNAL DEATHS WERE
ATTENDED BY ALL NPCs
CHALLENGES RELATED TO THE TRAINING
OF NPCS IN CEMOC
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Demand for accrediting the training programme is
increasing
How to effectively supervise the trainees in the
clinical areas as trainers are few
How to handle the issue of absenteeism from work
places for the selected staff (12 weeks absence)
How to make the course really hands-on as some
of the trainers lack teaching methodology skills
OUR OBSERVATIONS REGARDING THE
TRAINING OF NPCs
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At the end of the course, all NPC could fill the
Partograms and interpret them correctly whereas
before they could not
Before training, all AMOs could do C/S but were not
conversant with the indications as well as the
importance of C/S on the lower segment and the
prevention of bladder injury.
Following the training, the importance of
Preoperative antibiotics, catheterization (Catheters
frequently not available in HCs) and early
ambulation were well understood.
OUR OBSERVATIONS REGARDING THE
TRAINING OF NPCs CTD...
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In most health facilities, power supply was erratic and
~70% of C/S in Geita district hospital for instance
were done without power.
Transparent iron sheets were used for the roofing of
theatres. No complications occurred despite this and
NPCs appreciated the importance of internship within
their home environment.
Due to lack of power, manual aspiration machines
were used for suction during the operation and
sterilization of the tubes was emphasized
OUR OBSERVATIONS REGARDING
THE TRAINING OF NPCs CTD...
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There was a scarcity of gauze nationally and therefore
NPCs learned to use abdominal packs during C/S.
NPC were unaware of the use of Misoprostol in
prevention of PPH and induction of labour especially
IUD
Although use of V/E was emphasized it was rarely
used even in cases of IUD due to obstructed labour
with descent 1/5 and full dilatation; C/S was preferred
instead
OUR OBSERVATIONS REGARDING
THE TRAINING OF NPCs CTD...
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Only Spinal anaesthesia and bolus ketamine were
used in their HC/District hospitals but after the course
all the Nurse-NPC could give GA by intubation.
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The Leadership course which the NPCs underwent
helped them to face the often arrogant District
Authorities. The NPCs met the District Authorities
several times to present the problems their facilities
faced and they were neither shy nor scared during the
encounters.
WAY FORWARD
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All the District hospitals that were visited had no
Obstetrician and therefore the Maternity services
were run by AMO who did not have up to date
knowledge of CEMOC.
At Geita District Hospital, the authority requested
the CEMOC- trained- NPC to remain working there
instead of going to the HCs but this was declined.
WAY FORWARD CTD…
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AMOs running District Maternity services should
also be given priority for CEMOC courses as
they receive all the referrals from HCs.
Due to scarcity of medicines, gauze etc, the
funds collected for the CHF should be retained
by NPCs for purchasing these items instead of
sending it to the District where it is used for other
non medical purposes. Discussions with District
authorities are under way
WAY FORWARD CTD…
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The NPC we have trained are now complaining that
their burden of work has increased tremendously and
cannot go on leave/holidays and despite all this, they
have not received any on - call - allowances for the
extra work nor accreditation from the Ministry. This has
to be discussed with the authorities concerned.
To improve communications with the supervisors, the
trained NPCs requested Lap Tops for internet services.
Supervisors need reliable transport to enable them to
follow up the trainees in their working places
WAY FORWARD CTD…
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Supervisors should go with supply kits to
avoid compromising the internship
experiences
Further training of the NPCs from the regions
is required to encourage and promote
continuing education culture for NPCs
END
YES WE CAN! THANK YOU FOR LISTENING