v     Introduction:

With about 77,000 women dying every year during pregnancy and post partum period, maternal mortality in India continues to remain unacceptably high. To effectively reduce Maternal Mortality provision has to be made for providing basic and emergency obstetric care to every pregnant woman.

Reducing Maternal Mortality and providing Skilled Attendance at every Birth has been envisioned in Reproductive and Child Health Programme, under the umbrella of National Rural Health Mission (NRHM), which has been launched by the Government of India in April 2005, in order to improve the availability and access to quality reproductive health care services throughout the country.

To achieve the above goals, there is a commitment for operationalizing of all CHCs as First Referral Units for comprehensive obstetric care services and at least 50% of all PHCs to 24 X 7 centers to become proficient in providing basic RCH obstetric care services. To achieve this health workers at these facilities should be proficient in timely identification and management of basic complications during pregnancy and child birth i.e. they should be trained as Skilled birth Attendant.

A Skilled Birth Attendant (SBA) is defined as “an accredited health professional-such as midwife, doctor or nurse-who has been educated and trained to achieve proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and immediate postnatal period and in the identification, management and referral of complications in women and newborns.”

GoI also has taken policy initiatives to empower the SNs/LHVs/ANM to make them competent for undertaking certain life saving measures. These measures are as follows:

·         Permission to use Uterotonic drugs for prevention of PPH.

·         Permission to use drugs in emergency situations prior to referral for stabilizing the patient.

·         Permission to perform basic procedures at community level in emergency situations.

In view of this SBA training has been launched for SNs/LHVs/ANMs at District level, where intensive hands on training in mid-wifery skills will be provided to these health personnel. States are in process of gearing up their facilities for this training but there is a need to scale up this training to achieve our commitment of skilled attendance and by thus preventing women’s dying due to the lack of the same.

Under NRHM, there is a commitment to establish Public Private Partnership to involve private providers in the government health programs. With this in view a guideline for accreditating private health facilities for providing SBA Training have been prepared, through which private providers will train health personnel as SBA, whose services can then be utilized at Government Health Facilities for delivering quality obstetric care services.

The guidelines have been prepared by FOGSI in collaboration with GoI and WHO-India. It is hoped that this guideline will be useful in accreditating private Health Facilities for conducting SBA Training which in turn will help widening the skill based services at primary and secondary health level. It is expected that these facilities will maintain the quality in training which will enable our health workers in acquiring the desired skills for quality obstetric care services.

v    Objectives:

These guidelines are developed with following objectives:

1.     Develop a comprehensive, credible and transparent system of accreditation, for organizing SBA training in the private sector.

2.     Accredit private maternity/nursing homes/hospitals including those run by the trusts, public sector undertaking, missionaries etc which will be recognized as centers providing high quality Skilled birth attendant (SBA) training to auxiliary nurse midwives (ANMs)/SNs.

v    Accreditation Process:

The term accreditation reflects the systematic assessment of infrastructure (includes manpower, equipments etc) required for conducting SBA Training. In simple terms, we can say that accreditation refers to a voluntary process wherein the requirement of SBA training in participating health facility is accessed against set standards.   

Ø      Step 1: Establishing Committee for Accreditation (DAC):

·         District Accreditation Committee to be established by the Chairperson of DHS at District Level.

·         Committee to have following composition (including 1 women member):

ü      District CMO – Convenor.

ü      1 FOGSI member –Co Convenor.

ü      District RCH officer /District Program Manager (DPM) - Member Secretary*.

ü      Representatives from IMA/IAP/NNF.

ü      Any other Technical/Program Officer from the District Health Office can also be nominated by District CMO.

·         In case Chairperson decides to utilize already established District QAC, then he should ensure that private service providers especially members of professional organization like FOGSI/IMA/IAP at the district level are nominated and given due representation.

·         Nominated members from the professional organization will have tenure of 3 years.

·         DAC will meet quarterly in a year to discuss the accreditation progress other than the site assessment visits. Meeting of the committee shall be called by the convenor and facilitated by co-convenor.

·         Member Secretary will be the custodian of the records for the DAC meetings and shall be responsible for putting up files, notes etc. to the convenor /committee and convening the DAC meetings.

·         CMO/ Member Secretary of DAC will be primarily responsible for executing the TORs in which FOGSI will facilitate timely accomplishment of the process.

