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Report on the Focused Programme Review of the Diarrhoeal Diseases Control Programme in Viet Nam, 21 September - 3 October 1992 : joint report of the National CDD Programme, UNICEF and WHO

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(WP)ICP/CDD/OOI-E Report series no.: RS/921PR/02(VTN)

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REPORT ON THE /'//

FOCUS(D PROGRAMME REVIEW OF THE DIARRHOEAL DISEASES CONTROL PROGRAMME IN VIETNAM 21 September-3 October 1992

Joint report of the National CDD Programme, UNICEF and WHO

Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines May 1993 "HO/wppn !.TERn"!

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NOTE

The views expressed in this joint report are those of the CDD Focused Programme Review team and do not necessarily reflect the policies of the World Health Organization.

This joint report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for the Government of the Socialist Republic of Viet Nam.

CONTENTS ~

EXECUTIVE SUMMARY ................................................................................................ 1.1 1.2 1.3 1.4 Team 1 ........................................................................................................................... Team 2 ........................................................................................................................... Team 3 ........................................................................................................................... Team 4 ...........................................................................................................................

1 2 2 3 4

2. 3.

BACKGROUND OF NATIONAL CDD PROGRAMME ......................................... 5 PHASE I OF FOCUSED PROGRAMME REVIEW (FPR) ..................................... 6 3.1 Findings.......................................................................................................................... 7

4. 5.

PHASE II. OBJECTIVES AND METHODOLOGY ................................................. 12 REVIEW OF TEAM REPORTS..................................................................................... 13 5.1 Review of the activities to strengthen the teaching of COD and EPI in secondary medical schoo!........................................................................................... 13

REVIEW OF THE ACTIVITIES TO STRENGTHEN THE TEACHING OF COD IN MEDICAL SCHOOLS....................................................... 30 6.1 6.2 6.3 6.4 6.5 6.6 Priority area under review.................................................... ..................................... Background .................................................................................................................. Review methodology .................................................................................................. Key fmdings.................................................................................................................. Hospitals/Hospital Directors/DTUs ...................................................................... Recommended activities............................................................................................ 30 30 30 31 31 37

REVIEW OF SUPERVISORY SKILLS TRAINING AND SUPERVISORY ACTIVITIES AT PROVINCIAL AND DISTRICT LEVEL ............................................................................................................. 39 7.1 7.2 7.3 7.4 7.5 7.6 Statement of priority area ......................................................................................... Background to priority areas .................................................................................... Methodology ................................................................................................................ Key findings.................................................................................................................. Recommendations ...................................................................................................... Plan of action ............................................................................................................... 39 39 40 40 43 44

Keywords Diarrhoea - prevention and control/Programme evaluation / Viet Nam

- ii l1W 8. REVIEW OF COMMUNICATION ACTIVITIES ............................................ 47 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8

Priority area under review. ............. .... ...... ..... .... .................................. Background ..................................................................................... Review and methodologies.............................................................. .... Key findings .................................................................................... Problem areas discovered .................................................................... Observations and impressions ............................................................... Conclusions and recommendations ...... ................................................... Integration with the national strategy on health education and communication................................................... 8.9 Other................................................................................... .......... 8.10 Evaluation ....................................................................................... 8.11 Plan of action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47 47 48 49 51 52 53 54

55 55 55

SUMMARy ........................................................................................... 62 9.1 9.2 9.3 9.4 Team Team Team Team I ........................................................................................... 2 ........................................................................................... 3 ........................................................................................... 4 ........................................................................................... 62 62 63 64

ANNEXES: ANNEX 1 LIST OF PARTICIPANTS IN PHASE I, FOCUSED PROGRAMME REVIEW, 11-15 MAY 1992 ............... 65

ANNEX 2 - PARTICIPANTS, TERMS OF REFERENCE, AND SCHEDULE FOR REVIEW TEAMS FOR PHASE II, FOCUSED PROGRAMME REVIEW......................... 67 ANNEX 3 CHECKLIST FOR MONITORING OF IMPLEMENT ATION OF ACTIVITIES TO STRENGTHEN THE TEACHING OF EPI/CDD IN SECONDARY SCHOOLS .................................... 71 FIGURE I: RESULTS FROM THE CDD STUDENTS QUESTIONNAIRE FROM 12 SCHOOLS ................. 85

ANNEX 4 -

ANNEX 5 - SOME DATA ON MEDICAL SCHOOLS AND TEACHING HOSPITALS ..................................................... 87 ANNEX 6 QUESTIONNAIRE FOR REVIEW OF SUPERVISORY SKILLS TRAINING AND SUPERVISORY ACTIVITIES AT PROVINCIAL LEVEL.............................. ...................... 99 RESULTS FROM INTERVIEWS AT PROVINCIAL LEVEL ........ 111 NUMBER OF PERSONNEL TRAINED IN CDD COMMUNICATIONS BY PROVINCE AND PERCENT OF DISTRICTS COVERED 1990-1992.. ................... 123

ANNEX 7 ANNEX 8 -

1. EXECUTIVE SUMMARY

A review of the National Control of Diarrhoeal Disease Programme (NCDDP) was conducted by the Government of Viet Nam in collaboration with WHO and UNICEF using the Focused Programme Review protocol under development by the Diarrhoeal Disease Control Programme, WHO. The review was conducted in two phases: Phase I from 11 to 15 May 1992 and Phase II from 21 September to 3 October 1992. In Phase I relevant programme documents were reviewed and the programme secretariat were consulted in order to determine the programme's progress towards set targets and to obtain information on key programme indicators. On the basis of these fIndings, programme achievements were noted and the following priority areas were listed for review in Phase II: ( 1) Review of strengthening CD D /EPI teaching in allied health workers schools.

(2) Review of strengthening CDD teaching in medical schools and follow-up of training activities and case management in diarrhoea training units (DTUs) associated with medical schools. (3) Review of supervisory skills training and supervisory activities at provincial and district levels. (4) Review of communication activities. 1

In Phase II four teams were assigned to the four priority areas, and these areas were reviewed in depth in order to assess the current status, and to pinpoint achievements and constraints. The methodology for the in-depth reviews, although varying for each team, involved site visits using questionnaires, key informant interviews, surveys and review of documents. As all the required information could not be gathered during the two weeks in which the consultants were present the NCDDP secretariat made several site visits during July and August. For the constraints encountered a problem-solving approach was used to find solutions. Each team made recommendations based on the findings and prepared a plan of action for their relevant areas. The NCDDP will incorporate these action plans into their overall mid-term plan of action which will be presented in the annual review and planning meeting in December 1992. A summary of major findings and recommendations for each team are found below.

1 Review conducted 12-23 October 1992 owing to availability of WHO and UNICEF consultants.

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1.1 1.1.1

Team 1 Key fmdines:

(1) In general, the teaching of COO and EPI in the paramedical schools has improved considerably since the activities were initiated in 1990. (2) All schools had received official instructions from the Department of Training regarding the revised curricula. (3) The staff attitude to the new curricula was considered overall very positive.

(4) In general, there was a feeling that to teach the content in the new curricula, more hours than indicated are needed. (5) Most schools had prepared their own teaching materials, mainly because of the lack of modules for both EPI and COD. In addition, none of the schools had received any equipment for EPI practice. (6) In most schools there are different teachers for EPI and COD. Therefore, usually only one teacher per school was "trained". (7) Quantity and quality regarding collaboration with the Stations of Hygiene and Epidemiology and the schools varied from province to province. (8) The results from the student questionnaires indicate generally very good knowledge. However, when it comes to the implementation of the knowledge, the skills were weaker. 1.1.2 Recommendations:

(1) All schools should have an adequate number of COD and EPI modules and other relevant teaching materials (slides, manuals, etc.) and equipment (steam sterilizers, vaccine carriers, syringes, needles, ice packs, etc.). (2) All schools should have two teachers trained in diarrhoea case management at oro and two teachers trained in EPI with special emphasis on methodologies. (3) All schools should use the revised curricula in a similar way with the same number of hours allocated for the subjects. (4) The project ·Strengthening the teaching of COO and EPI for assistant physicians, nurses and midwives in Secondary Medical Schools" should be evaluated by the end of 1994 and plans made for long-term sustainability. 1.2 1.2.1 Team 2 Key findings:

(1) The majority of the schools had been able to pursue all objectives listed in their 12month workplans from 1990: establish/strengthen oro, follow COO guidelines in their teaching, introduce COO teaching material, assure supervised clinical practice, use more small-group teaching, coordinate teaching with other clinical and basic science departments, improve evaluation of knowledge and skills and train faculty and staff in CDD management and new teachng methods.

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(2) The medical education (MedEd) activities have had catalytic effects on general efforts to improve teaching in medical schools. (3) (4) (5) (6) (7) (8) 1.2.2 Too many students for too few patients. Lack of (free) teaching materials for the students. Shortage of equipment to further improve the teaching. (Free) food is not always available in OTU. Shortage of Ringer-lactate. Cooperation between hospitals and the EPI programme is not optimal. Recommendations:

(1) Medical schools and hospitals should improve the patient/student ratio and assure funding for free food in OTUs. (2) The national COO programme should provide more teaching material, explore funding for one video camera, video players and photocopiers, perform a KAP study on DO among doctors one to two years after medical school and conduct a national workshop on "Teaching in medical schools". (3) The Ministry of Health (MOH) should support national production of Ringer-lactate (or change the text in the management chart) and establish policies so that vaccines can be stored and used on a daily basis in hospitals. 1.3 1.3.1 Team 3 Key findin&s:

(1) Training coverage was high at provincial level (80% of provinces had at least two persons trained) but only moderate at district (43%) and at commune level (59%). (2) Although perceived as a problem, the results indicated that turnover of trained staff is not a big problem (40% of provinces reported that 100% of trained staff still working and 60% of the districts had 100% trained staff still working at site). (3) Training materials used varied from province to province and some did not meet the recommendation of the NCOOP. (4) The frequency of supervisory visits conducted has increased, although it does not usually meet the standard MOH recommendation (12 visits/year). (5) 80% of provinces and 56% of districts reported that they had used a supervisory checklist. (6) Lack of comprehensive training plan at central level and guidelines on how to conduct training. (7) Lack of monitoring of training at central and provincial level.

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1.3.2

Recommendations

(1) The NCDDP should develop a mid-term (three years) detailed plan of action for all CDD activities including supervisory skills training. The plan should state the current training coverage, targets and subtargets, spec£fy the target audience for each type of course, criteria for content and methodology of course, timetable of activities and sources of funds. (2) Before preparing the mid-term plan the NCDDP should review their current strategy of training only two staff at each level. As the supervision is integrated, the review team recommended training all staff doing supervision in each Hygiene and Epidemiology Station (HES) (approximately 10-12/HES) and all staff doing supervision in each Hygiene and Epidemiology Brigade (HEB) (approximately 7-10). (3) Following the preparation of this plan, short guidelines (1-2 pages) should be prepared outlining the NCDDP's requirements for courses (e.g., number of facilitators and participants, length of course, materials to be used, etc.). These guidelines should be distributed to those who will conduct courses and the quality of the training courses should be monitored. (4) The NCDDP should develop and maintain a monitoring system for all training activities. (This was discussed with the NCDDP during the review and draft forms were prepared). (5) The NCDDP should monitor the distribution of training materials to ensure that all courses are using materials approved by the national level and that each participant will be provided by a complete set of modules. (6) The NCDDP, WHO and UNICEF should improve their collaboration and set clear guidelines for request and timely release of funds. (7) The NCDDP should actively seek other potential donors. All these agencies should be invited to the annual review and planning meeting in December 1992, where the midterm plan will be presented in support of supervisory skills training supervision and other activities. (8) The NCDDP should assess the need for regular supervision from the national level and the Pasteur Institutes to provincial CDD staff. (9) As many staff reported shortage and delays in receiving ORS, the NCDDP should further investigate this to see if it is a significant problem and if so, action should be taken to ensure ORS availability. 1.4 1.4.1 Team 4 Key findings:

(1) The number of health staff trained in IPC skills in 1990 and 1991 has met or exceeded plans and expectations at all levels of the health system. (2) Many activities in 1992 have been suspended because of delays in funding.

(3) Interviews with health personnel responsible for CDD at province, district and commune level demonstrate an impressive awareness of the importance of advice-giving as part of their responsibilities.

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(4) Exposure to CDD messages and materials has shown a substantial increase from 1990 to 1992. (5) Orientation of private pharmacists in urban areas appears to be a useful means of disseminating information on correct case management. 1.4.2 (1) Major recommendations: Training on ICP skills should be carried out as indicated in the plan of action.

(2) Future training courses should put more emphasis on learning and practising the ICP skills. (3) (4) Future training courses should give equal attention to the messages on home care. Orientation seminars of private pharmacists and physicians should continue.

(5) A mechanism should be developed whereby all CDD related materials are reviewed by the national CDD secretariat for technical accuracy and consistency with national CDD policies and messages. (6) An integrated curriculum should be introduced at a case management/ICP training of trainers course in 1993. (7) A standard curriculum, with a provision for exercises and practice for commune level training should be developed. (8) The CDD/ICP module should be included in the core curriculum for the Centre for Health Education and Communication.

2. BACKGROUND OF NATIONAL CDD PROGRAMME

The National Control of Diarrhoeal Diseases Programme (NCDDP) for Viet Nam was intiated in 1982, with pilot projects in four selected provinces. The programme has been succesfully expanded in phases and is currently operational nationwide, covering approximately 84% of the target population of children under five years of age. The objective of the programme is to reduce morbidity and mortality due to diarrhoeal diseases in children below five years of age. The NCDDP is staffed by a director and six full-time staff and is based in the National Institute of Hygiene and Epidemiology (NIHE) at Hanoi. The structure of the MOH health care delivery system, through which the CDD programme is implemented, is a parallel system of curative and preventive services that extend to the regions, provinces and districts, and converge at commune level. Under the preventive services the programme has staff responsible for CDD activities in aU provincial and district Hygiene and Epidemiology Stations (HES) and in most of the communes. Its main strategies include increasing access to oral rehydration salts (ORS) and correct case management through extensive training of health workers in programme management, supervisory and case management skills. In addition, training in

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communication skills and the use of mass media has been given high priority. A communication plan for 1990 to 1995 has been prepared and actively implemented. Since 1987 the programme has put equal emphasis on introducing and integrating CDD concepts and training materials in basic training, i.e., in medical and paramedical schools. Promotion of exclusive breast-feeding has been selected as a nationwide priority intervention. In 1992 activities were initiated to adopt the international code for breastmilk substitutes for Vietnamese conditions and to train key health staff on breast-feeding management issues. During the first years of programme development major emphasis was placed on the implementation of preventive interventions. In 1987 the NCDDP became active also in the MOH curative services under the Director of the Institute for Protection of Child Health. Emphasis was placed on case management training and four Diarrhoea Training Units (DTUs) were established. In 1990-1992 12 provincial (mini) DTUs were established in order to decentralize training. Programme evaluation and monitoring through household case management and health facility surveys, follow-up visits after training and through annual review and planning meetings, has been a priority component. In 1987 a Comprehensive Programme Review (CPR) was carried out. The review assessed the status of the programme after its first six years of implementation a.nd provided the NCDDP with a set of recommendations for further programme development. In the annual review and planning meeting in Hanoi in November 1991, it was proposed that a Focused Programme Review of the NCDDP should be carried out in 1992. As the previous CPR was conducted quite recently and several surveys and other data were available on the status of the programme at both household and health facility levels, it was suggested that the review should focus on selected programme areas. The priority areas for in-depth review for Phase 2 were discussed and selected during the Phase I of the FPR.

3. PHASE I OF FOCUSED PROGRAMME REVIEW (FPR)

Phase I of the FPR was conducted from 11 to 15 May 1992. The objectives of Phase I were as follows: (1) to determine programme achievements

(2) to pick out constraints on programme implementation and to rank them in order to establish priority areas for review during Phase II and, (3) to make preparations for Phase II.

The list of participants for Phase I is found is Annex 1. The review team used a methodology under development by CDD/WHO and described in the draft document "Guidelines to conduct a focused programme review - Phase I". This consisted of review of documents, determination of progress towards targets, analysis of activities, achievements and constraints, ranking of constraints and listing of priority areas for review in Phase II.

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3.1

Findings: Tables 1 and 2 present the status of key programme indicators and training coverage.

Note that the training coverage rates for supervisory skills and commune health worker have been revised since the report of Phase I basoo on the findings during Phase II.

TABLE 1. KEY INDICATOR FINDINGS

Indicator 1.

1982-86 47% 37% 7%

1990 78% 38% 53% 62% 60% 68% 62% 47% 73% 84% 46% 83%

1991 84% 52% 76% 60% 65% 34% 52% 55% 18% 54%

2. 3. 4. 5. 6. 7. 8. 9. 10.

ORS access rate ORS use rate ORT use rate Increased fluid rate Continued feeding rate Correct referral (l reasons) Correct ORS preparation Correct RHF preparation Cases correctly assessed Cases correctly rehydrated II. Cases correctly advised 12. Dysentery cases given appropriate antibiotic

Source of information for indicators 2 to 8 are 43 MMT surveys in 1982-1986 and 4 case management surveys 1990-1991. Source of information for indicators 9-12 is a health facility survey in the delta region in 1990 and a health facility survey in the mountainous region in 1991.

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TABLE 2. TRAINING COVERAGE

Type of training: 1.

Covera&e 100% in old provinces (44/53) 0% in new provinces (9/53) 81 % (44/54) at provincial level 59% (32/54) at district level 22% (118/527) of districts have trained two CHW per commune by the end of 1992. 21 % (4413/20 720) trained by central level since 1989. An additional 26% received some training during 1982-1987. 100% (8/8) have introduced the CDD curriculum. 100% (46/46) schools have introduced the CDD/EPI curriculum.

Programme management Supervisory skills Commune health worker

2. 3.

Clinical management

5. 6.

Medical schools Paramedical schools

* The 20 720 figures for the denominator is based on (10 x 20) central level hospital staff, (45 x 20) provincial level hospital staff, (480 x 20) district level hospital staff and (10 020 xl) commune health centre staff. + NCDDP criteria for coverage is two staff trained at each provincial HES each district HEB and each commune health centre. Table 3 summarizes programme targets and subtargets and the progress towards these targets. As only four targets had been stated in the 1992 plan of action, the targets in the 1987-1991 and the 1988 draft plan of action were also considered. Overall conclusions towards targets were as follows: (1) Mortality and morbidity reduction

The mortality survey conducted by the NCDDP in collaboration with WHO in October 1991 and January 1992, reported results of a demographic health survey (1988) and a national census showing that childhood mortality had remained fairly constant during the period 1978-1989. The CDD survey estimated that overall childhood mortality for 1989 was 58/1000 (range 47-69/1000) and the diarrhoea-related deaths were 19% (range 12%25%). The only baseline data available are from the morbidity, mortality and treatment (MMT) surveys conducted by the CDD programme in 1982-1986 which estimated diarrhoea-associated deaths to be 18%. On the other hand routine reporting and anecdotal reports from hospitals suggest that case fatality rates for diarrhoeal diseases are dec1ining. In summary, there is not sufficient evidence to conclude that mortality has been reduced.

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With respect to morbidity, the MMT surveys estimated the number of episodes per child per year to be 2.2 for the years 1982-1986. However, these rates were not seasonally adjusted and the surveys in 1988-1990 did not estimate episodes per child per year. Thus, no conclusion can be drawn as to whether there has been a reduction in morbidity. (2) Proerarome expansion

The phased expansion has been realized as planned and there is good evidence that the target of 85% of communes (8517/10 020) in the whole country will be reached by the end of 1992. However, the quality of implementation varies from province to province. In particular, the NCDDP believes that the quality of training during the period 1982-1987 was less than optimal, resulting in the need to retrain. (3) DRS access

Along with programme expansion, DRS access has been increasing steadily and has now reached 84% for the whole country. based on availability of DRS at the commune level. DRS availability is only a problem in the newly developing communes which often have to wait for six months for DRS. (4) DRS and DRT use

Based on 43 MMT surveys in 1982-86 and four case management surveys in 19901991, the NCDDP estimates that the DRS use rate is 37% and the Oral Rehydration Therapy (DRT) use rate is 53% in the provinces where the CDD programme has been implemented. This means the DRS use target of 15% by 1992 has been exceeded and the DRT target of 80% by 1992 is unlikely to be met. (5) Training coveraee

Although significant and continuous progress has been made towards the training targets, exact coverage is difficult to determine because the quality and quantity of "echo" training conducted by staff who have attended DTU and mini DTU clinical courses and by the staff who have attended supervisory skills courses is difficult to determine. In addition, it has been difficult to determine the exact number of people requiring training in clinical management and supervisory skills. The estimated training coverage rates are presented in Table 2. (6) Case manaeement in health facilities

The target for the establishment of DTUs and mini DTUs has been far exceeded and reports from DTU show marked improvements in diarrhoea case management including decreased admission rates and marked decrease in the use of intravenous fluids and drugs. These improvements in case management were supported by findings from the health facility surveys.

