Changing the attitude of service providers, enhancing their skills and improving the condition of health facilities to meet standards have been identified as key interventions for improving the quality of services in the public sector.

All medical officers of the Government health department undergo a 3 day contraceptive technology update (CTU) at one of seven selected medical colleges. SIFPSA has developed a package, which introduces them to the latest features of contraception and the basics of counselling and informed choice. Women medical officers are exposed to a further 2 day module on issues related to IUCD insertion. During this session they also get an opportunity to practice on pelvic models and to thus sharpen their IUCD insertion skills.

Abdominal Tubectomy induction training was given to the team of medical officers & staff nurses of 33 SIFPSA Districts. Two centres at district hospital Jhansi & Agra were established.

Laparoscopy is the most preferred method of tubectomy in U.P. However, it requires sophisticated equipment, skilled surgeons and only women medical officers are accepted as providers in rural areas. SIFPSA developed a two day refresher training package for laparoscopy under local anaesthesia. The curriculum covered surgical procedure, post operative recovery, anaesthesia, and management of complications. Participants who were trained laparoscopists were given demonstration of laparoscopic ligation on clients and practice on ZOE models to refine their skills. Whole state was covered for this training.

Laparoscopic Tubal Ligation Training Centers had been established in Obs. and Gyane department of Lucknow, Meerut and Kanpur Medical Colleges

Master Trainers / Monitors of from 7 Divisional Clinical Training Centres were identified and trained for conducting Laparoscopic Training and follow up at CSMMU, Lucknow, GSVM Medical Collge, Kanpur and LLRM Medical College, Meerut.. These Master Trainers will intern provide trainings to Medical Officers / Paramedicals at 7 Divisional Clinical Training Centres and conduct Follow Ups.

Vasectomy or male sterilization acceptance is insignificant in Uttar Pradesh, being less than half a percent. Therefore, No-Scapel Vasectomy (NSV) has been promoted in order to popularize male voluntary sterilization. To promote male sterilization, initially the training was provided at Dehradun, Almora and Nainital in 1999 - 2002. 65 Doctors were trained in NSV in these districts from all over the 33 SIFPSA districts.

LHVs (lady health visitors) and ANMs (auxilliary nurse midwives) are the female family welfare supervisors and workers respectively in rural areas. Studies conducted on practices followed by female health workers have shown that their IUCD insertion skills were poor, resulting in frequent infection and high expulsion rates. They were also not able to screen or counsel IUCD clients.

To remedy this situation SIFPSA developed the Clinic Based Family Planning Training (CBFPT) package. Health facilities which had adequate IUCD case load were selected as training sites. A team of one woman medical officer and a public health nurse were chosen as trainers and given a two week TOT on clinical practices and training skills. Each team trains four ANMs in a week-long programme, which includes IUCD insertion practice on ZOE pelvic model and then on at least two clients. The trained ANMs are given IUCD kits and other supplies and followed up by trained Regional Family Welfare Training Centre (RFWTC) staff to verify whether they were performing to standard with respect to IUCD handling, insertion and counselling.

 Steps Involved in Clinic Based Family Planning Training of LHVs and ANMs are:

Counselling training is given to all female workers who have undergone CBFPT. A four day counselling training through a participative, user -friendly package developed by SIFPSA is provided to further improve their client screening and counselling skills. This training has been very useful in changing attitudes of workers, inculcating in them the ability to discuss clients' needs and offer services according to the client's choice and preference. 10,578 ANMs have been trained in CBFPT by SIFPSA in 34 districts. This activity is now closed in all districts.

A 18 months CMW training, using syllabus of 18 months training of Basic Health Worker female was implemented on pilot basis in 4 districts. Total of 239 were admitted for training against 240, and 216 have been passed out.

An Infection Prevention Training package has also been designed and implemented by SIFPSA. Its objective was to protect providers, clinic staff and the community from infectious diseases that originate in health care facilities. A two-day on-site programme is conducted for all staff members working in teams at health care facilities. A five-day TOT has produced training teams comprising medical officers and staff nurses who conduct on site training. This training emphasizes hands-on learning to enhance knowledge and practice of disinfection, decontamination and sterilization of instruments and surfaces, and involves all categories of service providers and support staff at CHCs and PHCs. Infection prevention training has been given at 498 sites in 38 districts.

RTI/STI training has also been designed and implemented. Total of 773 service providers have been trained.

Upgrading facilities is one of the approaches used to improve the quality of services in rural health centres. The specific needs for upgrading have been identified in District Women Hospital Post- Partum Centres (PPCs), all Community Health Centres (CHCs) and Block Primary Health Centres (PHCs) in 38 districts.

A needs assessment is done by a team visiting each facility. This ensures identifying critical needs, avoids duplication of funding and helps make accurate budget estimates. The needs identified included essential repair and renovation of buildings, water supply, electricity (including generator set), operation theatre, counseling rooms, equipment and supplies, and is done by a team visiting each facility. Detailed guidelines were drawn up for procurement of each item in consultation with UP State Director General, Health Services; estimates are prepared on site and Chief Medical Officers contract out the upgrading activities. With these clinical facilities appropriately equipped and trained medical officers and paramedics posted there, the quality and variety of services provided by them also increases. 558 sites to include PPC, PHCs, CHCs, in SIFPSA districts have been renovated for providing quality services. In addition, 7265 subcentres and 37 health posts have also been upgraded.

One of the constraints in providing good quality reproductive health services in remote rural areas is the shortage of women medical officers with the Health & Family Welfare department. SIFPSA has initiated an innovative scheme for hiring private women medical officers to serve at block PHCs and at CHCs where there is no woman medical officer. CMOs contract practicing medical professionals who are paid on a visit basis.

Where no allopathic doctor is available even women practitioners of the indigenous system of medicine are hired.

The women medical officers provide services from 8 a.m. to 2 p.m. SIFPSA funds up to two visits a week at CHCs and one at the block PHCs in 15 districts. 156 women medical officers have been contracted under this scheme throughout UP. More than 27,726 visits have been made by women medical officers who have counselled 492,839 clients.