Ø      Step 2: Orientation of DAC members

·         One day orientation of DAC members on the TORs of the committee and the process of Accreditation including the tools can be done at District/State level.

·         TORs of the Committee are:

1)      Ensure that the accreditation scheme gets necessary publicity, to be taken up by the PHFs and to generate awareness among clients.

2)      Committee will be responsible for the whole process of accreditation which will include inviting letters of interest for accreditation, screening the same, undertaking site assessment, certification, monitoring, reviewing the progress of accreditation and undertake remedial measures. 

3)      Facilitate formalization of MOU between the DHS and PHF.

4)      Committee will have the power to revoke the accreditation of the PHF in case of non-compliance/ unethical practice etc.

5)      To provide budgetary estimates for the accreditation process to be reflected in respective district PIPs.

Ø      Step 3: Publicizing the Scheme:

·         DAC will take necessary steps for the adequate awareness generation of the scheme among the Private Health Facility.

·         Information about the scheme can be communicated through mass media like newspaper, radio, TVs, poster etc.

·         Appropriate information about the scheme including the service detail, minimum standards for getting accreditation etc. will be available at websites of national/ state health ministry and professional bodies like FOGSI/IMA/IAP etc.

·         DAC will publish adequate number of brochure/forms which include information on the scheme, process, package, self evaluation checklist, liabilities of PHF/ DAC etc.

Ø      Step 4: Pre- accreditation procedure

·         PHFs who are interested in the scheme will obtain forms including the self evaluation checklist (in accordance with Annexure 1).

·         PHFs will submit duly filled self evaluation checklist along with the application fee of Rs 1000/- at the office of District CMO.

·         Office of District CMO will issue acknowledgment receipt on receiving the LOI.

·         Member Secretary/DPM scrutinizes the application, lists the eligibility of PHFs.

·         Quarterly meetings will be called by CMO and during these meetings; plan for the Site Assessment for Accreditation is developed according to the number of application.

·         Whole process of accreditation including site assessment, certification and signing of MoU, release of funds has to completed by the DAC within 3 months of submission of LOI by the PHFs.

Ø      Step 5: Site Assessment for Accreditation:

·         Site Assessment has to be undertaken within 21 days of the Quarterly meeting.

·         Site Assessment will be done by at least 2 members of DAC, comprising of 1 member from Government and 1 representative from professional bodies in the DAC.

·         During site assessment of the PHFs self evaluation checklist submitted by the PHFs has to be verified. Authenticity especially in terms of manpower, service delivery protocols has to be judged.

·         Site assessment team submits it report to District CMO within 7 days of site assessment, giving the detail that whether the accreditation to the PHF for conducting SBA training can be granted or not.

·         Adequate funds have to be kept by the DHS, for DAC members to undertake the site assessment visits.

Eligibility criteria for the PHF to conduct SBA Training

Ø      Step 6: Certification and  Signing of MoU:   

·         As per the report of site assessment team PHFs is notified on the acceptance/rejection of its application by the District CMO within 10 days.

·         If the site assessment team recommends PHFs for accreditation, certificate of Accreditation ( Annexure III) is issued, TOT for the trainers and MoU (Annexure II) is signed between the CMO and owner of PHF and adequate funds are released to the PHF ( detail under the financial head). The whole process has to be accomplished within 3 weeks of the visit of site assessment team.

In case application of the PHF is rejected as per the recommendation of Site Assessment team, reasons for the same have to be communicated to the PHF within 3 weeks of site assessment teams visit. Such PHFs can strengthen the gaps and reapply on the same application number within 6 months from the date of rejection. No additional application fee will be charged for 6 months from the date of rejection. Beyond this period PHF has to reapply and will be treated as new application.

Ø      Step 7: Release of Funds, initiation of the training and posting of the trainees:

·         Selection of Trainers:

ü      Trainers will be the following staffs of the PHF/ Training centre who have received the orientation training:

o        Ob-Gyn doctors as Master Trainers.

o        Pediatrician as co facilitators for sections pertaining to neonatal health.

o        MOs, Nursing Teachers/ SNs of the PHFs/Training Institute.

·         Training of trainers:

ü   Out of all the envisaged trainers in PHF, it is essential that at least Ob/Gyn, Paediatrician and 1-2 SNs of PHF must attend the State/District level TOT.