- 10TABLE 3. PROGRAMME PROGRESS TOWARDS TARGETS

Target or Subtarget

Current Status No evidence to suggest reduction

1. 2.

Reduce mortality by 45% by 1991 Programme coverage at commune level by 1992 - 100% in CDD provinces - 85 % countrywide

100% target achieved 81 % is likel y to be achieved

ORS access at end of 1992 - 100% in CDD provinces - 90% countrywide 100% target achieved 84% will probably be achieved

ORS use rate at the end of 1992 15% in CDD provinces 10% countrywide 38 % target achieved n.a.

ORT use rate at end of 1992 80% in CDD provinces 70 % countrywide 53%, target not achieved n.a. 81 % at provincial level, target reached 59 % at district level, target not reached

80% coverage in supervisory training by 1990.

70% of doctors in paediatric hospitals trained in clinical management by 1990 60% of communes trained in CDD case management by end of 1990 Institutionalize CDD curriculum by end of 1989 - in 8 medical schools - in 4 paramedical schools

50%-70% Target likely to be achieved.

22 %, target not achieved

100%, target achieved

46/46, target overachieved 4 DTUs and 12 mini DTUs Target achieved

10.

Establish 7 DTUs by end of 1989

* The current figure of 22 % is based on courses conducted in 1991-1992. If quality of CHW training from 1982-1990 was considered adequate, the current status of training coverage would be 90%-100%; thus the target would have been achieved.

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The programme's achievements and constraints during Phase I were as follows:

TABLE 4. LIST OF PROGRAMME CONSTRAINTS

Highest priority (1) Quality of programme implementation varies from province to province and this results in the need to retrain health workers. (2) There has been no assessment of the activities to strengthen CDD teaching in medical schools. (3) There has been no assessment of the activities to strengthen CDD teaching in paramedical schools. (4) Quality of training (supervisory skills and CHW training) at district level has not been well monitored in the past and there is no plan for monitoring in the future. (5) Uncertainty of funds causes delay in activities. There is a delay in getting ORS (from UNICEF) to newly developed communes. (6) The quality and quantity of supervision from provincial and district level is poor. Central staff have no time for supervisory activities aside from those related to communication activities. Supervisory reports are inaccurate and incomplete. (7) Although a number of household surveys have been done, it is difficult to know what these results mean in terms of the whole country. (8) Hi~h

Salaries for staff are very low.

priority (9) The Programme needs strengthening in mountainous areas. There are many cultural and social economic barriers to reaching the ethnic groups living there. (to) Communication activities have not been evaluated. There is a need for better collaboration between NCDDP, UNICEF and WHO concerning these activities. Communication training has not been integrated into clinical management training.

(11) Assessment of training coverage and determination of target audience for training is difficult. (12) There is no comprehensive long-term plan for supervisory skills, clinical management and CHW training. (13) Sub-targets for many aspects of the programme have not been updated and some sub-targets for important programme areas are missing.

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(14) Case management in health facilities at district level is not optimal. A particularly weak area is advising mothers on home care. (15) There is insufficient staff at central level to do all the work.

(16) Although there are yearly plans of action, there is no updated long-term plan of action (except for communications). (17) There is no budget to support the setting up of "nutrition units· in DTUs and miniDTUs. (18) Follow-up of staff trained in clinical management is poor. Monitoring of DTU courses is not done. Quality, quantity and effectiveness of "echo" training by those trained in DTUs and mini DTUs is not sufficiently known. (19) Training materials for clinical management courses is lacking.

(20) Although there have been many evaluation activities, there is no clear evidence that there has been a reduction in diarrhoea-associated mortality. (21) The country is not self-sufficient in producing ORS. All ORS is imported.

(22) Home treatment of diarrhoea is not optimal (i.e., improvement should be made in the amount of fluid given, drug use and correct preparation of ORS). (23) Although the private medical sector is rapidly expanding in Viet Nam, the CDD Programme is not active in this sector.

4. PHASE II. OBJECTIVES AND METHODOLOGY

Phase II of the FPR was conducted from 21 September to 3 October 1992. The objectives of Phase II were as follows: (1) (2) (3) (4) (5) to assess the current status of the priority areas under review; to determine achievements and constraints in the priority areas; to pinpoint important factors that contribute to the constraints; to select potential solutions for the constraints found; and to develop a plan of action for each priority area.

The list of participants, terms of reference and schedules for each of the priority area teams in Phase II are found in Annex 2. The review team used a methodology under development by CDD/WHO and described in the draft document "Guidelines to conduct a focused programme review Phase II.

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In Phase II four teams were assigned to the four priority areas and these areas were reviewed in depth in order to assess the current status, and to determine achievements and constraints. The methodology for the in-depth reviews, although varying for each team, involved site visits using questionnaires, key informant interviews, surveys and review of documents. As all the required information could not be gathered during the two weeks in which the consultants were present the NCDDP secretariat made several site visits in July and AUgust. Once all data had been collected it was analysed for key fmdings (achievements and constraints). According to the focused programme review protocol, for the constraints encountered, a problem-solving approach using predesigned worksheets was to be used to fmd feasible solutions and develop a work plan. However, given the time constraints faced by each team the worksheets were not always used. On the basis of key findings and the solutions selected, each team made recommendations and prepared a plan of action for their relevant areas.

5. REVIEW OF TEAM REPORTS

5.1 5.1.1

Review of the activities to strengthen the teaching of CDD and EPI in secondaQ' medical school Priority area under review

Strengthening the teaching of CDD and EPI in basic training of assistant physicians, nurses and midwives. 5.1.2 Background

A comprehensive review of the national CDD programme (NCDDP) in the Socialist Republic of Viet Nam was conducted in 1987. The review found that the basic training of medical and paramedical staff did not always include the most up-to-date CDDjEPI information or optimal teaching methodologies. It was therefore recommended that CDDjEPI training material and methodologies should be included in the curricula of basic training of all medical and paramedical schools in Viet Nam. As a result of this recommendation, the CDD and EPI secretariats in collaboration with the Department of Training planned activities to update the curricula of assistant physicians, nurses and midwives (medical schools were to be dealt with separately). It was also decided that the activities would initially be focused on the curriculum for assistant physicians. A planning visit was made by a WHO consultant in March 1989. Initially, two workshops were planned with the following purpose: (1) to update the technical knowledge of the teachers with relation to EPI and CDD; (2) to expose the teachers to alternative teaching methods suited for CDDjEPI;

(3) to develop an updated curriculum for assistant physicians with relation to CDDjEPI.

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The first workshop was held from 9 to 18 May 1989 with 19 participants representing 16 provincial secondary medical schools and one national secondary medical school in the northern provinces as well as the public health school in Hanoi. The second workshop was held in Ho Chi Minh City (HCMC) from 8 to 15 March 1990 with 23 participants representing 21 provincial secondary medical schools, one participant representing the Centre of Training and Retraining in HCMC and one participant representing the Institute of Hygiene and Public Health in HCMC. The Ministry of Health organized the first workshop for the revision of the nursing and midwifery curricula in Hai Phong from 18 to 22 June 1990 with participants from 20 schools. The second workshop was organized in Ho Chi Minh City from 18 to 22 June 1991 with participants from 21 schools. During follow-up discussions of the first workshop, a plan of action was prepared for the implementation of the revised curricula. The plan also included activities to update the curricula of nurses and midwives on CDD/EPI. The key activities of the plan were related to ensuring that all schools were provided with the relevant teaching material such as modules and demonstration equipment, that schools were officially obliged to implement the revised curriculum, that schools were regularly kept up to date on programme development, revision of the curricula for nurses and midwives, and to monitor and evaluate both the curriculum strengthening procedure and the outcome in the terms of student knowledge and practice. This plan of action has been reviewed and revised on two occasions; the fIrst following the second workshop in March 1990, and the second following the monitoring visit made in January 1991. One important activity in the plan of action was to monitor the implementation of the revised curricula. These monitoring activities were undertaken in 1991. In January 1991, a team consisting of representatives from the CDD programme, EPI, the Department of Training, and WHO developed a checklist to monitor the process of implementing the revised curriculum. The checklist was field tested in the secondary medical school in Vinh Phu province. The questions focused on the following: - official information to the school regarding the use of the revised curricula; - school directors and teachers activities to implement the revised curricula; - teaching methodology and allocation of hours to CDD /EPI subjects before and after workshops; - availability of teaching material and demonstration equipment. The checklist also asked school directors and teachers to indicate what they considered as problems with the implementation of the revised curricula and asked for their recommendations. Following the field test, a team with representatives from CDD and EPI visited ten randomly selected secondary medical schools. The major fmdings of these visits were: - not all schools had received the official instructions to use the new curriculum - lack of teaching material on the forms of modules, posters, slide sets, etc.

- 15 -

- lack of demonstration equipment particularly for EPI - not enough teachers trained - oral rehydration therapy (ORT) corners not well equipped These findings prompted the COD programme to make modifications in their programme plan for 1992. Included in the plan were four training courses at DTUs for teachers at secondary medical schools. There were also plans to print more training modules for distribution to the schools. COD also sent money to the schools to buy equipment for the ORT corners. The EPI recommended teachers who had not been trained at the two national workshops organized so far, to participate in EPI training courses at the provincial stations of Hygiene and Epidemiology. The department of training sent out an additional letter to all schools regarding the use of the new curriculum. Added to this letter was a copy of the COD curricula for assistant physicians, nurses and midwives. EPI was at that time unable to provide the department of training with copies of the EPI curricula. The letter also stressed the need for close collaboration between the secondary medical schools and the local Hygiene and Epidemiology Stations. 5.1.3 Review methodology During Phase I, it was decided to use the following methodology: (1) Visit 10 to 15 paramedical schools to: (a) interview relevant staff on implementation of their plan of action, curriculum content, methodology of teaching, use of teacher assessment forms, collaboration with the Station of Hygiene and Epidemiology, availability of teaching materials, and support of director of school. To do this, the questionnaire that was used during the monitoring activities in 1991 will be used. Only minor modifications were made following the previous experience (Annex 3). (b) administer a questionnaire to students to assess their knowledge with respect to the learning objectives stated in the curriculum (Annex 3). (c) observe preparation of Oral Rehydration Salts (ORS) (5-10 students at each school). It should be added that although this was a cnn FPR, the assessment at the paramedical schools also looked at EPI, as this activity has been a collaborative one from the start of the project.

Seven schools were visited by a team from COO and the department of training prior to the start of Phase II of the review. The full team visited three schools, then the team divided into two teams and visited an additional two schools. 5.1.4 Key findings

It is clear that in general, the teaching of COD and EPI has been improved considerably following the workshops and the activities that followed them. The awareness of the two programmes has also increased. These factors form an excellent basis to build

- 16-

on. However, considerable problems remain that will need to be solved before a solid foundation is in place to ensure that the teaching of the two programmes is conducted at optimal levels. (1) All schools2 have received the official instructions from the department of training regarding the revised curricula. (2) Schools are not consistent when, during the training, the curricula are introduced (second or third year). This does not apply to the primary nurse training. (3) Regarding the curriculum for nurses and midwives, it is not indicated on the curriculum whether it is intended for the primary or the secondary nurse/midwife training or both. (4) Most school directors highly approve the new curricula and consider the two programmes to be very important. However, when it comes to the allocation of hours, the attitude differs slightly. Some schools say it is difficult to allocate the necessary hours as they have to be taken from another subject. Other schools have allocated more hours than recommended as they feel that the content of the new curricula requires more hours than indicated. There is a general feeling that to teach the content in the new curricula, more hours than indicated are needed. (5) There is also a confusion in some schools regarding the different number of hours allocated for the assistant physicians and the nurse/midwives. Some schools have given the same number of hours to the two groups. It was not clear whether the same curriculum had also been used. (6) After having received the new curriculum from the department of training most schools prepare their own material. One reason given for this is that there is not enough modules for each student to use. It is not clear, however, how this material related to the learning objectives in the curriculum. The quality of the locally prepared material varies but all the materials seen by the review team included some form of student checklist. One advantageous point about the locallyproduced material is that the students can keep the material. It also seems that the schools rather than trying to adapt to the new curricula, adapt

the curricula to suit their situation. This may have considerable implications on the aim to standardize the training. (7) In all schools, the teacher that participated in the workshop is the teacher responsible for teaching COO or EPI or both. However, in most schools, there are different teachers teaching COD and EPI and only one teacher per school has been trained. There is also a varying number of "assistant teachers" involved in the teaching. Some of these have attended a training course at the Hygiene and Epidemiology Station.

2 In the following "all schools" will refer to all schools visited during the FPR.

- 17-

(8) The student ~oup~ are generally big (30-60) which makes other teaching meth?ds tha.n ~ect~rmg difficult. The area that is suffering most from this is the practIcal trammg 10 the school. (9) There i~ ~ tendency among the t.eachers to put more emphasis on the theory part of the trammg and refer the practIce more or less to the clinical practice periods. This refers to both CDD and EPl. devel?p~ent wo~kshops is only involved in the teaching of the theory part while practIce IS organlZed by another teacher. It is unclear whether or how they

(to)

In some schools, the teacher who has been trained during the curriculum

collaborate. (11) The schools have implemented the new curricula in the school year either of 1990-91 or 1991-92. A few schools implemented the curriculum immediately foll.o~ing the workshops, not awaiting the instructions from the department of trammg. (12) . All schools have set up ORT corners with adequate equipment for student practice. (13) With a few exceptions, the schools collaborate with the Hygiene and Epidemiology Stations. The quality and quantity of this collaboration varies from province to province. (14) The student and teacher checklist that was developed during the workshops is used in all schools. Some have made modifications and are not using the whole checklist. Some reasons for this was lack of time or lack of funds for production of the checklist. Another problem related to the checklist is that the standards for some of the points might have been set too high. This needs to be looked into by the programmes for possible modifications. (15) Teachers use different teaching methods such as student reading, demonstration, slides. However, the quality is not optimal. For example, if the teacher is making a demonstration and one student (out of 50) makes a return demonstration, the teacher considers that the return demonstration is used as a teaching method. As modules art~ either not available at all or only in limited number, no teacher was using student reading during classroom hours. From follow-up questions and discussions with teachers, it is clear that most of them find it difficult to use any other teaching method than lecturing. One reason for this is clearly the big student groups but another reason is limited pedagogical training in general. About 50% of the teachers have attended a two-week diploma course in pedagogy, the other 50% have no special training in that field. (16) No schools have received any equipment for EPI practice. One school had asked the Hygiene and Epidemiology Station to have one vaccine carrier and a steam sterilizer, had been given one of each and was allowed to keep the material. The other schools borrowed material from the Station. (17) Only a few schools had received all 50 sets of COO modules (Treatment of Diarrhoea, Prevention of Diarrhoea, and Talking with Mother about Diarrhoea) and EPI modules (8 modules of the series Immunization in Practice with Facilitator Guide). A variety of reference material was available for the two programmes but

- 18-

with no consistency among the schools. In general, all schools .had ~ome posters available on CDD in the practice room whereas for EPI very little m the form of posters was found. On the open-ended question to both school directors and teach~rs regarding major constraints to implementing the new curricula, the following was mentioned by all schools: - lack of equipment for EPI practice - not enough modules for students - not enough teachers trained in CDD/EPI Other problems mentioned by almost all schools in one way or the other were: - time indicated on the curricula was not enough to teach the subject - limited money for local production of handouts - lack of time for student evaluation - teachers need more time to work with small-group methods - CDD practice is difficult - difficult to accommodate the number of hours needed for CDD/EPI with relation to the other subjects - need for more audiovisual aids, such as slides for COD - more money needed to pay teachers invited from outside as teachers' time has increased - guidelines from the department of training on how to accommodate the increased number of hours for all subjects - more support from national level - some teachers lack training in methodology - poor collaboration between Secondary Medical Schools and Hygiene and Epidemiology Stations The issues mentioned as the priority problems by the schools were all initially considered in the plan of action as essential items for the strengthening of the teaching of the two subjects. The review has also pinpointed a number of other problems, some of which may be within the capacity and authority of CDO/EPI to solve, others are not. In addition to the three items above mentioned by all schools, a priority problem is also the different "interpretations" by the schools of the new curricula. This needs to be addressed by the training department. The results from the student questionnaires for CDO shows generally very good results. However, the weak points relate to taking the knowledge from the assessment of the child into what treatment should be given with relation to the specific amount of ORS. The answers shows a very wide variation.

- 19-

In each schoo~ four to six students demonstrated the preparation of ORS. In general. the students know the procedure of the preparation of ORS. However. the amount of fluids prepared varied between 880 mI to 1570 mI. There seem to be more of a mechanical approach to the preparation than a careful thinking whether what has been prepared is realistic or not. This observation ill also consistent with the fmdings in the questionnaires. As for the results for EPI, the trend is similar to CDD; the students are strong on pure knowledge questions but when it comes to implementing the knowledge, the skills are weaker. It should also be reminded that the review team did not observe students using either steam sterilizers or vaccine carriers. Even if this would have been desirable. the quality of the equipment borrowed from the Hygiene and Epidemiology Stations was in many places poor and would not have allowed student evaluation. 5.1.5 Recommended activities

The team recommends that the plan of action presented in the following section with ten objectives and related activities should be given high priority and implemented according to the proposed time frame.

5.1.6 Plan of action for strengthening the teaching of CDD/EPI in secondary medical schools Note: For the objectives in this draft plan only target dates have been indicated. programmes will have to add the detailed timing for each activity. The

OBJECTIVES

ACTMTIES

BUDGET

SOURCE

( 1)

Objective 1

All schools have 100 sets of the CDD modules (Treatment of Diarrhoea, Prevention of Diarrhoea, Talking with Mothers about Diarrhoea, and Facilitator Guide) and 100 sets of EPI modules (the eight modules and the facilitator guide from the series Immunization in Practice) Target date: June 1993

1. Print adequate number of modules for all schools (CDD/EPI). Time:

2. Put the modules together as sets and put sets in clearly marked boxes for each school (CDD/EPI). Time: 3. Notify schools about the arrival of the material and ask schools to report back to Dr Phien, Department of Training, as soon as they have received the material. (Department of Training, CDD/EPI). Time: The above activity should be done separately by CDD and EPI so that a delay in one programme will not delay the other.

CDD: printing of Modules: 46x200 sets putting sets together and packing (including cost for boxes) mailing costs Total $ 9500 ($2 per set) EPI - printing of modules: 46xlOO sets putting sets together and packing (including cost for boxes) mailing costs Total $19000 ($4 per set)

WHO ICO/CDD/HQ special allotment 1992, pending ICO approval WHO ICO/EPI/HQ special allotment 1992 pending ICO approval N

OBJECTIVES

ACfMTIES

BUDGET

SOURCE

(2)

Objective 2

All schools have two teachers trained in diarrhoea case management at DTU at regional level. Target date: December 1993.

1. Implement the four courses with 12 participants in each course already planned for following the monitoring activities in 1991. Funds for these activities have been approved from WHO but funds have not yet arrived. (ADD/Department of Training) Time: Nov-Dec 1992 2. Plan and implement four additional courses with 12 participants in each course. (COD/Department of Training) Time: May-June 1993

4 courses with 12 participants: $ 4000

WHO (already approved 4 courses with 12 participants: $ 4000 WHO ICO/CDD/HQ special allotment for 1992, pending ICO approval.