ü   Trainers will undergo 2-3 days orientation training by SIHFW/ FOGSI-ICOG members at any site selected by the State. During the TOTs, trainers will be oriented on the operationalization of SBA training, training material, mode of certification etc.

ü    If all the trainers from the PHF is not able to attend State /District  level TOT, in that case it will be responsibility of the Ob/Gyn and trained personnel to orient and train other trainers in their PHF.

·         Posting of trainees:

ü     CMO nominates the name of the trainees as per the District Training Calendar, for SBA training at PHF.

ü     Trainees have to join the training on the first day.

ü   Training material will have to be provided by the training institute.

ü     Duration of the training:

o        For staff nurses:  Two to three weeks.

o        For ANMs and LHVs: The total duration of the course will be for a minimum of three weeks which can be extended to six weeks.

ü      However, it is suggested that the extension ideally should not be of more than 1 week. If the proficiency is still not achieved the trainee can be called in the subsequent batches, after practicing the skills either at the same institution or at her place of work. TA and DA as per State rules can be provided. Extension for such cases can be undertaken on the advice of Master Trainer, who will inform the MS, with a copy of the communication to the CMO of the District, for necessary actions including payment of TA/DA.

·         Release of funds:

ü      PHF will be given a one time grant of Rs 40,000/- (20,000/- at the time of signing of MoU to strengthen the training centre and on successful completion of the training, as per the satisfaction of the District Accreditation Committee in the first year an additional grant of Rs 20,000/- will be released to the PHF in the second year). On renewal of the same no additional grant other then the funds for conducting the training.  

ü      Following the release of first grant PHF will have to conduct training for at least 2 years. But if the PHF parts away with the training, they will have to return back the one time grant.

ü       75% of funds are released to the PHF before the start of the training..

ü      PHF submits SOE after completion of training and intimates the next date of the training.

ü      CMO examines SOE and remaining 25% of the funds are released to the PHF along with deputation of trainees for the next batch and simultaneously release of 75% advance funds is released.

ü      State/DHS can decide on the frequency of submission of the accounts/ SOE by the PHFs. It can be batch wise/ monthly/quarterly.

v     Validity of Certificate/Renewal of Certificate:

·         Certificate of accreditation once issued will be valid for a period of 3 years.

·         After expiry of the certificate, PHFs will have to reapply for accreditation.

·         To maintain the continuity of accreditation, during the interim period (3 months) facility will be deemed as Accreditated.

v    Monetary/Non monetary benefits /Budgeting

Illustrated Budget per Batch for Training of Skilled Birth Attendant

ü     



























PHF will be given a one time grant of Rs 40,000/- (20,000/- at the time of signing of MoU to strengthen the training centre and on successful completion of the training, as per the satisfaction of the District Accreditation Committee in the first year an additional grant of Rs 20,000/- will be released to the PHF in the second year). On renewal of the same no additional grant other then the funds for conducting the training.  

ü      This grant shall be released by the State health Society/SCOVA to the District health societies, which in turn will place the funds at the disposal of the accreditated PHFs for conducting training of ANMs. Following the release of monetary grant, PHF will have to conduct training for at least 2 years. But if the PHF parts away with the training, they will have to return back the grant.

·         ** Honorarium to the Trainers:

Ø      Rs 200/day for 4 persons X actual duration of the training.

Ø       Suggested Honorarium Plan for the trainers:

ü     1 OBG (Master Trainer).

ü     1 Nursing Personnel In charge Labour Room/ On duty Supervisor at LR.

ü     2 Co Trainers as per the direction of Master Trainer.

ü     In c/o single trainee, honorarium for the trainers will be for 2 trainers/day.

·         Funds for conducting 2 days training (travel, stay, material, DA) of PHF team of trainers (TOT) at SIHFWs/Districts and also for monitoring of training programmes in Districts shall be provided to the concerned SIHFW from the RCH – Flexi Funds placed with the State Health Society/SCOVA.

·         * In case of extension of the training duration for some trainees, the Honorarium (for the trainee only) along with expenditure on lunch/tea for the added days can be calculated accordingly.

·         The entire cost of SBA training shall be met out of the RCH- flexible pool placed at the disposal of States and this should also be reflected in the States PIP.

·         The names and other details of the accreditated PHFs conducting SBA training will be publicized in ICOG/FOGSI/GOI journals and websites.

·         District CMO will release 75% of the budget to the PHF for the training ( depending on the number of trainees) before the start of the training and rest 25% will be released after the PHF submits Statement of Expenditure.