Q!JJECTIVES

ACTMTIES

BUDGET

SOURCE

(3)

Objective 3

All schools have two teachers trained in EPI with special emphasis on methodologies at nationalleve! courses. Target date: One course in April, one course in August 1993.

1. Plan two courses of 6 days with 23 participants in each course. (Department of Training should ensure that the teachers participating in these courses are not the same as those who participated in the previous workshops). (EPI/Department of Training) Time: 2. Ensure participation of facilitators from national level and a WHO consultant for the first course.

1 course x 23 participants x 6 days: $ 4000 Total: 2 courses: WHO consultant

$ 8000 $ 6000

WHO ICO/EPI/HQ special allotment for 1993, pending ICO approval.

N N

OBJECTIVES

ACTIVITIES 1. National EPI in collaboration with WHO to prepare a detailed list of equipment. (EPI/WHO) Time: $ 7000

BUDGET

SOURCE

(4)

Objective 4

Equipment: $150 per school: Packing, including cost of boxes, mailing: $ 500 Total: $ 7500

All schools have the following EPI equipment: - one steam sterilizer with syringes, needles and forceps - one vaccine carrier with icepacks - four syringe and needle kit B (UNICEF catalogue) Target date: June 1993

WHO ICO/EPI/HQ special allotment for 1992 pending ICO approval

2. Equipment list submitted to UNICEF for procurement and earmarked specifically for the Secondary Medical Schools so that this equipment does not go into the regular EPI distribution system. This point should be clarified by EPI and UNICEF before the equipment is procured. (EPI/UNICEF) Time: 3. Equipment put together in boxes at national level with clear marking for each school. (EPI/Department of Training) Time: 4. Notify schools about the arrival of the equipment and ask them to report back to Dr Phien, Department of Training as soon as they have received the equipment. . (Department of Training/EPI) Time:

..., N

OBJECTIVES (5) Objective 5

ACfMTIES 1. Department of Training send out a letter to all school directors covering the following points:

BUDGET No budget needed

SOURCE

All schools use the revised curricula in a similar way with the same number of hours allocated for the subjects. Target date: December 1993.

- When during the raining the new curriculum should be taught. - That the curriculum for nurses and midwives relates to both the primary and secondary training programmes. - That material produced locally has to follow the learning objectives in the new curriculum. - That the number of hours for the two subjects differs between the curricula for assistant physicians and nurses/midwives. The official hours for the two subjects are now: Assistant physicians: CDDtheory: CDD practice:(in the schools) EPI theory: EPI practice:(in the schools) Nurses and midwives: CDDtheory: CDD practice(in the schools) EPI theory: EPI practice:(in the schools)

N ~

OBJECTIVES

ACTMTIES

BUDGET

SOURCE

There are minimum hours required. The schools should not go below that. - To accommodate the new curricula additional hours can be taken out of

------

- That the whole student/teacher assessment check-list is to be used, not only parts. - That the practice in the schools before the students go out in the field is essential. For COD, this should not only be preparation of ORS but also assessment of diarrhoea cases using written case studies. (Department of Training/COD /EPI) Time: Before December 1991 2. Further implementation of this letter to be followed up during supervisory visits to the schools and during School directors' meetings. (Department of Training) Time: Ongoing

N VI

OBJECTIVES

ACTIVITIES

BUDGET

SOURCE

(6)

Objective 6

All schools have two copies of the Vietnamese translation of the "Instructors Manual"! for COD and two copies of the "Instructors Manual" for EPI. Target date: December 1993

1. Obtain the English version of the manuals from WHO (COD and EPI/HQ to send the manuals to the programmes as soon as they are available). (CDD/EPI/WHO) Time: First quarter of 1993

Total EPI: $ 5500

WHO ICO/CDD/HQ special allotment for 1993 pending ICO approval WHO ICO/EPI/HQ special allotment for 1993 pending ICO approval

2. Translate the documents into Vietnamese. (CDD/EPI) Time: 3. Print and assemble the documents. (CDD/EPI) Time:

4. Distribute the documents to the schools through the Department of Training (CDD/EPI/Department of Training) Time: N

(7)

Objective 7

All schools have the COD slide sets prepared by WHO/CDD/HQ. Target date: April 1993

1. NCDDP obtain the slide sets from WHO (COD/WHO) Time: December 1992 2. Distribute the slide sets to all schools (COD/Department of Training) Time: April 1993

No budget needed, WHO to provide the slide sets

l"Instructors Manual" is the working name. Both the COO and the EPI versions are expected to be available in final English versions during the tirst quarter of 1993.

OBJEC TIVES

ACTM TIES

BUDGET

SOUR CE

(8)

Objective 8

All studen ts have a person al copy of the Assess ment Check-list for CDD and EPI. Target date: June 1993

1. CDD and EPI print the Assess ment check-list (CDD jEPI) Time: 2. CDD and EPI provid e the check-lists to the Depar tment of Traini ng for distrib ution to the school s (Need : 100 studen ts per year x 46 schools: 4600 copies of each che.ck-list) (CDD jEPljD epartm ent of Trainin g: Time:

Printing: 5000 x $0.05: $250 Distrib ution: $100 Total CDD:$ 350

ICOjC DDjH Q specia l allotm ent 1992, pendin g ICO approv al Total EPI: $350

ICP jEPIjH Q specia l allotm ent 1992, pendin g ICO approv al Note: this cost will be a yearly cost that will need funds allocat ed each year.

.....

OBJECTIVES

ACTMTIES

BUDGET

SOURCE

(9)

Objective 9

All students have their personal copies of the CDD and EPI modules. Target date: Starting the school year 1994-1995 and then ongoing. The programmes will have to decide in collaboration with the Department of Training if this will be done to cover the needs for more than one year at a time. The below calculation is made on the basis of one year.

1. Print adequate number of modules for all schools (CDD/EPI). Time:

CDD: printing of modules: 46xlOO sets putting sets together and packing (including cost for boxes) mailing costs Total: $ 9500 ($2 per set)

EPI: printing of modules: 46xlOO sets putting sets together and packing (including cost for boxes) mailing costs Total: $ 19000 ($4 per set)

OBJECTIVES

ACfMTIES

BUDGET

SOURCE

(10)

Objective 10

The project "Strengthening the teaching of CDD and EPI for assistant physicians, nurses and midwives in Secondary Medical Schools" evaluated and plans made for long-term sustainability. Target date: December 1994 NOTE: The detailed planning for this objective will be made at a later date. Indicated below are the main activities.

1. Prepare survey questionnaire to cover implementation proce:.s at national and school level. (CDD/EPI/Department of Training/WHO) Time: May 1994

Budget: To be determined later

2. Prepare survey questionnaire for students based on revised job descriptions covering CDD and EPI. (CDD/EPI/Department of Training/WHO) Time: May 1994 3. Implement survey (sample size to be determined later) (CDD/EPI/Department of Training) Time: June-October 1994 4. Follow up and preparation of Plan of Action for sustainability (CDD/EPI/Department of Training/WHO) Time: November 1994 N

-c

- 30-

6. REVIEW OF TIlE ACI1VITIES TO STRENGTIlEN TIlE TEACHING OF CDD IN MEDICAL SCHOOLS

6.1

Priority area under review Strengthening education of medical students about diarrhoeal diseases.

6.2

Background

In July 1990 teaching stafffrom Departments of Paediatrics in Hanoi, Bac Thai, Hai Phong and Thai Binh participated in a workshop arranged in Hanoi on the teaching of medical students about diarrhoeal diseases. A similar workshop was held in Ho Chi Minh City in September 1990 with the participants from Hue, the Medkal University and the Medical Training Center of HCMC, Can Tho and Tay Nguyen. During these workshops 12 months workplans were developed by each team of paediatric faculty. They consisted in general of the following objectives: (1) (2) establish and strengthen a DTU within each teaching hospital of the medical schools; strengthen the teaching about diarrhoeal diseases: follow guidelines of WHO and the national CDD programme on case management and disease prevention; introduce CDD teaching materials such as the student manual "Readings on diarrhoea" and the chart "management of the patient with diarrhoea;" assure supervised clinical practice in managing patients and teaching mothers, preferably in a DTU; use more small-group teaching and coordinate teaching on diarrhoeal diseases with other clinical and basic science departments. (3) (4) improve evaluation of students knowledge and skills; train faculty and staff in CDD case management and new teaching methods.

Recommendations were made that a follow up external review of progress should be performed. 6.3 Review methodology

All medical schools except Hai Phong and Tay Nguyen were visited. Each review was completed during a one-day visit to the medical school and hospital.

- 31 -

The day usually started with a short meeting with the hospital officials, always including the hospital director, representatives of the Department of Paediatrics including the Head of Department and the DTU Director as well as other faculty members and/or hospital doctors who participated in the earlier workshops. The Dean of the medical school or his representative - was also usually present. After 30-60 minutes discussion the whoie group visited the DTU. 20-40 students as well as DTU staff were waiting. In those circumstances, it was rather difficult to propose to observe their ordinary teaching session. Instead one or two of the students were asked to present diarrhoea patients. These presentations also included clinical examination of the patient and led to questions on clinical as well as theoretical aspects of diarrhoeal disease. The whole group was involved in discussions for at least one hour. After that a student was observed demonstrating to a mother how to manage diarrhoea at home, including preparation of ORS, advice on nutrition and hygiene. This was followed by a talk with the students on communications skills. Finally, discussions were held with a small group of students to get their reaction to the new curriculum and teaching methods. After lunch the review group met with the representatives of the Faculty of Medicine and the Department of Paediatrics and discussed the teaching activities following the Medical Education workshop. The check list used was a very valuable tool in efforts to gather information, but could be modified and shortened. 6.4 6.5 Key findings Hospitals/Hospital Directors/DTUs

6.5.1 Hospitals The size and relevant activities of the teaching hospitals can be seen in Annex 5. 6.5.2 Hospital Directors They had all, at an early stage, been informed by faculty members on the Medical Education activities. Establishing a DTU (or further supporting already existing ones) was generally given high priority - also when balanced to competing demands from other departments in the hospital. Infants and mothers are always strongly supported by the People's Committee. In two hospitals (Hue and Thay Binh) the Directors were told of shortcomings in their DTUs (toilets and kitchen, respectively). As a result of discussions promises were given to allocate funds for improvement. 6.5.3 DTUs The number of patients visiting DTUs can be seen in Annex 5. HCMC Children's Hospital No. 1 by far has the highest numbers.

- 32-

Diarrhoeal diseases still cause a high proportion of hospital admissions: in Thai Binh 26% and in Can Tho 15%. Much lower figures, 7-9%, in HCMC and Hue may in part be explained by their well functioning DTUs. Each hospital has now an established DTU or mini-DTU. Bach Mai hospital in Hanoi, which cares for 25-30 six-year students, so far has only an ORS corner. The DTUs are usually located as part of the outpatient department (OPD) or in close relation to the paediatrics wards. The treatment areas were clean, well organized and equipped and - in the circumstances - of acceptable size. The DTU in Can Tho, one of the best organized for teaching, had however a striking shortage of (working) toilets and areas for washing diapers, etc.

Staff in DTU Doctors Trained Hanoi Hue HCMC Can Tho Bac Thai Thai Binh 4 4 6

Nurses Untrained 0 0 0 1 0 1

Trained 8

Untrained 0

2 16

2 4

7 4

a 1

0 0

In Hue they have one nutritionist; in HCMC one of the nurses has had special training and functions as a nutritionist. Most DTUs operate 24 hours a day, seven days a week with competent staff. The supply of DRS is now excellent in all DTUs and so is the availability of other items - with one exception: intravenous fluids, i.e., Ringer-lactate. In Hue charity funds together with hospital funds enable the hospital to give 20% of the patients free food during their hospital stay. The situation in Bac Thai is similar: around 80% pay for their food: 1000 d/day. In HCMC the costs are estimated to be 3000 d/day and there are perhaps 10% of the patients get food free. In Can Tho, on the other hand, more than 80% of DTU visitors get free food. Food is offered to DTU patients as well as to outpatients being treated according to plan B. Thai Binh Hospital does not provide food in the DTU. The quality of patient care was not studied in detail but examples were given on the dramatic reductions in use of intravenous fluids and antibiotics over the last few years. What the team saw of the assessment and treatment was of good or acceptable standard.

- 33 -

6.5.4 Teaching Some data on paediatric rotations No. of assigned weeks to paed. 8 8 10 14 10 10 8 18 8 10 8 8 6 No. of students in subgroups 15 12 10-15 10-15 10-12 10-12 ?

Year Hanoi Hue HCMC Can Tho BacThai Thai Binh 3(1) 5(2) 4 6 4 6 4 6 3 5 3 5 6

to 6-8 6-8 10

to 10

(1) (2)

St Paul Hospital IPCH/Bach Mai Hospital

6.5.5 Materials and equipment The student textbook "Readings on diarrhoea" was translated into Vietnamese and printed in Hanoi by the national COD programme. 5000 copies have been distributed to all medical schools - with some distribution problems in the South. As this was enough only for students of the two years 1991-1992, most schools printed their own version of the book and kept the original copies in their libraries. A majority of students prefer to buy their own copies: prices are 5-7000 dong per copy. (10 000 dong = USD 1). In Hue 20% of the students and in Bac Thai and Thai Binh tOO% borrow the book from the library. COD teaching slides were available in all schools as well as updated management charts printed in 1990 in Vietnamese. Slide projectors and overhead projects were available in all DTUs: in some cases the teaching staff wanted to have a second set of projectors for teaching on other subjects. Videoplayers were not available, but the video tapes on diarrhoea were shown either with private equipment or with equipment belonging to the faculty. Most schools had access to simple duplicating machines, but many preferred to place - even simple - copying with a local "printing office". There was, however, a general demand for photocopying machines in order to be able to upgrade the teaching activities, as discussed during the workshops. 6.5.6 Methods Many of the concepts and guidelines introduced during the Medical Education workshops were now used in the teaching of medical students.

- 34-

Role plays were felt to take too much time to prepare and was rarely practised. The exception was Bac Thai, where this activity was much appreciated among students. Discussions, supervised clinical practice (with checklist as a ~ool) and the u~ of written case studies (especially when few case" were seen or exammed) were mentioned as new methods considered to be most effective. 6.5.7 Content Most relevant subjects were taught also before the workshop, but aU departments considered that their teaching now better followed the WHO and national guidelines. Definitely more emphasis was given to home care, the importance of feeding during diarrhoea and preventive interventions. Most teachers indicated that they very much relied on "Readings on Diarrhoea" and that the content of their teaching was more better and more up to date. All students were scheduled for clinical work in a DTU for at least one week in year 3-4 and 5-6 respectively. The number of diarrhoea patients managed by an individual student varied. In Hue and (in low season) Bach Thai students saw a minimum of one patient - but that patient was often shared by 2-3 students. In HCMC, Can Tho, Hanoi and Bac Thai the average number of patients per student was 3-4 and all students handled at least one patient during their practicum in the DTU. The CDD management chart was generally used which was also repeatedly noted during the field visits. Case record forms were used to record information (except Thai Binh): either in the form presented by the national CDD programme or as locally produced copies of the form used at the Medical Education workshops. The students were found well acquainted with the forms which - with their logical step-by-step layout presumably in part explained how all students came to correct assessment and suggested treatment. Questions were reportedly raised on more theoretical aspects, e.g., risks for osmotic diarrhoea (when too much sugar is added to ORS) or problems with disaccharide absorption. Answers were always satisfactory, sometimes excellent. During the week in DTU the teaching has definite objectives. Most DTUs have a fixed schedule for the morning sessions - best shown in Can Tho as a wall poster. Perhaps the most striking new activity was the use, in most medical schools, of a Clinical skills checklist", where a number of defined skills are listed. Supervised by teaching or hospital staff, the student can assess dehydration, select correct treatment or teach the mother how to prepare and give ORS (any of another 10-12 activities listed). The monitoring of an acceptable student performance is subsequently confirmed with a signature. This checklist was much appreciated by the students as well as by the staff. Some departments have actually introduced similar checklists also for other weeks in the paediatric rotation and bound them together to a small book. The teachers were satisfied with this method as it gave them a better chance to individually assess and record student skills. Students unanimously declared that the teaching in the DTUs had been more aimed at ensuring the adequacy of their clinical experience than they were used to in other departments. They saw the checklist as a useful instrument in these efforts. They - as well as the teachers - expressed, however, the opinion that there were too many items listed: with many students around it sometimes

- 35-

was difficult to find a teacher to give the signature. In some schools the students gave their own signature as proof that the activity in question had been performed. Analysis of the checklists had also shown some shortcomings in the teaching activities. Owing to the shortage of severely dehydrated patients, students had to leave out tasks such as estimating needed volume of instravenous fluid, setting up a drip, etc. All schools, except Thai Binh, had made their own version of checklists - all in Vietnamese - and printed them locally. Students, however, had to pay for the paper used for printing. The students in DTU were during daytime always supervised by faculty and/or hospital doctors. 6.5.8 Integration Most of the departments had after the Medical Education workshops organized a two- to three-day meeting to summarize the content to faculty and staff within the Department of Paediatrics, as well as to representatives of other clinical and basic science departments such as Internal medicine, Infectious diseases, Microbiology and Pathophysiology. The training officer in the medical school, as well as the dean often participated . The programme in these workshops presented WHO guidelines on case management and disease prevention, and also introduced new teaching methodologies. In several instances teachers from e.g. pathophysiology gave their own lecture in its updated "Readings on diarrhoea" version, followed by a discussion with the participants. These meetings obviously led to better collaboration between medical school and hospital: an example is that more faculty staff are now working in DTUs. In some schools such as in Hue. Can Tho and Bac Thai. several steps were taken towards bett.er integration where the different departments agreed to give extra stress to topics discussed in "Readings". but specifically relevant to their specialization. The Department of infectious diseases thus gave more emphasis to dysentery than secretory diarrhoea, while the Department of Internal medicine presented symptoms and signs in diarrhoea comparing infants and adults. The only "mistake" noted was perhaps, that in Bac Thai, the Department of infectious diseases had been given responsibility to teach persistent diarrhoea. There had also been lengthy discussions on more sensitive issues, such as the restricted use of antibiotics, as advocated by the national CDD programme. Several DTUs have also in 1991-92 given diarrhoea management courses where faculty and staff had opportunity to participate. 6.5.9 Findings All schools had made substantial progress and the majority had been able to pursue all objectives listed in their 12-months workplans. In spite of these impressive results a number of problems common to many schools were discovered. (I) In general there are too many students for too few patients.

In some hospitals the size of student groups in DTU is impractically large. This is partly due to the parallel training of former assistant doctors (see Annex I for an

- 36-

explanation). Another example is that the Children's Hospital No. I in HCMC is presumed to be used soon for the clinical training of the lOOper year students of Ho Chi Minh City Medical College (medical training centre) - now in its second year of existence. Mild/moderate cases are often handled at OPDs instead of being referred to the DTU where management is presumed to be better and where the cases could also be used for teaching purposes. For the Bac Thai medical faculty only the Thai Nguyen hospital is used for teaching, but not the nearby provincial hospital. (2) Students have to pay for checklists in DTUs. This is not ideal, as the list is something the school has decided that they should use. On the other hand the departments are using checklists with somewhat different contents (and for other paediatric activities) and thus a centrally printed list would perhaps be of lesser value. (3) (4) (5) Free tlJOd for infants in DTUS is not always available. Can Tho DTU has too few toilets and areas for washing up. Thai Binh DTU lacks a kitchen.

(6) Some students have problems in following the English text in the set of slides on diarrhoea. (7) Schools have had to print their own version of "Readings on diarrhoea" and sell them to the students. (8) Students would like to have simpler but modern texts to read.