·         Ensuring timely release of funds to the private health facility for conduct of training program and training site maintenance.

·         Maintain logistics of the training.

·         DPMU to ensure that TA/DA of the participants is distributed in time.

Ø      Monitoring and evaluation

1. Monitoring for accreditation:

a.     There will be 5% Random Checking of the accreditated PHFs by DAC or representative to ensure adherence to the site readiness checklists. (TA/DA required for the same to be paid from the respective State – RCH funds).

b.     If at any time it is found out that PHF is not adhering to the norms laid down while certification of Accreditation for the training or is found to the compromise on the quality of the training imparted or is found to compromise on residential and food facility being provided to the trainee, then its certification will be deemed to cancelled with an immediate effect.

2. Monitoring for SBA training: The following steps will ensure monitoring of quality of training.

a.     Visit by a team consisting of District Level CMO or representative (e.g. DPM) for every batch of SBA training.

b.      Any National/State health official visiting district for routine Monitoring and Supervision will also visit the PHFs.

c.      National Monitoring Tools will be used by the monitoring teams /officials.

d.     DPMU will be regularly monitoring the personnel trained as Skilled Birth Attendant at their centers and will be providing the feedback to CMO, who then will be take actions and provide necessary assistance

Annexure I

(For use by District Accreditation Committee for Certification of Training Institute)

(For use by Private Health Facility for up gradation of Training Institute)

Checklist for Training Site Readiness

Name of training site_______________________________________________

District and State__________________________________________________

Date of assessment_________________________________________________

Name and designation of Assessor____________________________________   

Note: Items marked with an asterix (*) are critical for the training of ANMs, LHVs and SNs and

should be present at the training site prior to initiation of training. All the items mentioned in the

list are critical for the functioning of the district Women’s Hospital and should be present at the

training site after the orientation of district level trainers.

Annexure 2

Draft

MoU between Private Health Facility and District Health Society

This agreement is made on the ____________________ day_____________ 08 between the District Health Society which in turn shall include its successors , assigned and authorized persons of the first part and Dr.­­­­­­­­­­­­­­­­­­­­_______________,Medical Director/Incharge of__________________________(Private Health Facility ), and affiliated Training Centre of National Association of Reproductive Child Health of India, (NARCHI), which is partnering the Ministry of Health, Government of India, in the SBA Training Programme, hereinafter called the implementing agency which shall include its successor ,assigns and authorized persons of the second part.

Whereas the District Health Society is working with _______________________(Private Health Facility ) for Skilled Birth Attendant (SBA) training of ANMs of PHCs and Sub Centers..

The Skilled Birth Attendant (SBA ) training programme addresses the evidence-based best practices for the provision of Skilled Attendance during pregnancy and at birth by ANMs/LHVs and Staff Nurses  .

The expected outcomes/outputs are:

1)      Improvement in the knowledge and skills of the health workers which will enable them to  provide the mandatory minimum standard for a skilled birth attendant at all levels of health care

2)      Improving the availability and accessibility of skilled attendance at birth and management of emergency obstetric and newborn complications at all levels.

3)      Reducing the maternal morbidity and mortality by improving the quality of services during pregnancy and child birth.

NOW THEREFORE, THIS AGREEMENT WITNESSETH AS UNDER

That the parties to this agreement have discussed, mutually agreed and accepted the project on the following:

1)      The agreement will be in force from _____________to __________.

2)     PHF will be given a one time grant of Rs 40,000/- (20,000/- at the time of signing of MoU to strengthen the training centre and on successful completion of the training, as per the satisfaction of the District Accreditation Committee in the first year an additional grant of Rs 20,000/- will be released to the PHF in the second year). On renewal of the same no additional grant other then the funds for conducting the training.  

3)     This grant shall be released by the State health Society/SCOVA to the District health societies, which in turn will place the funds at the disposal of the accreditated PHFs for conducting training of ANMs.

4)     Following the release of monetary grant, PHF will have to conduct training for at least 2 years. But if the PHF parts away with the training, they will have to return back the grant.

5)     The total budget for to train ___ health worker is Rs.________________has been approved by the Government of India for the above said period .The grants will be released to the Private Health Facility for establishing SBA Training Center at the Private Health facility.

ü      75% of funds will be released to the PHF before the start of the training and remaining 25% will be released after PHF submits SOE.