(9) Many of the teaching activities introduced need printed texts: patient record forms, checklists, written case studies, etc. Outside copying/printing is costly for the medical school. (10) No videoplayers are available in the DTUs. (11) Videotapes on assessment and treatment of dehydration are in general not available in the DTUs. (12) Available videotapes are sometimes not optimal in the setting where they are used, e.g. among minority groups in the north. (13) Further follow up is needed, especially to assess the qualities of the "final product" of a medical school, i.e. the practising doctor. (14) Students would like to read the original English version of "Readings on diarrhoea." (15) More teaching materials for the medical schools are needed. (16) According to the local diarrhoea management chart, Ringer's-Iactate is the preferred solution for IV treatment of dehydration.

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Ringer's-Iactate is, however, only available on a larger scale in HCMC Children's Hospital No.1. In other hospitals families are asked to purchase the solution from a nearby pharmacy at a price of 30000 dong. Also surgeons and ICU doctors have expressed their need for buffered solutions. The problems include availability and costs for good chemicals and preparation of a pyrogen-free product.

It is not good teaching practice to teach the use of a substance, which then, owing to local circumstances, will not be commonly available. (17) Cooperation between DTUs (or other hospital activities) and the EPI programme is not optimal. In Hue and Bac Thai integration is not accepted: vaccines are kept in the hygiene station and not given to hospitals - where infants are seen. Thus the missed opportunity concept is not working. 6.6 Re<:ommended activities

The Medical Education activities in Viet Nam have improved the content of teaching on diarrhoeal diseases in the medical schools. There has also been a transformation of new ideas on teaching methods, which have been much appreciated among teaching staff and students. It is essential that advantage is taken of the surge of interest in teaching matters, which is now seen in the medical schools. The question is, however, whether that is an activity for the national CDD programme only intensified collaboration with the Ministry of Health and the Ministry ofTraining and Education (also directly responsible for two of the schools) is necessary. Recommendations of the team include a provision to the medical schools of some "communication equipment" as further support in their efforts to improve their teaching and as a first step in a nationwide effort to upgrade teaching quality in the medical schools. On the basis of the findings a number of recommendations were made by the review team. They are listed in the same order as the findings above: Medical schoolslhospitals should: (I) Improve the patient/student ratio by: (a) if possible arranging for affill iation with other nearby hospitals; and

(b) referring all diarrhoea patients now seen in OPD to the DTU, where they could benefit from a uniform approach to management and adequate aids for effective patient education

(2) provide "clinical skills checklists" free of charge (CDD funding could be considered); (3) provide food for infants in DTUs. Support for staff training and equipment should be sought from the national CDD programme as well as from other sources (such as NGOs, etc.). (4) improve the localities of the DTU in Can Tho;

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(5)

arrange a kitchen in the DTU in Thai Binh.

The national CDD programme should: (6) provide nine sets of "slides on diarrhoea" with Vietnamese text to each medical school; (7) allocate funds for continued printing and distribution of the Vietnamese version of "Readings on Diarrhoea" so that each student can have a free copy; (8) explore ways to distribute "Dialogue on diarrhoea" and similar publications from relevant WHO programmes to the medical school libraries (as well as to DTUs and nursing schools) in an English and - when possible - a Vietnamese version; (9) (10) explore funding for photocopiers for the medical schools; make videoplayers available in all DTUs;

(11) provide copies of the videotape on "Assessment and treatment of dehydration" to all medical schools; (12) explore funding for a video camera which could then be used by the medical schools; (13) ensure further evaluation of the Medical Education activities by: (a) performing a survey of knowledge and practice in diarrhoeal diseases among 30-40 doctors one to two years after they have left medical school; (b) conducting a national workshop based on the finding in this review and of the survey mentioned above. The topic could be "Teaching in medical schools", the deans as well as representatives for training departments in the medical schools should also be invited;

(c) conducting review visits to Hai Phong and Thai Nguyen medical schools. WHO should consider to: (14) provide 20 copies of "Readings on diarrhoea" in its original English version to be distributed to the medical school libraries; (IS) provide five copies of "Instructors Manual" and "Guide to student evaluation" to paediatric departments (three copies were distributed during this review). The Ministry of Health should: (16) support national production of Ringer's-lactate. If this is not feasible a change of the text in the management chart should be considered when reprinted. (17) establish policies to ensure that vaccines can be stored and used on a daily basis in hospitals.

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7. REVIEW OF SUPERVISORY SKILLS TRAINING AND SUPERVISORY ACTIVITIES AT PROVINCIAL AND DISTRICT LEVEL

7. 1

Statement of priority area

The CDD programme has been conducting supervisory skills training since 1988. Many of these courses were conducted at provincial level with little monitoring or feedback on quality and quantity of training or resultant supervisory activities. The CDD secretariat has no set targets for training and has difficulty in assessing training coverage. 7.2 Background to priority areas

In the early 1980's when the programme was first implemented, the focus of training was on programme management. Staff at provincial and district levels were trained in programme management and staff at commune level were trained in diarrhoea case management and prevention. However, in 1988, the programme introduced supervisory skills training for provincial and district levels, believing that this was a more appropriate course for this target audience. Provincial supervisory courses:

In 1988-1991, the national CDD staff with the assistance of the Pasteur Institute in HCMC and Nha Trang conducted six courses and trained at least 2 staff from each Provincial Hygiene and Epidemiology Station(HEC) in the then existing provinces (44). As there are now 54 provinces and by NCDDP definition coverage is two persons trained, the current coverage is 81 % at provincial level. These courses were intended to be 7-day courses using the 7 modules of the CDDIWHO supervisory skills course. The majority of these courses were funded by WHO. District supervisory skill courses Following their training the staff from the provincial HES were suppose to conduct supervisory skills courses for the staff from the District Hygiene and Epidemiology Brigades (HEB) in their provinces. These courses were intended to be 7 days in length using the 7 modules of the WHO SS course. Occasionally staff from NIHE or the regional Pasteur Institute would act as facilitator for these courses. Participants were to be two staff from each HEB (the head of the HEB and the one responsible for COD). In 1991-92,32 courses were conducted resulting in a coverage rate of 59% using the NCDDP definition of coverage as 2 trained staff per district (32/54). The majority of courses were funded by WHO. Commune COD courses: CDD courses for commune level staff commenced in the mid 19805. These 1-3 days courses were coordinated and run by province but were intended to train 2 staff per commune health centre on diarrhoea treatment and prevention using the WHO booklet entitled "Guidelines for treatment and prevention of acute diarrhoea". Up to 1990, 294 such courses were conducted. There was little quality control or monitoring of these courses by central level. Since 1991, central level became more involved in organizing and monitoring these courses and in 1992, the courses started using two modules (treatment and prevention) of the WHO SS courses rather than the booklet previously used. The NCDDP feels that the quality of the course from up to 1990, is questionable and thus is reluctant to include these courses in calculating COD coverage. If only the 118 courses

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conducted in 1991 and 1992 are considered, 118 of 527 (22%) of district have trained commune level staff. The 1991-1992 courses were funded by UNICEF. Supervision: The NCDDP staff and regional institutes supervise provinces on ad hoc basis based on request from province. These visits generally focus on problem solving. CDD supervision below provincial level is part of an integrated MOH supervisory system which recommends 1 visit per month to each site. At HES approximately 10 staff and at HEB approximately 5 staff are responsible for supervision. However these figures vary from provinces to province. Checklists for CDD supervision at all levels have been developed by national programme; 7.3 Methodology

Fifteen provinces were visited - six from the north, six from the south, two from the central region and 1 from high plateau region. The list of provinces visited is found in Annex 2. Provinces were not chosen randomly but were felt to be representative of each region. In each province, one staff person from the Hygiene and Epidemiology stations (HES) and five staff recruited from five district hygiene and epidemiology brigades (HEB) were interviewed using structured questionnaires on training and supervision for their respective province and districts. One district was then visited by the team and five commune level health staff from that district were interviewed. Key programme documents and issues were discussed with the team members. Annex 6 provides copies of the questionnaires used and Annex 7 detailed results from the interviews at provincial, district and common levels. 7.4 Key findings (a) At the national level there is no comprehensive plan for training (including supervi:;ory skills training) with targets, sub-targets and details of planned activities. (b) lbere is inadequate monitoring of supervisory skills and CDD training at central level.

(c) There is lack of funds for supervisory skills training and supervisory activities partially due to delays in requesting, obtaining and receiving funds from donor agencies. (d) The NCDDP currently considers the target audience for SS training to be 2 staff from each HES and HEB. The target audience for CDD training is 2 staff rom each commune health centre. Thus if 2 staff are trained the coverage is deemed to be 100% for that province, district and commune respectively. Using this definition training coverage was high at provincial level, 80% and moderate at district level, 43 % and 59 % of communes had at least 2 staff trained since 1991, which are the only courses considered by the NCDDP in assessing the coverage.

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Level

Course

% meeting NCDDP requirements (2 trained) 80 43 59

% with at least 1 staff trained

Provincial District Commune

SS SS CDD

100 61 6

(e) Although the NCDDP plan is to train only 2 staff at each provincial HES and each district REB, the number of staff doing supervisory activities is significantly more than 2 and all supervisory staff supervise a number of programmes, not just CDD. On average the number of staff trained was 4.5 per HES (result is skewed and the mode was 2) and one per HEB. However, staff interviewed felt all health workers doing supervision should be trained. On an average, this would mean a total of 10-12 staff per HES, and 710 per HEB should be trained. (t) Turnover of trained staff was perceived as a problem by those interviewed. The results showed that in 40% of provinces, and 60% oof districts, 100% of the staff that had been trained in SS since 1988 were still working at the site. Sixty-two percent of the commune level staff that had been trained in CDD since 1987 were still working at the site.

Level Provincial District Commune

100% of staff still working 40 60 62

50% of staff still working 26 30 32

33% of staff still working 26 2 6

(g) Only 53 % of provinces had conducted SS courses for district HEB staff. The main constraint was the limitation and/or delay in funds as a result of poor central level planning in requesting, obtaining and receiving funds. There appeared to be no provincial level governments funds for this type of training although it was not clear whether or not this had ever been pursued. This figure is consistent with the central level monitoring that 32/54 (59%) of provinces nationwide had conducted courses. (h) Including courses that were conducted in the two periods 1987-1990 and 19911992, 76% of districts have conducted at least one CDD course for commune staff.

(i) One half of courses conducted for provincial RES staff by the national level and the Pasteur Institute met the requirements of the NCDDP in terrns of length of courses (seven days). The other courses were five to six days. In all courses the seven WHO Supervisory Skills modules (translated into Vietnamese) were used and the participants were provided with a copy.

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G) Seven of the eight district level courses conducted by the province did not meet NCDDP criteria for length of courses (seven days), lasting only five days. However, the NCDDP criteria were met with respect to the number of participants and the mixture of methodologies with an average of 10% lecture, 15% practical, and 75% exercises and role plays. (k) CDD courses for commune staff conducted by the district level did not meet the NCDDP requirements as there were too many participants, (33% of courses had more than 40 participants), too short (72% were less than two days) and too much emphasis on lecturing as a method (40% of courses were 100% lecture). Although the national level is supposed to provide the seven supervisory skills modules for each participant at the provincial level courses and either the "blue booklet" (prior to 1992) or the treatment and prevention supervisory skills modules for each participant in the commune level courses, this has often not been the case and various training materials were reported as having been used. Thus in some courses modules were summarized, revised and photocopied. In some cases no materials were provided for the participants. The lack of training materials for the course is due to lack of printed materials at central level and problem in monitoring of distribution. (I)

(m) Although the frequency of supervision does not meet the government recommendations of one visit per site per month (only 27% of provinces and 25% of districts), the results indicated that the frequency of supervisory visits had increased from 1987 when the visits were usually limited to one or two per year. Using a definition of at least four visits per year as adequate, for 73 % of provinces and 81 % of district supervision was adequate. Seventy-five percent of all supervisory visits were reported to be at least three to fours hours. (n) Supervisors seemed to be focusing on relevant areas during visits as reflected in the following list of activities: Activity % of provinces doing activity % districts doing activity

Observes diarrhoea case management Assess ORS and other stock Review records Discuss personnel issues Discuss problems Discuss budget Check ORT corners* Discuss home care with mothers* Discuss communications skills*

93 86 100 67 70 33 47 33

96 92 91 24

69 6 30 27 21

* Unprompted response, other responses mayor may not have been prompted. (0) Eighty percent of provinces and 56% of districts reported that they used a checklist (usually the nationally prepared checklist) while supervising. There were several requests for the checklist to be shortened but very few other suggestions for changes. A shortage of checklists was reported by a number of staff owing to lack of funds for printing. Some staff had never seen the checklist.

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(P)

The following problems related to supervision were reported: % of provinces reporting

Problem

% of districts reporting

86 Lack of or delayed funds 70 Lack of transport Staff not motivated 33 Lack of training 40 CDD staff absent when visit made 33 Geographical area too big 33 Not enough ORS High CDD staff turnover 40

69 41

47 13

23 27 25

7.5

Recommendations (a) The NCDDP should develop a mid-term (three years) detailed plan of action for all CDD activities including supervisory skills training. The plan should state the current training coverage, targets and subtargets, specify the target audience for each type of course, criteria for content and methodology of course, timetable of activities and sources of funds. (b) Before preparing the mid-term plan the NCDDP should review their current strategy of training only two staff at each level. As the supervision is integrated, the review team recommended to train all staff doing supervision in each HES (approximately 10-12/HES) and all staff doing supervision in each HEB (approximately 7-10).

(c) Following the preparation of this plan, short guidelines (1-2 pages) should be prepared outlining the NCDDP's requirements for courses (e.g. number of facilitators and participants, length of course, materials to be used, etc.). These guidelines should be distributed to those who will conduct courses and the·quality of the training courses should be monitored. (d) Commune level training is based on the supervisory skills courses modules on diarrhoea management and prevention. However, it should be noted that there is no standard curriculum for the course, and that the application is determined by the trainers in each province. It is recommended that a standard curriculum, with a provision for exercises and practice, be developed and that the course include a clear emphasis on the three rules of case management in the home, and the exercises from the IPS course on: Asking questions/Checking questions (Exercises B, C) Using Simple Language (Exercise D) Lead a Demonstration (Exercise F) Use Materials Effectively/Use the National CDD Flipchart (Exercise H).

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In order to ensure that support services for referred patients will be in place, commune-level training should be carried out in those communes where CDD activities are already implemented at district level. (e) The NCDDP should develop and maintain a monitoring system for all training activities. (This was discussed with the NCDDP during the review and draft forms were prepared).

(0 The NCDDP should monitor the distribution of training materials to ensure that all courses are using materials approved by the national level and that each participant will be provided by a complete set of modules. (g) The NCDDP, WHO and UNICEF should improve their collaboration and set clear guidelines for request and timely release of funds. (It)

The NCDDP should actively seek for other potential donours. All these agencies should be invited to the annual review and planning meeting in December 1992, where the mid-term plan will be presented in support for supervisory skills training, supervision and other activities. (i) The NCDDP should assess the need for regular supervision from national level and the Pasteur Institute to provincial CDD staff.

G) As many staff reported shortage and delays in receiving ORS, the NCDDP should further investigate this to see if it is a significant problem and if so, action should be taken to ensure ORS availability.

7.6

Plan of action

A ~raft plan of action for 1993 w~ developed with major emphasis on the key tasks to be earned out by the NCDDP secretarIat. A more detailed plans for 1993-1995 will be developed and presented in the annual review and planning meeting in December 1992.

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DRAFT PLAN OF ACTION

ACTIVITY

TIME FRAME

PERSON(S)

COST

SOURCE

RESPONSIBLE 1 Preuare Plan

OF FUNDS

T.-\SKS:

1. NCDDP to discuss target audience 2. Assess curren~

X/92

NCDDP'

X/92

coverage based on target audience 3. Set targets X/92

NCDD?/ Dr Thang

NCDDP/ Dr Thang NCDDP/ Dr Thang

NA NA

4. Plan activities

courses/year - select provinces - asses requirements for training materials - estimate cost for each course 5 .. Present plan at

- U of

X/92

Xll/92

NCDDP

annual Review meeting 6. Finalize the Midterm Plan

Xll/92 Xll/92

NCDDP/ Dr Thang NCDDP/ Dr Thang

NA NA

7 . Reques t funds for 1993 activities

2.CONDUCT

T~~INING

1.Prepare guidelines on criteria for courses at provincial. district and commune level - duration - materials - methodology - number of participants - number of facilitators

1/93

NCDDP/ Dr Thang

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(Draft Plan of Action continued)

.. -------------------------------------------------------------------------

ACTIVITY ,~

TL'iE FRAME

. . .............................. ........................................................................................................................................................................................... ...

PERSON(S) RESPONSIBLE

COST

SOURCE OF FUNDS

2.Secure funds (focal cos~), t=ansfer ·funds ~o

NCDDP/ Dr Thang NCDDP/ Dr Thang NCDDP/ Dr Thang NCDDP/ REGIONAL INSTUTUTES/ PROVINCES/

regicn/?rovince

3. P::int, dL;t::ibute t=aining m,aterials

4.Monitor distribution S.Gonduct training courses - North: courses - H.Plateau: courses - Central: courses - South: courses

3. DEVELOP MONITORING

SYSTEM FOR CENTRALL PROVINCIAL LEVEL TASKS l. Design system/forms

NCDDP NCDDP NCDDP NCDDP NCDDP/ PROVINCES

2. Print forms 3. Instruct provincial

staff 4. Distribute forms S. Compile data

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8. REVIEW OF COMMUNICATION ACTIVITIES

8. I

Priority area under review: CDO communication activities, in particular: training of health personnel in interpersonal communication skills; orientation of private pharmacists and physicians to sell or distribute ORS; distribution and use of printed materials.

Recommendations from this review will include a plan of action for 1993, and a major proposed activities for 1994-1995. In addition to the three areas listed above, the plan will consider the integration of interpersonal communication skills into clinical management training and into the training for commune-level health workers, as well las the integration of COD materials with the core curriculum on health education skills developed as part of the national strategy on health education and communication. 8.2 Background:

The National COD Programme of the Socialist Republic of Viet Nam initiated a series of communication activities in 1990, following the development of a five-year plan which incorporates five strategies. These strategies are: Training of health personnel in interpersonal communication (IPC) skills, orientation of private pharmacists and physicians to sell or distribute ORS, introduction of COO into the in-service and basic training curricula for pre-school and kindergarten teachers, development and distribution of printed materials, and promotion of COO messages via the mass media (with emphasis on radio). Descriptions of the status of each strategy may be found in the consultant report on the preparation for Phase 2 of the Focused Programme Review (E. Eng, July 1992). During the preparation visit, it was determined that owing to recent government policy shifts with respect to public support for pre-schools and kindergartens, and with respect to prices charged for radio time, the future of those two strategies was tenuous. Thus, the present review focuses on the three remaining strategies. 8.2.1 Training of health personnel in IPC skills

This strategy is based on the results of a training needs assessment carried out in 1990, which indicated that health workers responsible for treating cases of child diarrhoea at government health facilities lack the skills to effectively communicate with parents. A practice-oriented three-day curriculum was developed and tested later in the same year, and a five-year training plan was designed. The curriculum focuses on simple counselling skilIs, on techniques of demonstrating the preparation of ORS and rice water, and on the use of communication materials (e.g., the national COO programme flipchart and posters) as teaching aides. As of 1991, this course had been applied in 10 provinces; in 8 of these provinces staff from all districts have participated in the course. No province- or district-level courses were held in 1992.

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8.2.2

Orientation of private pharmacists and physicians

The rationale for this strategy is the rapid growth and popularity of the private sector, and the suspected high sales of unneeded or harmful drugs for the tr~atment of child diarrhoea. The orientation consists of a one-day seminar to inform pnvate practitioners about the physiological basis for ORT and feeding during diarrhoea, and national CDD programme guidelines for treatment. Participants are then requested to stock and sell/distribute ORS packets, to advise clients on the correct preparation of ORS solution, to display at least one CDD programme material, and to send inventory records of ORS distribution to the national CDD programme. It is also anticipated that the sale and use of antidiarrhoeal drugs and unnecessary antibiotics will decrease. The first series of seminars has been held in urban areas where the concentration of private pharmacists and physicians is the greatest. At the time of this review, 259 private practitioners have attended seminars in Hanoi, Hai Phong and Ho Chi Minh City. 8.2.3 Distribution and use of printed materials

The national CDD programme has developed a variety of printed materials to promote practices of home case management and diarrhoea prevention. These materials include a set of posters on ORS preparation, rice water preparation, continued feeding and breast-feeding; a flyer for mothers on ORS preparation; a "mother's card" on home management and prevention of diarrhoea; and a 12-page tlipchart. The use of these materials is taught and practised during the IPC skills training, and discussed during the seminar for private practitioners. 8.3 Review methodologies

Three techniques were used to collect the data for this review: group interviews with health personnel and private pharmacists, the monitoring checklist used during follow-up visits to health facilities with trained staff, and a survey to assess caretakers' exposure to CDD materials and messages. These methodologies were determined and the necessary instruments developed during the visit of Dr Eng in July 1992. 8.3.1 The &:OU[> interviews were conducted with trained and untrained health staff at province, district and commune level. The selection of provinces (Hai Phong, Thua Tien Hue, and Long An) was purposeful; all three are "sentinel" provinces in the original training plan for COD communications. Within each province,the selection of districts and communes was random. At each site, available personnel were interviewed, with those staff trained and untrained in CDD/fPC skills comprising separate groups. Some private pharmacists were also interviewed, in separate groups. Although the methodology was intended to be focus groups, the small number of personnel responsible for CDD at any given site made it impossible to gather an optimum number of participants. Thus, group interviews were conducted using the same interview guide. Interviewers were national COD secretariat staff and two physicians external to the programme, with experience conducting CDD household surveys. The interview guide was designed to elicit information about: the respondent's knowledge of CDD policies on home case management, their opinions on the most important messages to communicate with clients, and their application of the skills learned during the IPC training (using simple language, checking mother's understanding, using printed materials, and conducting demonstrations). It also asked about their perceptions of changes in their jobs and among the client popUlation as a result of the knowledge and skills learned.

- 49-

A total of 32 group interviews were conducted: 18 groups of trained staff, 8 untrained, 3 groups of pharmacists who had attended a CDD orientation, and 3 groups who had not (see Annex 4). It should be noted that in many places trained and untrained staff from the same facility were interviewed. Also, a number of private pharmacists are medical staff of hospitals who open drug stores in the evenings. These two sets of respondents may have been exposed to CDD communication messages and skills at their workplace. 8.3.2 The monitoring checklist was designed during the first training in IPC skills in 1990, and had been applied duirng follow-up visits to a number of sites since that time. These data were compiled, and additional data collected during this review were added. A total of 123 monitoring visits were made. The checklist was designed to assess the application of skills learned during IPC training once the trainees returned to their health facilities. The main categories are: whether communication materials are displayed and used correctly, whether ORS demonstration equipment is available, and whether counselling skills are applied. This last item is assessed by observation of a health worker-client interaction (real or role-play) or, if no clients are available, by interviewing the health worker. 8.3.3 The survey on exposure to CDD messages and materials was conducted in 1990 as a set of additional questions to a COO household survey. The same questions were repeated in the same areas in 1992, to investigate a change in reported exposure to various media. 8.4 8.4.1 (a) Key findings Achievements Interpersonal communication (lPC) skills training for COO

The number of staff trained in IPC skills in 1990 and 1991 has met or exceeded plans and expectations at all levels of the health system. Table 1 shows the percentage of districts having trained staff in sentinel and expansion provinces; it is noteworthy that 8 of the 10 provinces have trained health personnel in 100% of districts (see Annex 8, Table 1). Owing to administrative delays in funding, the province and district-level courses planned for 1992 were not able to be implemented. Activities continued to be carried out at the local level, however, with local staff seeking support from other sources such as the People's Committees. The original plan for the diffusion of training included only regional, provincial, and district-level staff. In all provinces visited during the review, it was found that IPC skills, via various adapted training methods <on-the-job, one-day courses, added on to clinical management training), have been transferred to co-workers at the district level and at commune health stations. This, and many of the findings related below, reflects the initiative and commitment of local staff to carry out primary health care activities in general and COO activities in particular. Analysis of the group interview responses demonstrates a consistent awareness and understanding of IPC skills, and of the health worker's responsibility to advise mothers as part of the health worker's COO activities. A summary of the top three answers to the major categories of questions may be found in Table 5, Annex 8.

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Trained health workers reported using the IPC "counselling skills", including asking open questions and checking the understanding of clients; they also reported doing ORS/rice water demonstrations, and using communication materials such as the tlipchart. They consistently expressed the importance of demonstration and practice as the best method to teach a mother and to verify her understanding. Similar findings were noted among health workers who have not been trained in the IPC skills, but to a lesser extent. It should be recognized that the untrained health workers interviewed work in the same place as the trained personnel so the IPC skills from the trained personnel could have been partly transferred to the untrained personnel. Group interview responses indicated an important awareness of the policy change from salt-sugar solution to rice water as the recommended home fluid. However, the heaviest emphasis for advice and practice is still on ORS. Table 5 in Annex 8 shows that the three most common subjects on which health workers counsel clients are to im:rease fluids by giving ORS, to continue feedinglbreast-feeding and to know when the child need to be taken to the health centre. The most important practices for clients to know for home therap} are reported as how to prepare ORS, to continue feeding and to practice "good hygiene". Positive changes in COO activities and services were mentioned more often among trained than untrained health personnel. Personnel trained in IPC skills perceived their jobs to be easier now, i.e. less use of IV, higher knowledge and awareness of clients on COO, and a greater number of mothers who are convinced about ORT than was the case two years ago. Trained health workers also reported that the number and severity of diarrhoea had decreased. The results from the observation checklist of applied communication skills confirmed that the IPC "counselling skills" were put into practice correctly among the majority of those who have been trained. Although the number of observation checklists is small, the data show a consistent improvement over time. The counselling skills are applied, materials are displayed correctly, and ORS demonstration equipment is available at most facilities monitored (Tables 6, 7 & 8 in Annex 8). Results of the survey on exposure to COO messages and materials ("mini-household survey", Annex 8, see Tables 2 and 3) indicate a substantial increase from 1990 to 1992 in the percentage of care-takers who recall having seen COO communication materials; however, at one site individual counselling between the health worker and the client during the same period seems to have decreased considerably. The percentage of care-takers receiving COO messages through radio was low in 1990 and has not changed over time (consistent with the programme decision not to pursue radio as a channel), but a higher and increasing percentage of respondents recall having heard COO messages through public loudspeakers. This latter may reflect the opinions expressed by both trained and untrained health personnel that their target groups for COO communication are (in decreasing order of mention during the group interviews) all the people in the community, parents of sick children or parents who bring children for immunization, and parents of children with diarrhoeal diseases. (b)

Orientation of private pharmacists and physicians

In this review, the sample size of the private pharmacists and physicians interviewed was too small to draw useful conclusions about differences in activities and knowledge between those who had attended an orientation seminar and those who had not. Nonetheless, some observations may be made. For example, a number of the private practitioners described their knowledge gains on ORS preparation: "I know now that the whole packet has to be prepared; whereas before I used to advise mothers to use half at a

- 51 -

time". There is also a potential conflict between making profit and distributing ORS. One pharmacist claims that pharmacists cannot accept that ORS alone is sufficient treatment. Another mentioned about the need for pharmacists to keep their reputation by prescribing medicine that yields quick result. In addition, private pharmacists and physicians in Ho Chi Minh City cited the problem of ORS sapply, and of the policy concerning the sale of UNICEF ORS packets. (c) Distribution and use of printed materials

In the group interviews with health personnel, the top responses about the changes seen in CDD communications concern the increase in the quality and quantity of printed materials available. Results of follow-up visits indicated that most of the health facilities visited have the materials on hand, and display and/or use them correctly. These findings were confirmed by the report of care-takers in the mini-household survey that they have seen the materials at the health facility and the health workers used visual materials. There was a substantial percentage increase reported for the use of posters and flipcharts (see Annex 8, Table 3). 8.5 8.5.1 Problem areas identified IPC skills

As is indicated above, the greatest emphasis for advice given to mothers is on the correct preparation of ORS solution. This emphasis may overshadow other important advice, particularly the correct use of ORS, giving increased fluids, continued breastfeeding, or timely referral. Most health workers recall the technical content of the IPC training before the skills content. This is reflected in the training that they then carry out for co-workers or lowerlevel workers, which focuses increasingly on ORS preparation. As IPC training activities are passed down the levels of the health system or transferred from worker to worker, they tend to get shorter owing to logistic and budgetary constraints. In order of decreasing mention, the topics that are included are: ORS preparation, use of printed materials and counselling skills.

It was not possible to observe a training course in IPC skills during this review; thus there are no findings concerning the quality of the activity. Some national and provincial-level activities were delayed owing to administrative difficulties in funding. 8.5.2 Orientation of private pharmacists

Discussions with private pharmacists in Ho Chi Minh City revealed that the distribution and sale of UNICEF ORS may be problematic, but that commercial ORS is available in the Southern Region through a variety of sources. It is not known whether these commercial packets conform to WHO standards, and it is likely that there are various sizes other than one litre. A small-scale study on health-seeking behaviour carried out in 1992 in one commune suggests that the number and types of drug-sellers is increasingly important in the rural areas. There is no information at present about how this population may be reached.

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8.5.3

Distribution and use of printed materials

Observations reveal that printed materials may be distributed to health facilities where staff have not been trained to use them, perhaps via other programmes, ministries and organizations with CDD-related activities. The quality and appropriateness of national CDD materials for all parts of the country have not been evaluated. Regional vocabularies vary and there may be other important differences to consider as the CDD communications intervention grows in scope. 8.6 Observations and impressions

Informal discussions with health workers involved with CDD and visits to health facilities also revealed valuable information for this review. Staff at all levels from national to commune show impressive initiative and commitment to carrying out CDD activities, and in particular, to promoting and supporting good communication skills. This is demonstrated, fur example, by the inclusion of selected IPC skills in the curriculum for commune level CDD training developed by the secretariat of the Southern Region. It is also shown by the existence of ORT corners equipped with locally-appropriate demonstration materials in the vast majority of sites visited for the group interviews. It should be noted that these sites had been selected at random and were visited with very little advance notice. It has been mentioned above that many health personnel have taken the initiative to train co-workers in selected IPC skills. This is tu be commended. However, it should also be noted that in nearly every case the IPC training has had to be shortened at the discretion of the trainer, to meet logistic and budgetary needs. Most of the follow-on training seems to focus on ORS demonstration, followed by the use of printed materials; counselling skills are added if time allows. This is also reflected in the fact that ORS preparation is considered to be the single most important practice for clients to learn. 8.6.1 Private drug sellers

Eighty per cent (80%) of the population of SRVN live in the rural areas. Various studies and site visits indicated that few people use the services of the government health facilities for "common illnesses". Instead, the majority buys drugs from the most convenient places: the urban population uses private clinics and pharmacies, while the rural population buys drugs from drug sellers in their neighborhood. In most cases in the rural areas, the drug sellers do not have ORS and their knowledge of home treatment of diarrhoea is limited. 8.6.2 Communication channels in rural communes

Many communes, particularly in the south, are quite spread out. The three communes visited in Long An Provinces are between 5 to 12 kilometres long from one end to the other. Mothers are farmers, usually working in the tield all day. Approximately half the population is reported to have access to the radio or television, but not to newspapers. Communication from government offices to people is usually through the heads of production groups, mass organization groups, via hand-grip megaphones on bicycle or by boat.

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8.7 8.7.1

Conclusions and Recommendations Training in interpersonal communication skills

The IPC skills taught appear to be well ajJplied at all levels. In many cases, training activities have been carried out despite the lack of financial support from external sources. Staff trained demonstrate a good understanding of home care rules and of communication skills. It is recommended that the training activities continue as planned, with several slight modifications: (a) Training courses were conducted according to plan in 1990 and 1991. However, 1992 saw various difficulties with resources and many of the programmed activities were not able to take place. These training activities have been replanned and should be carried out in 1993. (b) The group interviews revealed that most trained staff recall the technical content of the training more readily than the skills content. This indicates that future training courses should put more emphasis on learning and practising the IPC skills.

(c) Of the technical content recalled, most respondents mentioned ORS preparation. This is understandable, since it is an important, concrete and familiar activity. However, the findings may indicate that too much time or emphasis is being put on this activity during training. This should be reviewed, so that in future training courses other home care messages such as giving quantities of fluids, continued feedinglbreast-feeding, and knowing when to seek medical help may be given equal attention. 8.7.2 Orientation of private pharmacists and physicians

From the data gathered during this review, no valid conclusions can be drawn about this activity. Nonetheless, given the rate of growth and of use of the private health sector, it should be recognized that drug providers are a very important population to reach. It is recommended that the orientation seminars be continued in urban areas as a means of disseminating correct information and promoting effective diarrhoea treatment. In Ho Chi Minh City, discussions revealed that the distribution and sale of UNICEF ORS by private pharmacists may be problematic, but that commercial ORS is available through a variety of sources. In this case, it is suggested that the orientation seminars there emphasize the importance of ORS which conforms to WHO standards, and the correct mixing of ORS packets which may be other than a one-litre preparation. A small-scale study on health-seeking behaviour carried out in 1992 in one commune suggests that the number and types of drug sellers is increasingly important in the rural areas. It would be useful to conduct a study on means of reaching this population. UNICEF has expressed interest in supporting a study on this subject as part of the preparations for launching the Bamako Initiative. 8.7.3 Distribution and use of printed materials

It is commendable that, according to the latest data from the monitoring checklist, printed materials have been distributed and are correctly displayed in the vast majority of sites monitors (see Annex 8, Table 8). Furthermore, trained staff at those sites are aware of the correct ways to use each material.

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Discussion and observation reveal that materials may also be distributed to health facilties where staff have not been trained to use them, and via other programmes, ministries, and organizations with COD-related activities.

It is recommended that COD communication materials, in particular, the flipchart, be distributed only with instruction on their proper use. As a back-up measure, instructions for use should be printed on the inside cover or back of the material itself. Preparations for the new national health education and communication strategy have revealed a number of COD-related communication materials produced by other programmes and organizations. In collaboration with the CHEC, a mechanism should be developed whereby all such materials may be reviewed by the national CDD secretariat for technical accuracy and consistency with COD policies and messages. 8.7.4 Integration of IPC and clinical management (CM) training

This activity should take place in 1993 as scheduled in the original five-year training plan. A sample agenda for an integrated CM/IPC course, developed by the Bangladesh national COD programme (see trip report of Ms Cathy Wolfheim, August 1992) was presented and discussed with the COD secretariat. An integrated curriculum should be introduced with the participation of a qualified consultant at a CM/IPC training of trainers in June/July/August 1993. This training of trainers course would include trainers from the OTUs, min-OTUs, and provincial hospitals of one region, and would be followed by similar courses in the other two regions. All CM courses at provincial level should be integrated by 1994.

It was agreed that WHO will send the national COD secretariat for consideration a sample agenda for the integrated training of trainers, as well as a version of the recentlydeveloped" Advising Mothers", adapted to Viet Nam. 8.7.5 Commune-level training Please refer to team 3 recommendations. 8.8 Integration with the national strategy on health education and communication

The Centre for Health Education and Communication (CHEC) has developed and begun to implement a national strategy. The first step in implementation includes the development of a core curriculum for health education, to be used to build capacity at the CHEC and at Hygiene and Epidemiology Stations and Brigades. It is foreseen that the core curriculum will eventually include a module for each national programme, and as such training courses will also involve personnel of these programmes. It is recommended that one staff from the national COD secretariat attend the training of trainers in the core curriculum to be held before the end of 1992. The counselling skills and process taught in the core curriculum and those in the CDO/IPC course are very similar. Thus, it is recommended that the COD/IPC module be suggested to the CHEC as the COD contribution to the core curriculum. It may be reasonable to field-test an integrated curriculum (core plus contributions from various programmes) in a pilot commune in 1993. COD should participate in this test. In the interest of ongoing collaboration, one person from the national COD secretariat should continue to represent COD on the CHEC working group.

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8.9

Other

There is no staff in the national or regional COO secretariat with adequate training in communicationlhealth education. UNICEF has agreed to help seek out resources and opportunities for training of COD staff in this area. This is in full agreement with the national strategy for health education and communication. Eighty percent of the population of SRVN live in rural areas and most adults have completed at least primary school. Small-scale studies indicate that up to 50% of the rural population have access to radios. However, the primary target group for COD communications, mothers of children under 5, spend at least 8 to 9 hours working in the field and do not listen to radio. Recent information indicates that radio air time costs up to $26 per minute. For these reasons, it may be reasonable to test if a newsletter is a viable channel to reach rural mothers. A mechanism for publishing and distributing such a newsletter should be carefully discussed at the 1992 Annual Review and Planning Meeting. 8.10 Evaluation Taking into account the delay in implementing some of the planned communication activities, the household surveys to assess behaviour change in sentinel provinces have been rescheduled from 1993 to 1995. 8.11 Plan of action

A draft plan of action for 1993 with proposed major activities for 1994-1995 was developed on the basis of previous plans and findings of this review. The plan can be found in table format on the following pages.

DRAFT' PLAN OF ACfION, COD COMMUNICATIONS ---------

Strategy

---I--

1993

1994

1995

1. Training in IPC skills

Reprint training materials (if not done in 1992)

Reprint as needed

Training of trainers in 6 additional provinces J course, $2 000 April

Training of trainers in 10 additional provinces

(Same: add 10 provinces)

VI C\

Training in each new province (district-level staff) 6 courses, @ $1 000 = May $6000 Follow-up visits to six sentinel and 3 new provinces by National and Regional COD staff August $3000

Train in districts (x 10)

(Same)

Follow-up visits to six sentinel sites and 5 new provinces

Strategy 2. Integrate with CHEC core curriculum for health education

1993 Propose CDO/IPCS as module to be used with core curriculum Jan/Feb Participate in test of integrated curriculum in pilot commune(s)

1994 .

1995

One national COO secretariat attend TOT for core curriculum (may be held 1992)

-.J

l.II

One national COD secretariat represent COD in CHEC "working group"

(Ongoing)

Strategy 3. Commune-level training in CDD

1993 Revise/improve curriculum (increase no. of days?): Treatment, Prevention, IPC skills and use of printed materials Jan/Feb Training in communes where COD is imnlemented at districtlevel

1994

1995

(Ongoing:

April-Dec (about $20 000; not communication budget) Integrated curriculum to be agreed February . Training of trainers in CM/IPC curriculum: DTU and miniDTU, provincial hospital trainers " June-July-August $2 000 x 3 (N,C,S) = $6 000 • ·consultant requested first course Manuals translated, printed

VI 00

4. Integration IPC skills . and case management (cm) training

All CM courses for province level to include IPC

AU CM cours'es for district level to include IPC

-----

I 5. Private sector pharmacists, physicians, and drug-sellers

1--

----

----------

-_ .. _-

--- - -

1993

1994

1995

Develop mechanism for allowing drug-providers to sell ORS at reasonable profit (to be discussed by February) .