ü      CMO examines SOE and remaining 25% of the funds are released to the PHF along with deputation of trainees for the next batch and simultaneously release of 75% advance funds is released.

ü      State/DHS can decide on the frequency of submission of the accounts/ SOE by the PHFs. It can be batch wise/ monthly/quarterly.

FUND RELEASES AND FINANCIAL REPORTS

1)      The expenditure may be incurred only on approved items of activities

2)     Funds are to be utilized as per approved budget and no transfer of funds from one head of activity to another head of activity is allowed.

3)     All expenditure under this sanction should be incurred with reference to the guidelines prescribed by the Government of India/State Government and as per the financial and administrative rules and regulations of the Government.

4)     State/DHS can decide on the frequency of submission of the accounts/ SOE by the PHFs. It can be batch wise/ monthly/quarterly.

5)     If the training not conducted by the Accreditated Health Facility within one year from the date of awarding accreditation certificate (subject to the posting of Trainers by CMO) , then the money will be returned to granting authority with 18% interest.

ACCESS FOR AUDIT

The books of accounts and relevant records and minutes of meetings and other documents pertaining to the project should be made available at all times to the Chief Medical Officer District Health Society and at the time of Audit of Accounts by the Auditors.

STOCK REGISTERS

The Private Health Facility must maintain accurate records pertaining to fixed assets and stocks of store items and keep purchase orders or requests and make such records available to the Chief Medical Officer, District Health Society

ACCESS FOR SUPERVISORY AND MONITORING VISITS

Health officials from District, State and National level officials would have a right to visit the PHF to ensure Site Readiness for Accreditation and Quality of training

QUATERLY PROGRESS REPORT

1)      Physical Progress Report should be sent to the Chief Medical Officer ,District Health Society /District Project Management Unit (DPMU) every month

2)     The expenditure statement should be sent to the Chief Medical Officer, District Health Society and DPMU every Quarter  for the total period.

3)     The Private Health Society should submit utilization certificate annually  to the Chief MO ,District Health Society and DPMU 

4)     The report should highlight the quantitative and qualitative performance

TASKS

1)      Theory and Practical Training of health workers assigned to the health facility by the CMO of the respective district

2)     Maintenance and Submission of all records and reports associated with the training programme

The unspent amount if any at the end of the project or termination of the contract must be returned to the Chief Medical Officer, or the granting institution/District Health Society within 15 days by way of Demand Draft.

The District Health Society will ensure the following:

1)      The District Health Society will inform the State Government of the provisions of the present Memorandum of understanding which will help implementation of activities for SBA training in their State and ensure coordination among all concerned partners.

2)      The District Health Society will ensure the timely release of funds to the Accreditated PHF for SBA training.

3)      Within 30 days of certification of Private Health Facility funds will be released and trainees deputed by the DHS to the PHF.

4)      The DHS will ensure timely release of funds to the accreditated PHF. 75% of the amount to be given before start of training and 25% within 30 days of submission of accounts by the PHF to the DPMU

5)      The CMO of the DHS will have a right to visit the Accreditated PHF to ensure quality of training.

6)      CMO/Member Secretary of DAC will ensure all above tasks.

SUSPENSION

Non compliance of the commitments and obligations set in the MOU may require the District health society to review the assistance committed through this MOU leading to suspension ,reduction or cancellation thereof.The DHS commits to issue sufficient alert to the state government before contemplating any such action.

If there were to be any differences between the District Health Society and the implementing private health facility the same shall be settled amicably and any undecided dispute shall be referred to the Principal Secretary, Health and Family Welfare Department, _____________ (Respective State).Whose decision shall be final and binding on the parties to the agreement.

In witness whereof the parties hereto have here unto set their hands on the day indicated below:

Chief Medical Officer                                                 Incharge/Medical Officer

District Health Officers

For and on behalf of First Party        (Name and Address of Private Health Facility)

                                                            For and Behalf of Second Party

Annexure III: Accreditation Certificate

Annexure 4

SBA training completion certificate

(SAMPLE)

District Health Society (DHS) of Ministry of health, Govt. of India

Awards SKILLED Birth Attendant (SBA) Training

Completion Certificate

This certificate authenticates that ___________________has successfully completed the   3 weeks - SBA competency based Training Course during the period    _______________________________                               conducted by ____________________________________