Continue one-day seminars 10 @ $800 = $8 000 10 VI

Develop new strategy to address rural drug-providers (based on study. See no. 7, below)

-'Implement new strategy in one province Expand to additional provinces if successful

Strategy 6. Development and distribution of printed -materials

1993 Reprint sufficient quantities of present materials for activities planned 1993 (about $10 000) January/February Revise materials as indicated based on effectiveness study (see no 7, below) Pretest; print

1994

1995

All distribution to be carried out with training; materials to include instructions for use

Develop mechanism for: I

1. distributing national COD materials via other ministries and

organizations (e.g. Women's Union, NOO's) 2. reviewing COD-related materials developed by other programmes, ministries and NOO's for technical content and consistency with national programme messages ,

Strategy/Activity

1993 Evaluate existing COO printed materials (as basis for redesign, pretest and production) "Loc al consultant requested Survey on exposure to CD 0 materials and messages in 3 additional sentinel provinces

1994

1995

7. Resea rch and evaluation

Household survey in three sentinel provinces and 3 non-sentinel provinces

Participate in study on communication channels to reach mothers (in collaboration with other PHC programmes)

Study on drug-providers' practices and behaviour (in collaboration with other programmes) • 'consu ltant reque sted early 1993 if possible -

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9. SUMMARY

A Focused Programme Review (FPR) of the Diarrhoeal Disease Control . Programme in Viet Nam was conducted in ord~r to assess the c~~r~nt s.tatus o.f the ~aJor programme indicators and to evaluate recently Implemented actiVIties, In particular m the areas of basic and supervisory skills training and communications. The review was carried out in two phases, as outlined in the WHO COD FPR methodology. However, adaptations were made particularly in the second phase, as the review was focused more on priority areas picked out in the first phase than on problems, as outlined in the review methodology. The selected priority areas under this review were mainly activities that were recommended by the 1987 Comprehensive Programme Review. Therefore, it wa~ felt important to focus on programme areas that were given high priority by the NCDDP and that had not been previously evaluated. 9.1 Team 1

In general, the review team 1 encountered remarkable progress and success in the implementation of activities in paramedical schools. In paramedical schools the teaching of COD and EPI had considerably improved, staff attitude to new curricula was overall very positive and the results from the student questionnaires indicate generally good knowledge. In general, major problems encountered in the schools visited were lack of training matl~rials and equipment, which was mainly due to problems in distribution and lack of teachers trained in COD and EPr. A plan of action for 1993-1995 was developed by the team, which gives high priority for developing and maintaining a distribution system to ensure that all schools have adequate number of COD and EPI training materials, visual aids and equipment required for practical demonstrations. Equally imponant is to ensure that all schools have adequate number of teachers trained on COD and EPI and that all schools use the revised curricula in a similar was with the same number of hours allocated for the subjects. The project "Strengthening the teaching of COD and EPI for assistant physicians, nurses and midwives in secondary medical schools· should be evaluated by the end of 1994 and plans be made for long-term to ensure sustainability. 9.2 Team 2

The team that reviewed the activities to strengthen the teaching of CDD in medical schools found the project, in general, very successful as majority of the schools had been able to pursue all objectives listed in their 12-month workplans for 1990. These included establishment/or strengthening of DTUs, follow CDD guidelines in their teaching, introduce CDD teaching materials, assure supervised clinical practice, use more small group teaching, coordinate teaching with other clinical and basic science departments, improve evaluation of knowledge and skills and train faculty staff in CDD management and new teaching methods.

It was felt that CDD medical education activities have had catalytic effects on general efforts to improve CDD teaching in medical schools. In general, major problems and constraints encountered during the visit were similar to those in the paramedical

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schools, i.e.: lack of training .materials and shortage of equipment. Also, it was found that the cooperatlon between hospitals and the EPI programme was not optimal. In order to fu~er improve COO training in medical schools, it is recommended that the .school~ ~d .hosplt~s sh~uld ensure that adequate amount of "hands-on practice" durmg trammg IS proVided (Improve the patient/student ratio) and that all OTUs meet the recommendations by the programme. The NCOOP should ensure that all schools are provided with adequate amount of training materials, visual aids and teaching equipment and that a system for distribution wiII be developed, maintained and monitored.

9.3

Team 3

The team that reviewed supervision and supervisory skills training, found in general, that the frequency of supervisory visits has increased since 1987 Comprehensive Programme Review, although it did not usually meet the MOH recommendations of one visit per month. Use of supervisory checklists had increased and was in particular high among the staff from provincial HES. Staff turnover, although perceived as a problem, the results indicated that it is not a big problem (40% of provinces reported that 100% of trained staff still working and 60% of districts had 100% trained staff still working at site). Regarding the training on supervisory skills, the review data reveal that the coverage was high at provincial level (80%), but only moderate at district level (43%). The course content, length and methodology were considered appropriate in most provincial level courses, but less good in courses conducted at district and commune level. Training materials used varied from province to province, and some materials used did not meet the criteria set by the NCDDP. At central level the major problems encountered were the lack of a comprehensive training plan and guidelines on how to conduct training, especially at district and commune levels. In addition, lack of monitoring of training at central level has made it difficult to estimate the current training coverage and target audience for each type of a CDD course. The team strongly recommended the NCDDP to develop a mid-term detailed plan of action for all COO activities, including training on supervisory skills. This plan should state the targets, sub-targets, specify the target audience for each type of course, timetable of activities and sources of funds. The NCODP should review their current strategy of training only two staff at each level, as supervisory visits are integrated and are therefore carried out in each HES, approximately by 10-12 staff and each HEB, by approximately 7-10 staff. It was felt important that the NCOOP should develop and maintain a monitoring system for training activities at central and at provincial levels. As many training courses were delayed, postponed or not conducted owing to unavailability of funds, it is recommended that the NCDDP seek all possible sources of funds for the support of the CDO programme in Viet Nam (in addition to WHO and UNICEF) and that these potential donors be also invited to the annual review and planning meeting in December 1992. Further improvement to monitor the distribution of materials, timely request and release of funds for training need to be done to ensure that all planned training courses can be successfully conducted.

•

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9.4

Team 4

This review examined the three principal communication strategies: training in interpersonal communication skills, orientation of private pharmacists and distribution and use of printed materials. In 1990 and 1991, activities in these three strategies were carried out according to plan. Many activities planned for 1992 have been suspended owing to delays in funding. Despite problems with support from external sources, many training activities have been carried out at district and commune level on the initiative of local staff. Interviews with health personnel responsible for COD at province, district and commune level demonstrate an impressive awareness of the importance of advice-giving as part of their responsibilitit~, and an understanding of the IPC skills learned during training. It was not possible during this review to observe a training course; thus no comments have been made on the quality of the training. However, interviews indicate that the duration of training is often shortened owing to time and budget constraints, and that the health workers tend to focus on technical content (especially ORS preparation) more than on IPC skills. Future training courses should stress these skills, as well as other important home care messages. Taking into account the delay in implementing some of the planned communication activities, the household surveys to assess behaviour change in sentinel provinces have been rescheduled from 1993 to 1995. Exposure to COD messages and materials has shown a substantial increase from 1990 to 1992. Distribution of COO printed materials has for the most part been carried out according to plan, however, some materials are distributed through means other than the national programme, and thus are distributed without training in their use. This will need attention by the national COD secretariat. Orientation of private pharmacists in urban areas appears to be a useful means of disseminating information on correct case management. Given the growing number of drug providers in rural areas it may be important for the programme to investigate how this population can effectively be reached. Recommendations are also made in this report for the integration of IPC with clinical management training, the inclusion of IPC skills in commune-level COO training, and for the integration of COD/I PC with the recently developed national strategy for health education and communication.

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ANNEX 1

List of participants in Phase I, Focused Programme Review II - 15 May, 1992

Prof. Dang Duc Trach,deputy Dire~tor,NIHE, and CDD Programme Manager Dr. Nguyen Anh Dung, CDD Secretariat Dr. Nguyen Van Cuonq, CDD Secretariat Dr. Tran Dai Thanq, CDD Secretariat Dr. Do Gia canh, CDD Secretariate Dr. Nguyen Gia Khanh, Depts Pediatrics, BUMS, Gastroenterology,IPCH Dr. Heleni. Argyrides, Senior Programme Officer, UNICEF, Hanoi Dr. Luula Maziano, Project Officer, UNICEF, Hanoi Dr. Elizabeth Sherwin, Medical Officer, CDD/WHO, Geneva

- 67 ANNEX 2

Participants. terms of refernce. and schedules for review teams for Phase II. Focused Programme Review

Team 1:

Review of strengthening COD teaching in medical schools and review of DTUs associated with medical schools.

Participants: Dr. Nguyen Anh Dung, CDD Secretariat Dr. Nguyen Gia Khanh, Dept Pediatrics, HOKS, Dept Gastroenterology, IPCB Dr. Lief Gothefors, WHO consultant Terms of reference: 1. To evaluate the implementation of the activity to strengthen CDD teaching in medical schools. 2. To assess DTU (and mini DTU) contribution to the training of medical students, and to follow up on other DTO training activities and quality of case managemEmt in DTUs. 3. Make recommendations for improving COD teaching in medical schools, including revision of training materials. Schedule: 21 September - Arrival of Dr. Gothefors. Breifing at NlKE 22 September - Visit medical school, Hanoi 23 September Travel to Hue 24 September - Visit medical school, Hue 25 September - Travel to Ho Chi Minh City 26 September - Visit medical school, Ho Chi Minh City 27 September - Travel to Can Tho 28 September - Visit medical school, Can Tho 29 September - Travel to Ho Chi Minh City 30 September - Travel to Hanoi 1 October - Visit medical school, Bac Thai 2 & 3 October - Analyse results, present findings and recommendations to review teams, prepare plan of action and write report.

Team 2:

Review of strengthening CDD/EPI teaching in paramedical schools.

Participants: Dr. Nguyen Van cuong, COD Secretariat Dr. Ngeyen Phein, Department of Training, MOH Ms. Karin Bergstrom, Technical Officer, EPI/WHO, Geneva Terms of reference: 1. To evaluate the implementation of the activity to strengthen CDD/EPI teaching in paramedical schools. 2. Make recommendations for improving implementation and develop a mid term plan of action.

- 68 -

Annex 2

Team 2 Schedule: 21 September - Breifing at NIRE 22 September - Travel to Nam Ha. Visit paramedical school, Ham Sa 23 September - Travel to Hanoi 24 September - Visit paramedical school, Hanoi 25 September - Travel to Da Nang. Visit paramedical school, Da Hang 26 September - Travel to Ho Chi Minh City 27 September - Part of team travels to Da Lat 28 September - Part of team visits paramedical school, Da Lat - Part of team travels to Vinh Long. Visit paramedical school 29 September - Travel to Ho Chi Minh City 30 September - Travel to Hanoi 1-3 October - Analyse results, present findings and reco~endations to review teams, prepare plan of action and write report.

Team 3:

Review of supervisory skills training and supervisory activites at provincial and district levels.

Participants: Dr. Tran Oai Thang, COD Secretariat Dr. Nguyen Xuan Diem, Department of Virology, NIRE Dr. Seppo Suomela, Medical Officer, COD/WHO, Manila Dr. Elizabeth Sherwin, Medical Officer, COD/WHO, Geneva Terms of refernce: 1. To assess the quality and quantity of supervisory skills training and supervisory activities at provincial and district level. 2. To assess the knowledge of some recent trainees. 3. To review supervisory skills training target and training plan. 4. To make recommendations on activities related to supervisory skills training and supervision. Schedule: 21 September - Briefing at NIRE 22 September - Travel to Nam Ha. Visit provincial Hygiene and Epidemiology Station (lIES) and district Hygiene and Epidemiology Brigade (REB) Travel to Hanoi 23 September 24 September - Visit RES and HEB, Hanoi Province 25 September - Travel to Da Nang. Visit RES and REB, Da Nang Province Travel to Ho Chi Minh City 26 September 27 September - Part of team travels to Da Lat Part of team visits RES and REB, Da Lat Province 28 September - Part of team travels to Vinh Long. Visits BES and BEB 29 September - Travel to Ho Chi Minh City 30 September - Travel to Hanoi 1-3 October - Analyse results, present findings and recommendations to review teams, prepare plan of action and write report.

- 69 -

Annex 2 List of Participants, Team 4 National CDD Secretariat: Dr Do D Canh Ms Pham P Lan Interviewers: Ms My, Dr Hoa, Dr Ha, Dr Luon, Dr Phuong International Resource Persons: Dr N Tunyavanich, Mahidol University (UNICEF) Ms C ~olfheim,

CDD Programme

(~OfUNICEF

Geneva)

Dr E Eng. University of North Carolina (WPRO) (preparation for Phase 2; see trip report July 1992)

- 70 -

Annex 2

LIST OF PROVHiCES

~ISITED

(1)

BniH THUAt-!

(2) (3) ( \"

DAC L";C H';~iOI

)

~••f

( '" ., (I)

HAl HUt,l:] H~ I f'HO:--·!G HO C:1 I ;'1! ~~H LAi'J Dm~G *) LOt~G At~

(6) (10)

tJAI1 ~lGHE

HA Atl

*) ~!Ht'~G

t11) DUAt"G NAt'1 - DA

(12) SONG BE

(:3) THAI BINH (1~)

(1~')

TIEN GI~;'JG 'IINH LO,,;G *)

*1 Provinces visited during the

ictu~l

F?R

- 71 -

ANNEX 3 Checkllst for monitoring of implementation of activities to strengthen the teach!.ng C'f EPIICDD in secondary schools Date: Name of School: Name of Director: Name of COD Teacher: -Nanle eE EP-I-TlnJt!he t"! Name of Inte.rviewer: QUESTIONS FOR TIlE DIRECTOR: 1. Did you receive instructions to start using the new curriculum for CDD/EPI from the Director, Department of Training, MOil 7 '" For assistant physicians: For nursing/midwifery: 2. YES YES iNO NO

Did any teacher from your school participate in the EPI/CDD curriculum workshop 7 YES NO If yes, how many 7

Have the teacher(s) that participated in the workshop.discussed the workshop 7 with you: YES

NO with other teachers (departments): YES

NO 4.

Have you discussed the new curriculum with the teacher(s) in charge of EPI/CDD 7 YES NO Is the teacher that participated in the workshop the teacher responsible for. . ' teaching: COD 7 EPI 7

YES YES

NO NO

Is the teacher in charge of the subject the same teacher that is teaching the subjects 7 For COD: For EPl: COI-U1 ENT S : YES YES _ _ __ NO tlO

- 72 Annex 3 7. Are there any more teachers teaching: If yes, specify how many for EPI and COD, respectively. EPI? YES COD? YES rIO

NO Y or N. Where were they trained?

Have these new teachers been trained? 8.

Problems related to the new CDD/EPI curriculwn:

Recommendations from the director ~ith relation to the new CDD/E?I curriculum:

10.

How many students are there in each class 7

11.

How many students have been taught to use the new curriculum? - assistant doctors - nurse and midwives

----

QUESTIONS FOR TIlE TEACHER: 1. 11 ave you implemented your plan prepared during the

workshop ?

YES NO If yes, please describe: If no, why?

wnen did you s tart us ing the new curriculUIII for EPI/CDD ? COD

EPI - - - - -

- 73 -

Annex 3

What kind of teaching methods did you use/are you using? Before workshop Lecture Student reading Discussion by group Demonstration Return demonstration Supervised field practices Role play Written exercises Slides Films After workshop

How many hours have you spent for the EPI/COO curricul\Ull 7

-----

Assistant doctors Before After Workshop Workshop EPI theory EPI practice

Nurses and Midwives After Before Workshop Workshop

CDO theory COO practice

If the llurnber of tr."chi.lI~ hours does not correspond with the curricul\Ull, explain why:

5. a) Are you collaborating with the Hygiene and Epidemiology Station? YES NO

If yes, describe 1,0101: If no, describe why not. b) Are staff from the station participating in the teaching Ln the school ? YES NO

Have you set up an ORT corner in the school? YES tlO

If no, describe why not.

Annex 3

- 74 '"

II:\V~

.,.nll

1'"rtic:il',Ie-,1 i.1I CI)()/F.l'l ncti·.'itiC'!: i.1I 'iES tID

th~

lucltl comrnullity ?

II".,.c you u!:~d thC' "twJe-nt o1!HI durirlp. the ,"o(\:"hop 10 .,~~r~,; '; F.S

t',!tor~

!'>l!!dr!!t~

,'!:5cssrncnt chccklbt dcvcloped ?

tID If no, describe why not:

Describe the constraints, if any, in implementing the new EPI/CDD curriculum:

10.

Recommendations from teacher:

QUESTIONS RElATED TO THE AVAIlABILITY OF TEACHING/LEARNHIG HATERIALS: (material to be verified by the interviewer)

Are EPI/COO tCilchine;/lcarning materials available in your school? YES NO If yes, which of the following are available: Posters COD treatment chart: EPI target diseases: Sterilization Others, please specify: Number: Number: NWDber:

Slide 5ets EPI target diseases: F.rr col,! ch.,in EPI stcnrn stcrili~cr: Number: tllImhl"r: /lumber:

- 75 Annex 3 2. \.Ihere are the materials kept 1 Library: \.lith teacher: In classroom: Elsewhere: (please specify) 3. Problems found by the teachers:

Recommendations by tile tcacller:

Recommendations by the interviewer:

- 76 -

Annex 3

Treatment of d l.lrri1 n l'.1 :

rrC"'Jf'Ur i on

d i ,., to r hn,>:}·

th "nhl' r: l/"IIIhr r :

Talking with mor:hl'r~ about di:trrhoC':1 F:P[

f1umhr.r:

Immunization in practice 1-8 .1nd facilitator guide Others, please specify Reference material: COD Please specify what is available:

Humber:

EPI Please specify wilat is available:

Demonstration matC'rial: Number Cup Spoon Container for measuring Container for mixing ORS ORS packets Nasogastric tube

Steam sterilizer Vaccine carrier Ice packs Thermometer Cold box Refrigerator 5 ml Syringes: 1-2 ml BCG 18 G Needles: 22-2/' G

26 G Vaccine vials: Polio BCG

DrT !1C'1I~

I ~s

forceps Immunization cards Immunization records Immunization monitor ch.ut

- 77 -

Annex 3

EPI Questions for Students of Paramedical Schools Focused Programme Review, Viet Nam, September 1992

1. List the diseases that can be prevented by immunization.

1_____________________________

2, ______________________________

3______________________________ d __________________________________

5__________________________________ 6~

___________________________

2. What are the fIrst signs of neonatal tetanus?

a. The baby will not suck even at birth. b. At birth. the baby's fists are clenched and the mouth is tightly closed. c. The baby starn having fits the day after birth. d. The baby stops sucking three to five days after birth and will not open his mouth.

3. The vaccine.

OPT. protects against which three diseases?

a. Diphtheria. tetanus. and polio. b. Diphtheria. tetanus. and pertussis. c. Diphtheria. tuberculosis. and pertussis.

How can damaged vaccines be made potent again? a. By putting them in the dark b. By keeping them cold c. By freezing d. By using them before the date indicated on the vial

e. Damaged vaccines cannot be made potent again

Annex 3 5"

- 78 -

Indicate which of the EFI vaccines listed below are damaged if frozen. a. Polio and measles vaccines b. DPT and IT vaccines c. Polio and IT vaccines d. Measles and IT vaccines

e. DPT and BCG vaccines

The maximum temperature at which any EPI vaccines may be safely stored is:

a. +6"C

b. tS·C c. +lO·C

d. +12·C

7 " Tae

shake test:

a. Is used to thoroughly mix reconsticuted BeG and measles vaccine b. Will reactivate vaccine that has passed the expiration date by less than one week c. Will indicate if DPT or IT has been frozen d. Will reactivate DPT and IT that has been frozen

8" Equipmen~

that is sterile:

a. Has never been used b. rs free from all micro-organisms c. Has been immersed in boiling water d. Has been cleaned with soap and water e. Has been soaked in alcohol

A sterile syringe and sterile needle should be used: a. For two children b. For two children if the needle is changed c. Uncil all the vaccine drawn into the syringe is finished" d. For all the vaccines for one chilq.n"iy /..or woman only

e. For one injection for one childlOnly I or woman only

- 79 10.

Annex 3

Temba has been brought by her mother to the immunization session for the first time. Temba is two months old and she has not yet received any vaccines. Which vaccines will you give Temba at this first visit? a. Measles. DPT. and OPV b. DPT. OPV. and BeG c. BeG d. DPT andOPV e. Measles and DPT

•

11.

What are the minimum and maximum intervals between doses of DPT? a. Minimum four weeks. maximum four months b. Minimum one month. maximum six months c. Minimum four weeks. no maximum limit'

d. Minimum six weeks. maximum one year e. There are no minimum or maximum limits

12.

What is the immunization schedule for IT? . Indicate the minimum interval between doses.

l3. DPT vaccine should be given to a two-month-old baby:

a. Intramuscularly in the upper thigh b. Intramuscularly in the upper arm c. Subcutaneously in the upper thigh

d. Subcutaneously in the upper arm

14.

What is the correct dose tor measles vaCCIne. a. 0.05 ml

b. 0.5 ml c. 1.0 ml d. 5.0 ml

- 80 -

Annex 3 15. What side effectS should you tell a mother about when giving DPT immunization?

16.

Following a BeG injection, you will advise a mother to:

a. Leave the site open or covered. with a dry dressing only b Clean the site regularly with soap and water c. Use antiseptic cream on the site

d.. Clean the site daily with alcohol

.17. 'How do you keep vaccines cold at an immunization session?

Vaccines (liat you are using

Unopened vaccines

18.

ifo protect reconstituted vaccine. you must:

a. Cover the vial or ampoule with foil b. Stand it'in a cup of ice or on an ice pack c. Keep it in the vaccine carrier

d.. Do both "a" and "bOO

19.

f'l'urse Nguyen is holding an immunization session at the health centre. When the mothers began to arrive she took one vial of each vaccine from the refrigerator and placed them on the immunization table in a cup of ice cubes. As she took the measles vaccine from the top shelf she noticed that the vial was touching the evaporation plate and was very cold; she was sure the vaccine was frozen. Nurse Nguyen was worried that the frozen vaccine would not mix properly with the diluent also cold from the refrigerator. So she decided to warm the diluent first by holding it in her hands. If she mixed warm diluent with frozen vaccine, then she was sure the temperature would be about right. What did nurse Nguyen do wrong?

- 81 Annex 3 20. . N gamba is ten weeks old. His mothe r has brought him to the immunization clinic for the

first time. She tells you that Ngamb a received his BeG injection at the mater nity establ ishme nt where he was born (there is a small scar on his upper left ann), and that she has come for the next injection. While talking to the mother. you notice that Ngamba has a runny nose and a cough. What do you decide to give Ngamba on his first visit? a. OPY, DPT. and measles in case his runny cose is the [lIst siin of measle s infection b. DPT. but not OPY because OPY is a live vaccine and lie may have a severe reaction when ill c. Nothin g, because children react severely to any vaccine when they are ill d. oPV and DPT. telling Ngamba's mother to bring him back in four weeks time e. Nothing~ because vaccine will not "take" when a child is ill

Annex 3

- 82 -

CDn Questions for Students of Paramedical Schools Focused Programme Review, Viet Nam, September 1992

PART A. Case studies 1.

Nguyen is 3 months old and weighs 4kg. He has had diarrhoea since yesterday. Today he has had six very watery stools, but no blood in the stool: When you examine Nguyen he is irritabl.£:, the eyes and the fontanelle are a little sunken, and the skin pinch goes back slowly. He drinks eagerly. a. b. c. boes this child have no, some or severe dehydration? What treatment plan (A, B or C) would you use for this child? Would you start giving this child ORS at the health ..facility or send him home with a packet of ORS?

If yes, you would treat at the health facility,: how much ORS would you give this child in the first 4-6 hours? 2. Tran is 3 years old and weighs 13 kg. Her diarrhoea started last night and she has had 3 loose stools. You assess the child and find that she looks quite well. Her mouth is wet, her skin pinch normal. Her eyes are not sunken, and her pulse and breathing are normal. However, the mother says the child is thirsty. a. b. Does this child have no, some or severe dehydration? What treatment plan (A, B or C) would you use for this child? Would you start giving this child ORS at the health facility or send her home with a packet of ORS?

If yes, you would treat at the health facility, how much ORS would you give this child in the first 4-6 hours?

... j

- 83 -

Annex 3 3. Ali is 8 months old and weighs 6kg. He has been weaned. His mother brings him to you because he has had diarrhoea for 10 days, with more than 10 stools in the last 24 hours. He has passed no urine since last night. On examination he appears very quiet and floppy. He is febrile. His eyes are very sunken and when he cries there are no tears. His pulse is rapid and weak.

a. b.

Does this child have no, some or severe dehydration? What treatment plan CA, B or C) would you use for this child?

What would be your first step in treating this child? Treat with intravenous fluids or with ORS? '¥by?

If you choose intravenous fluids, how much fluid would you give in the first 3 hours? If you choose ORS, how much ORS would you give in the first 4-6 hours?

- - -mls - - -mls

Lati is 18 months old and weighs lOkg. Her mother brings her to you because she has had 3 bloody stools. On examination, Lati looks well and happy. She is not dehydrated. Which of the following treatment plans would be most appropriate? A. 0 RS, metronidazole, return if no improvement. Home fluids or ORS, trimethoprim-sulftamethoxazole, and return in 2 days. ORS, tetracycline and admit as inpatient.

(enter letter)

When a child has diarrhoea what should you advise the mother about treatment of diarrhoea in the home (i.e., the three rules of home treatment) 1.

2. 3.

· Annex 3

- 84 -

.·;6:-

What are tl:1e most effective \Olays to prevent diarrhoea.£. 1.t... r)

3. 4. 5. 6. 7.

PART B (This page is for interviewer only)

j:ach.student, .depending_on..the..time available,-should be ·askedto-prepare-ORSand the foUowing should be completed by the interviewer. . .. . .

Was the powder completely dissolved?

Yes .or No

Was all of the packet content used?

Yes or No

Record the amount of water used

---mls

Was the solution prepared correctly? (note for solution to be prepared correctly the answers to 1 and 2 above must be ·Yes" and the amount of water used should be between 950.1200mls)

- 85 -

ANNEX 4

Figure 1:

Results from the CDD students questionaire from 12 schools. (Team 2: Review of CDD/EPI teaching in paramedical schools) Number of Number of Number of right answers wrong answers no answers Percentage right answers 96.2 97.5 98.3 88.2 87.3 97.0 93.3 100.0 99.6 96.6 29.8 69.7 95.4 96.6 91.6 90.0 90.3

Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question

1a 1b 1c 1d

2a 2b 2c 3a 3b 3c 3d 4 5.1 5.2 5.3 6.1 6.2 6.3 6.4 6.5 6.6 6.7

229 232 234 210 20.7 231 222 238 237 230 71 166 228 230 220 214 215 177

9 6

4 22 30 3

o o o 6 1

o 1 8

5 4

167

68 10 8 18 24 23 61 50 78 42 36

o o o o o o 4

188 160 196 202

o o o o o o o o

74.4 79.0 67.2 82.3. 84.9

Note: Question 5 and 6 does not indicate how many students gave all the right answers, but only how many answered right on each item.

Annex 4

- 86 -

Figure 2:

Results from the EPI students questionaire from 11 schools (Team 2: Review of CDD/EPI teaching in para.edical schools) Number of Number of Number of wrong answers no answers right answers Percentage right ansWers 98.2 87.6 93.6 90.1 89.0 81.6 55.5 87.1 94.0 64.2 58.2 66.5 58.7 92.2 93.6 82.1 '84.4 40.4 48.2 83.0

Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question Question

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

214 191 204 197 89 178 121 190 205 140 127 145 128 201 204 179 184 88 105 181

4 26 11 14 11 30 77

1 3 7 0 10 20 1 0 8 5 8 4 11 6 7 12 8 15 6

27 13 74 86 65 86 6 8 32 22 122 92 31

- 87 -

ANNEX 5

Some

da~a

on Medical

sc~ools

ang teaching

hosgit~l§

(Team 2:

Review of GDD teaching in Medical Schools) HANOI HUE

HCMC

CAN T

BAC T

THAI B ol'-

student (3) exam 1991 Fulltime faculty in Dpt of Paed Inpat beds Tot adm/yr OPO vis/yr Adm DD/yr Visits DD per year (1)

377(2) 374

320

120

220

130

27 400 10300 52000 1860

17 150 6000 12000 520

18 650 40000 15(1000 2700

13 170 7300 40000 1100

14 100 3600 36000 500(4)

8 60 2700 5700 700

2800

800

14000

1400

630

920

Hosp visits DO per day: peak season 15-20 5 low season

6 1

25-50 20-25

40-60 10-20

15 0-2

10 2-3

(1) including admitted patients (2) includes 240 -generalists- and 50 who in their 5th and 6th years subspecialize in paediatric. (3) excludes the parallell training of students who after examination as assistant doctor. and > 5 years practice have another 3 years of medical education. In HCMC - 250/year, in Bac Thai SO/year (4) many admitted only because of long way home, i.e. a majority of them are plan A cases only.

- 88 -

Annex 5 Date of review ______________

CHECKLIST FOR REVIEW OF CDD TEACHING IN MEDICAL SCHOOLS

1. Medical school

Name of medical school Location of school

Type of school

Government

Private

Number of years of medical education Number of students graduated last year

2. Hospital Director I Suuerintendent Has he been well informed about the effort to strengthen the teaching of medical students about diarrhoeal diseases?

* *

by teaching staff in the Department of. Faedia.trics YES by national authorities YES

NO NO

Does he consider this a priority activity for administrative support by the hospital? YES NO If no, explain:

What barriers, if any, make it difficult to establish a DTU in the hospital? Describe them.

What barriers, if any, make it difficult to provide optimal treatment for patients with diarrhoea in the hospital? Describe them.

- 89 -

Annex 5 3. Department of Paediatrics Name of Department Head: Number of teaching staff: Full-time Part-time

Number of inpatient paediatric beds: Number of paediatric admissions per year: Number of paediatric outpatient visits per year: Number of paediatric visits each year for diarrhoea: Number of paediatric admissions each year for diarrhoea: Peak season for diarrhoea (name ~nths):

Hospital visits for diarrhoea per day during peak season (range): Hospital visits for diarrhoea per day during non-peak season (range):

------

Faculty / hospital doctors who have attended eDD training courses away from the school: Name Course* ____________ Year _______

Other staff. such as nurses. who have attended eDD training courses away from the school: _______________________________ Course* ____________ Year __ ~

___

* Indicate type of course: DTU (DTU). Clinical Management (GMT). or Medical Education Workshop (MedEd)

- 90 -

Annex 5 4. Student assignment to Paediatrics Hours/day No of students

If students assfgned to Paediatrics are divided into subgroups, indicate for each year: Number in subgroup Ueeks in Outpatient Department ',leeks in Emergency Service ',leeks in Inpatient Service

If students are assigned to a DIU or ORT Unit, indicate: Year: Duration (days): HourS/day:

In addition to the DIU/ORT Unit, where do students manage patients with diarrhoea:

Infants and children with diarrhoea Number of hospital visits each year: Number of hospital admissions each year: Peak season for diarrhoea (name months): Hospital visits for diarrhoea per day (peak season): Hospital visits for diarrhoea per day (non-peak season):

- 91 Annex 5

Organization': Reception area ,ORT area Inpatient area Hours of operation: YES NO

YES NO space for how many patients YES NO _____ ,hours a day NO YES NO

_____ days a week YES

Supplies: Regular supply of ORS?

Other supplies available? Explain:

Food provided for: DTU outpatients on Plan B? DTU inpatients? YES YES NO NO

With regard to the work plan developed at the Medical Education Workshop: What has been done to establish or strengthen the DTU?

What objectives have not been achieved?

Explain why.

Comment on observed quality of patient care in the DTU; for example, assessment of hydration status, use of ORS solution and IV fluids, teaching of mothers, evaluation and management of dysentery and persistent diarrhoea, appropriate use of drugs and antibiotics.

- 92 Annex 5 6. Teaching materials and eguiument Readings on Diarrhoea: available t~

students?

YES

If YES', describe how the book is obtained and distributed:

Instructor Manual: how many copies with faculty? Guide to Student Evaluation: how many copies with teaching staff? References on Diarrhoea: how many copies in the library? Teachers have sets of CDD teaching slides? YES NO

Diarrhoea management charts available for 'teaching and in DTU? l YES NO _____ Year when printed Language Slide projector available and working? YES YES NO NO NO

Overheac. proj ector available and working? Video player available and working? YES

Access to working duplicating machine or photocopier? YES NO ~ith

regard to the work plan developed at the Medical Education What teaching materials and equipment have been obtained?

~orkshop:

What teaching materials and equipment have not yet been obtained? Why?

- 93 -

Annex 5 7. Teaching methods What used used than methods for teaching students about diarrhoeal diseases vere before the workshop on Medical Education? Yhat ones are being now? Which ones are used with small groups of students (less 20)? Before Lecture Readings Video Discussion Written exercises Case studies Drills Demonstration Role play Supervised clinical practice Case presentations Clinical rounds Are there teaching methods the teaching staff would like to use, but have not? Which ones? Why have they not been used? Now Small groyp

Are there teaching methods the teaching staff have tried but not continued? Which ones? Why were they not continued?

What new teaching methods have the teaching staff considered to be most effective? Why?

Annex 5

- 94 -

Content of teaching about diarrhoeal diseases lJhich of the following topics about diarrhoeal diseases were taught by the Department of Paediatrics before the Workshop on Medical Education? Yhich are taught now? Before Epidemiology and etiology of diarrhoea Pathophysiology of watery diarrhoea: dehydration and rehydration Assessmant of the diarrhoea patient Treatment of diarrhoea at home Treatment of dehydrated patients Management of dysentery, persistent diarrhoea and diarrhoea associated with other illnesses Diarrhoea and nutri-tion Prevention of diarrhoea Does the information taught on these topics follow the content of the student manual Readings on Diarrhoea? If not, why not? Now

Are students taught how to use the GOD chart: Management of the Patient with Diarrhoea. YES NO Do students practice using the chart when managing patients with diarrhoea? YES NO

Teaching in the DTU or ORT Unit Are all students scheduled for clinical practice in the DTU or ORT Unit? YES NO If not, why not?

On average, how many diarrhoea patients does each student practise managing? What percent of students would manage none?

- 95 -

Annex 5

In addition to the DTU/ORT Unit, where do students manage patients with diarrhoea? ___________________________

Briefly describe the schedule for student work in the nTU or ORT Unit: No. of Hours per sessions session Activitv*

for example: introduction to DTU, learn patient assessment, clinical practice

Does student teaching in the DTU have defined objectives? YES NO If yes, which of the following skills are included?

Assessing for dehydration Assessing for dysentery, persistent diarrhoea, severe malnutrition Selecting the correct treatment plan

Determining the amount of ORS solution for rehydration Giving ORS solution Teaching a mother to give ORS solution Determining the amount of IV fluid for rehydration Giving IV therapy Giving NG therapy Treating dysentery and persistent diarrhoea Obtaining a feeding history Teaching a mother to treat diarrhoea at home

- 96 -

Annex 5

Is a clinical skills checklist used by students and teachers in the DTU? YES NO If not, why not?

Is a case record form used by students to record information on patients with diarrhoea? YES NO If not, why not?

Who provides supervision for students working in the DTU? Faculty Other doctors Nurses Other staff Is a teacher or other supervisor present at all times when students work in the DTU? YES NO If not, could one be? YES NO 10. Teaching about diarrhoeal diseases in other departments Have steps been taken to coordinate teaching about diarrhoeal diseases with other departments? YES NO If yes, describe them briefly.

11.

Evaluation of students Following the Workshop on Medical Education, have any changes been made in the ways in which students are evaluated for knowledge and skills concerning diarrhoeal diseases? YES ____ NO ____ If yes, describe them briefly.

- 97 -

Annex 5

12.

Training of faculty and staff Have seminars or similar meetings been held with faculty members or staff to summarize the content of the Yorks hop on Medical Education? YES NO ____ If yes, briefly describe, indicating the number of meetings, their length, who attended, and the topic covered. If not, explain why.

Have courses been held at the school to train faculty members or staff in COD case management and teaching methods? YES ____ NO ____ If yes, describe. (an example is shown below) Participants Number 4

Duration hours/davs 3 days

Clinical practice? yes

Training materials Diarrhoea Management Course

1991

Paediatrics faculty

Mark with an (*) any courses in which an external facilitator assisted. If no training courses were held, explain why.

13.

Summary and Recommendations

- 98 -

Annex

SummarY and Recommendations (continued)

- 99 -

ANNEX 6.

. QUESTIONNAIRE FOR REVIE"7 OF SUPERVISORY SKILLS TRAINING AND SUPERVISORY ACTIVITIES AT PROVINCIAL LEVEL

CDD FOCUSED PROGRAMME REVIEW .. VIET NAM (SEPTEMBER 1992)

I·

Annex 6

- 100 -

Questionnaire for Provincial Station of Hygien~ and Epidemiology (RES) ~RVffiWER

____________

DA1E

-------

PROVINCE

PERSON IN1ERVIEWED _ _ _ _ __

Year CDD programme started in province _ _ _ __ CDD districts/total districts: ~ ___ CDD communes/total communes: ~_._ _

How many staff from this RES have participated in supervisory skills training (SS)?

What percentage of all staff in this RES have been trained in S5 When and where were they trained and how long was the course?

r-=-

Year . Place Length of course

Trained

How. many of those trained are now working in supervisory activities

Number • Per cent

DoSS the staff feel that this training prepared the'm to do supervision? Why or why not?

Yes or No

How many supervisory skills course did this RES organize? (Surveyor to fill in details of courses) No of courses Year Number of participants Type of participant

Length of course

- 101 -'

Annex 6

Did you use course materials provided by the National Programme. What materials were used?

Yes of No

Did the course agenda inchide the {ollowing? What proportion of course time was spent on each of the following . ~

(a) (b) (e)

Lectures Practical sessions with patients Exercises and role plays

YesorNoL%) ,I

Yes or No ( Yes or No ( ,

--%)

(Interviewer should obtain a copy 9f the course agenda and any other training documents of interest)

How would you improve supervisory skills training in your province?

r~sponsible for supervising

What types of facilities and how many facilities, is the liES ' . . Type Number

. , "

How often do the staff from the HES go out on supervisory visits? (number month) How long do they 'stay at each site (hours)

- 102 -

Annex 6

10.

What do the staff do during these sup'ervisory visits? (Ask as open-ended question, and reco.rd answers given, prompt if no response). Tick if answer includes:

Observation of diarrhoea case management Observation of patient care in general Assessment of stock supply (drugs; ORS, etc) Review of recprds Budget and administration Personnel issues/health worker performance Discussion of problem areas Other (specify)

11.

Does the staff use a checklist during these 'supervisory visits? If yes, do they find it helpfuL' How could it be improved?

Yes or No

12.

Do you receive supervision from the national level) If yes, how often (number of times per year)

Yes or No

Do you find these v;sits useful? Why or why, not?

Yes or No

- 103 -

Annex 6

13.

What are the majo.r problems that the staff of the RES have.encountered in doing supervision? (Ask as an open-ended question and record answer given. If no response, prompt). Tick if answer includes:·

Lack of funds/delayed funds Lack of transport Supervision not con'Sidered priority Staff not motivated Lack of time Lack of training and skills in supervision . Not a useful way to spend time Other (specify)

14.

How would you improve the supervisory system in your province?

·15.

What are the main problems related to the CDD programme that have been encountered during supervisory visits?

- 104 -

. Annex 6

QUESTIONNAIRE FOR REVIEW OF SUPERVISORY SKILLS TRAINING AND SUPERVISORY ACTIVITIES AT DISTRICT LEVEL

CDD FOCUSED PROGRAMME REVIEW VIET NAM (SEPTEMBER 1992)

- 105 -

Annex 6 Questionnaire for District level

nnERVffiWER ______________

DATE

---:-------

""YSTRICT

PERSON ·INTERVIEWED

-------

Year CDD programme started in district _ _ _ _ __ CDD communes/total communes'

--.1___

How many 'staff from this district have participated in supervisory skills training (SS)?

What percentage of all st.lff in this district have been trained in SS Whenand·where were they trained and how long was the course? Trained. .

Year

Place

Length of course

How many of those trained are now working in supervisory activities

. Number Percent

. Does the staffJeel that this training prepared them to do supervision? Why·or why not?

. Yes or No

How many supervisory skills courses did tn-is. district . organize? (Surveyor to fill in details of courses) No. of courses Year Number of participants Type of participant Length of course

•

• ,

- 106 -

Annex 6

Did you use course materials provided oy the National Programme. What materials were used?

Yes of No

. Did the course agenda include the following? What proportion of course time was spent 00 each of the following . (a) (b) (c) Lectures Practical sessions with patients Exercises and role plays YesorNoL%) YesorNoL%) Yes or No

C_o_%)

(Interviewer should obtain a copy of the course agenda and any other training documents of interest) . 0 •

How would you improve supervisory skills training in your district?

What types of facilities and how many facilities, is the district responsible for supervising Type Number .0

107

Annex 6 9. How often do "the staff from the district go out on supervisory visits? (number/month) How long do they stay at each site (hours) 10. Wliat do the staff do during these supervisory visits?(Ask as-open ended question. and record answers given. prompt if no response). Tick if answer includes:

Observation of diarrhoea case management Observation of patient care in general Assessment of stock supply (drugs. ORS, etc) Review of records Budget and administration Personnel issues/health worker performance Discussion of problem areas" t

Other (specify)

11.

Does the"staff use a checklist during these supervisory visits? If yes, do they fmd it helpful How could it be improved?

Yes or No

12.

Do you receive supervision from the provincial-level) If yes, how.often (number of times per year)

Yes or No

Do you fmd these visits useful? Why or why not?

Yes or No

- i08 Annex 6

13.

Wllat are the. major problems that the sT"rf of the district have encountered in doing supervision? (Ask as an open-ended question and record answers given. If no response, prompt). Tick if answer includes:

Lack offundsjdelayed funds Lack of transport .

Supervision not considered priority Staff not motivated Lack of time Lack of training and skills in supervision Not a useful way to spend time Other (specify)

14.

How would you improve the supervisory system in your district?

15.

What are the main problems related to the COO programme that have been encou~tered during supervisory visits?

- 109 -

Annex 6

QUESTIONNAIRE FOR COMMUNE LEVEL

-------------------------------- Date Commune ---------------------------- Person interviewed----------Year CDD programme started in commune 19 1.

Interviewer

~--------------

How many staff from this commune have participated in a CDD training course

----

----% When and where were they trained and how long was the course -------+l Trained ,

Year

Place

Length of course .

How many of those trained are now working for the COD Programme

----%' 3. 4. Does the staff feel that this training help them to work for the CDD Progra_e? Why or why not? [ ] YES [ ] NO

Uyes, number/year

Does the staff from the district go to the commune on supervisory visits? / _________

[ ] YES [ ]NO Do you find this visit useful? Whyorwhynot?_____________________________________________________

What are the main problems related to the CDD programme in the commune? Solutions for these problems? _________________________________

- 111 ANNEX 7

RESULTS FROM INTERVIEWS AT PROVINCIAL LEVEL 15 provinces visited coo coverage for districts 165/169 (97%) - ,13/15 provinces have 100% coverage ./'" COO coverage for commune level 3084/3426 (90%) - 8/15 provinces have 100% coverage Number of staff trained at provincial level with 5S: 3 provinces with 1 trained 6 provinces with 3 trained 1 province with 4 trained 1 province with 5 trained 1 province with 8 train~d 2 provinces with 10 trained 1 province with 13 trained Average number of staff trained per province is 4.5 Average percent of staff in provincial HES trained in SS is 11% Number 4 1 4 6 of trained staff still working in supervison: provinces have 33% of staff still working at site province has 40% of staff still working at site provinces have between 66% of staff still working provinces have 100% of staff still working

Length of SS course attended by provincial level staff - half of the courses were 5 or 6 days and half were 7 to 10 days. Reasons why staff felt course prepared them forthe1r work: 10/15 reported that it helped them make a plan 11/15 reported that they learned evaluation skills 5/15 reported that they learned case management skills Supervisory skills courses conducted at provincial level for district level staff: 8/15 provinces had conducted one SS course. In addition the provinces had conducted 7 other courses but these were 2-day courses on treatment and prevention.

- 112 -

Annex 7

Number of participants in courses averaged 31. 1 course had 21 participants (30 being the minimum suggested by NCDDP), 5 courses had around 30 participants and 1 course ha~ 40 participants. For the 8 SS courses conducted 6 of them were 5 days, one cOUrse was 6 days and one course was 7 days. For the 8 5S courses conducted the mix of methodolgies used was as follows: 10% lecture, 15% practical,74% exercises and role play The NCDDP recommendations are 0%, 10% and 90% respectively. In contrast for the 7 courses on treatment and prevention the mix of methodologies was as follows: 56% lecture 5% practical 38% exercises and role play When asked how they would improve supervisory skills training 8/15 provinces answered that they would make a training plan. There were no other common answers. supervision: Provinces are responsible for supervising district HEBs (average 11, range 7 -18), provincial hospitals (1-2) and district hospitals (average 8, range 1-17) Number of supervisory visits made per year by provincial level: 4 provinces make 2 visits per year 6 provinces make 4 visits per year 1 province makes 6 visits per year 4 provinces make 12 visits per year Length of stay during supervisory visit: 3 provinces stay 1-2 hours 5 provinces stay 3-4 hours 6 provinces stay 6 hours 1 provinces didn't respond Activities done during supervision: Observe diarrhoea case management - 14/15 (93%) Observe patient care in general - 8/15 (53%) Assess ORS and other stock - 13/15 (86%) Review records - 15/15 (100%)

- 113 -

!Annex ·7

Deal with budget and administration - 5/15 (33%) Personnel issues - 10/15 (67%) Discuss problems - 11/15 (70%) Check ORT corners* - 7/15 (47%) Discuss home case management with mothers* - 5/15 (33%) supervise other programmes* - 3/15 (20%) * unprompted response, othere mayor may not have been prompted. Provincial level used a checklist in 12/15 provinces. 5/15 thought checklist was too long. 11?15 reported shortages of checklists. 8/15 provinces received supervisory visits from the national provinces). The reasons the provinces gave for why this visit was useful were as follows: I 3 provinces reported that it helped correct their mistakes 3 provinces reported that they learned about COD planning 2 provinces reported that they learned new information level once a year (6 provi.Aces) and. J:~ice

a year (2

Problems encountered during supervision: Lack of funds/delayed funds - 13/15 provinces (86%) Lack of transport - 11/15 (70%) supervision not considered a priority- 3/15 (20%) Staff not motivated - 5/15 (33%) Lack of time - 2/15 913%) Lack of training and skills in supervision - 6/15 (40%) Staff absent when visit made* - 5/15 (33%) COD staff not trained or no COD staff appointed* - 4/15(26%) * unprompted suggestions for improving supervision: Train more people in SS - 8/15 More training materials - 2/15 Need more reporting forms and checklists - 2/15

- 114 -

Annex 7

COO problems encountered during supervision: High COO staff turnover - 6/15 Not enough ORS - 5/15 Funds inadequate - 4/15 COO staff not trained - 3/15

~-.,~

- 115 -

Annex

RESULTS FROM INTERVIEWS AT DISTRICT LEVEL Staff from 71 districts interviewed CDD coverage for communes (in those districts interviewed 1445/1501 (96%) - 58/71 districts have 100\ coverage Number of districts with 12 districts with 1 29 districts with 2 2 districts with 3 staff trained in 55 trained trained trained

= 43/71

(61%)

Average number of staff in district HEB trained in 55 is 1. In those districts where staff have been trained in 55 the percent of trained staff still working !in supervison: 3 districts have 0% of staff still working 1 district has 33% of staff still working 13 districts have 50% of staff still working 26 districts have 100% of staff still working (26/43 = 60%) Length of S5 course attended by district level staff; 35/43 (81%) districts attended a 5 or 6-day course 8/43 (19%) districts attended a 7-day course. Reasons why staff felt CDD courses (not necessarily just 5S courses) prepared them for their work: Learned supervisory and management skills - 37/71 (52%) Helped them prepare a plan - 28/71 (39%) Learned case management - 25/71 (35%) Provided them with evaluation skills - 15/71 (21%) Learned about prevention - 15/71 (21%) Learned communications skills - 13/71 (18%) Courses conducted at district level for commune level staff: Number of courses conducted: 17/71 (24%) districts had conducted no courses 54/71 (76%) of districts had conducted at least one course as follows: 27/71 (38%) districts had conducted 1 course 20/71 (28%) districts had conducted 2 courses

- 116 -

Annex 7

6/71 (8%) of districts had conducted 3 courses 1/71 (1%) districts had conducted 4 courses., Total number of courses = 89. 4 of these courses were shortened 55 courses while the majority of the remaining (90%) were courses on treatment and prevention~sometimes including communication and record-keeping. Number of participants in courses: 34 courses had less than 30 participants 14 courses had around 30 participants 18 courses had 40 - 60 participants 11 courses had more than 60 for 2 courses the number of participants was unknown. Length of courses: 62/89 (70%) courses 1 day or less 2/89 (2%) courses 1.5 days 15/89 (17%) courses 2 days 10/89 (11%) courses 3 days For the 89 courses follows: 67% lecture 8% practical 25% exercises 36/89 (40%) of the 17/89 (19%) of the conducted the mix of methodolgies used was as

and role play courses were 100% lecture courses had some practical sessions improve supervisory skills training: they would make a training plan would train more people in 55 would try to evaluate their program needed more training materials

When asked how they would 24/71 (13%) answered that 9/71 (13%) said they 8/71 (11%) said they 8/71 (11%) said they

Supervision: Number of supervisory visits made per year by district level: 3/70 (4%) districts supervise 1 time per year

- 117 -

Anaex 7

4/70 (6%) districts supervise 2 6/70 (8t) districts supervise 3 27/70 (38t) districts supervise 12/70 (17%) districts supervise 18/70 (25%) districts supervise 1 district did.pot respond

times per year times per year 4 times per year 5 -ll"times per year 12 times per year

Length of stay during supervisory visit: 18/70 (26%) districts stay 1-2 hours 37/70 (53%) districts stay 3-4 hours 11/70 (16%) districts stay 6 hours 4/70 (6%) districts stay more than 6 hours 1 district did not respond

Activities done during superv~s~on: Observe diarrhoea case management - 68/71 (96%) Observe patient care in general - 19/11 (27%) Assess ORS and other stock - 65/71 (92%) Review records - 70/71 (91%) Deal with budget and administration - 4/71 (6%) Personnel issues - 17/71 (24%) Discuss problems - 49/71 (69%) Check ORT corners - 21/71 (30%) Discuss home case management with mothers - 19/71 (27%) Discuss communication skills - 15/71 (21%) District level used a checklist in 40/71 (56%) of districts. All districts had received supervisory visits from a higher level. The number of visits that they had in a year were as follows: 8/70 (8%) districts received 1 visit 23/70 (32%) districts recieved 2 visits 8/70 (11%) districts received 3 visits 23/70 (32%) districts received 4 visits 2/70 (3%) districts received 5 -11 visits 2/70 (3%) districts received 12 visits 1 district did not respond

- 118 -

Annex 7

The reasons the districts gave for why these visits were useful were as follows: 19/71 (27%) reported that it helped correct their mistakes 17/71 (24%) reported that they learne~ new information 13/71 (li%) reported that it made them aware of COO plan 13/71 (18%) the supervisors checked their reports 12/11 (17%) reported that the visits encourage and motivate them Problems encountered during supervision: Lack of funds/delayed funds - 55/71 (78%) Lack of transport - 49/71 (69%) supervision not considered a priority - 14/71 (20%) Staff not motivated - 29/71 (41%) Lack of time - 13/71 (18%) . Lack of training and skills in supervision - 33/71 (47%) Staff absent when visit made - 9/71 (13%) COO staff not trained or no COD staff appointed - 9/71 (13%) Geographical area for supervision is too big - 16/71 (23%) suggestions for improving supervision: Train more people in SS - 20/71 (28%) More frequent supervision - 12/71 (17%) Need more funds for supervision - 10/71 (14%) Need to make a supervisory skills training plan - 9/71 (13%) Need more reporting forms and checklists - 7/71 (10%) COD problems encountered during supervision: FUnds inadequate - 27/71 (38%) High COD staff turnover - 18/71 (25%) Not enough ORS - 19/71 (27%) COD staff not trained or no COD staff - 12/71 (18%) Communication skills of staff are poor - 12/71 (18%)

- 119 -

Annex 7

RESULTS FROM THE COMMUNE LEVEL INTERVIEWS

(1)

PROGRAMME ESTABLISHMENT

The earliest year mentioned for programme establishment was 1979. the national eDD programme started in 1982, these have been presumably pilot communes.

Otherwise the programme has been implemented stepwise and

gradually expanded to cover nearly 85% of communes in 1992. (2) enn TRAINING IN THE COMMUNES

The training at commune level has mainly targeted in two programme aspects, namely treatment and prevention of diarrhoeal diseases. The

training has been called ·programme management" training, and the material recommended by the NCOOP is the Vietnamese translation of the WHO con publication "Treatment and Prevention of Diarrhoeal Diseases; Practical Guidelines". However, recent training courses in 1992 have used the two

enD Supervisory Skills modules "Management of the patient with diarrhoea and ·Prevention". In the 15 provinces visited, an average of 2.5 health workers were trained in each commune. Nineteen percent of the communes had one person persons. 8% had four persons

trained, 55% ha.d two persons, 15% had three

and 4% had five or more staff trained at commune level on CDD. It is the plan of the NCOOP that each commune should have at least two persons trained on COD (chief of the CHS and the person responsible

- 120 -

Annex 7

for CDD).

In 15 provinces visited about 59% of the communes had this

target achieved. A great majority of the training of commune level was carried out at the district level. However, t~

some cases provinces trained

simultaneously staff from both district brigades and Commune Health Centres. Length of the training varied from one day to four days. However, in

majority of cases the training lasted from one to two days. High staff turnover has been considered as a problem also at the commune level. If looking for the numbers of staff trained on CDD and

still working with the programme at commune level, it is noted that 57% of the communes had only one trained staff member working at time of the interview with CDD responsibilities, 24% had two, 9% had three, 5% had four and 4% had five or more staff members trained and still working in the commune on CDD. The great majority (99%) considered that the training helped them to work Yhen the staff interviewed were asked to specify

for the CDD programme.

how the training was found useful, the following comments were made: "64% felt that the training helped them to better treat patients, 33% said it improved their knowledge on preventive interventions, 31% said the training improved their programme management and implementation skills in general and 26% m,entioned that the training increased their skills on communication with ~are-takers

Nineteen percent said their skills on ORS

use were improved and 15% mentioned their improved skills in writing reports."

- 121 Annex 7

(3)

SUPERVISION

The staff in the commune health stations are supervise6 by the COO staff from the district brigades. According to the questionnaires the frequency of the visits is as follows:

* * * * * * *

1 visit/year

4% of communes 4% of communes 3% of communes 32% of communes 14% of communes 35% of communes 7% of communes q~estion

2 visits/year 3 visits/year 4 visits/year 5-11 visits/year 12 visits/year

> 12 visits/year

All those (73/75) who responded to the

"Do you find the

visit useful" said they find the visits useful. When the staff was asked to specify, why they find (or don't find) the visit useful the following reasons were most co_only given:

* * * *

Helps on solving problems and correcting mistakes (25/75; 33%) Staff advices/teaches on record keeping (17/75; 23%) Receive information on CDD programme activities, development etc. (15/75; 20%) Staff·help/advice on preparing reports (15/75; 20%) Supervisors encourage staff to work on COD activities (14/75; 19%) advice on communication skills (8/75; 11%)

* Supervises

- 122 -

Annex 7

(4)

PROBLEMS RELATED TO eDD PROGRAMME

The commune staff interviewed were asked to mention problems related to the eDD programme in the commune. The following responses were given:

Lack of (inadequate) communication skills of health workers (24/75; 32%)

* Lack * Lack * Lack

of funds (20/75: 27%) of ORS at commune level (13/75; 17%) of posters and other health education materials (12/75; 16%) ORS use rates (11/75; 15%)

* Low

- 123 !mE 1

8UIB2R OF PEiSO•• BL TaArlED II CDB CO~KU.ICATI08S BY PROYIIC! AMB PE1CEJf OF DISfaICfS COVEIID 1590-1992 1990 t Of ~

ANNEX 8

SENTINEL PROVINCB VIMB PHil H~a!th

PEiSONUL

DlSmm

1991

.oF

I Of

PEase.IIL DISTlrCfS SO ~a

1m lOr

pmom;. mUll:fS

Personnel

106~i

m PHONG Hulth ?Hscecel P:ivate Phar!acist! i~OllaOI

.....

13 2~

sm)

TaU! THIEHUE

Health !.eNG AN

F~rs~cnel

mill

50%151

Hellth Personnel OUA~J

i 101: 2li

mil)

HAM-DA NANG 21 50~lll

H~lit~ Pers~cne!

5G~t?)

-- . EXPANSION PROVINC~ HAl mG

Eeli:h Personnel HA HAM NINH Health Persoccel

hi'

ll!v:, i~ i

la 30 86 150

SSII)5 i

Hi HOI He!l:b Personnel Private Pharaacists Pre-School Teacbers mAMSION QUANG

mmsi 3~11 i

31111

m lOt J!)~\jii

Health Personnel BA

rna

Healtb Personnel rHm BOA

30'

1m 191

Health Personnel

30' 30 95 iOO:1211

9U111l

8ealth Personnel P!iv&te Pharmacists and Physicians aeiltn Pe!soncel

mIl

4:111

CUU LONG

190\1 !1l 30' lS:i?1 3~*

m GmG R!!ith ~er50nnel

iijij\115 I

AN GIANG

Health Personnel -J< ..

100"!1 i

Expected to be trained

Annex 8 ,Table 2

- 124 CDD ISFO~~TION SOURCES REPORTED BY CARE-TAKERS OF CHILDREN UNDER 5 YEARS SURVEYED IN 1990 AND 1992 IN HAl PHOSG .-\..>;0 THUATHIEN-HUE HAl PHONG 1990* 1992** SOI!RCES OF CDD INFORMATIO~

THUA THIES-HUE 1990* 1992**

COD PRINT MATERIALS SEE~ I~ PAST 3 ~ONTHS Poster Flipchart Leaflet OF THOSE EXPOSED TO COD PRIST ~TERIALS, WHERE VI El<iED Public Health Facility Private Practice Office Pharmacy Pre-School Soaewhere Else PEOPLE WHO GAVE COO INFORMATION IN PAST 3 MONTHS Pre-School Teachers Pharmacists Public Health Workers Private Practitioners Family and Friends Someone Else ~~ERE RADIO MESSAGES ON COD HEARD IN PAST 3 MONTHS Own Radio Public Loudspeaker Neighbour's Radio None

46.4 28.6 14.3

69;5 33.3 31. i

80.6 19.4 9.;

91.0 ;6.0 63.8

88.2 ;i.3 0.0 9.3 0.0 4.4 0.0 5.0 11.8, 4.0

84.6 i.i

0.0 0.0 7. i

87.8 13.8 3.5 4.3 39.5

0.0 0.0 0.0 1.8 i5.1 76.0 0.0 7.8 ;'1 . 3.7 0.0 10.2

0.0 0.0 71. 1 9.; 3.2 16.1

1.3 0.3 8LO 15.3 21. 7 2i.3

17.9 14.3 3.6 53.6

16.8 29.0 4.2 14.2

22.6 61. 3 6.5 45.2

21.0 76.8 4.5 8.2

* 1990: Cluster Sa.ple of 60 Households in All Districts, N=3600 ** 1992: Cluster Sample of 120Households in 5 Districts, S=600

- 125 Annex 8

TABLE 3. HEALTH WOauR COD COMMUNICATION PRACTICES REPORTBD BY CARB-TAURS OF CHILDREN UNDBR 5 YBARS SURVEYBD IN 1990 AND 1992 IN HAl PHONG AND THUA THIBN-HUB

COD COMMUNICATION PRACTICBS

HAl PHONG 1992** 1990* 57.1 17.9 29.7 37.7

THUA THIEN-HUE 1992** 1990* 35.5 64.5 24.9 64.2

Individual Counselling Group Counselling Visual Materials Used: Poster Flipchart ORS Demonstration Mother's Card ORS Mixing Leaflet Loudspeaker None Length of Time: More than other times Same as other ti_s Less than other times

27.3 24.2 15.2 3.0 0 9.1 21.2

51.8 30.5 52 20.8 1.2 5.0 14.2

26.8 7.3 2.4 2.4 0 7.3 34.1

77.0 72.2 41.8 56.7 0.8 41.5 8.2

33.3 61.1 5.6

40.7 25.7 18

7.1 64.3 28.6

4.5 75.7 4.7

* 1990: ** 1992:

Cluster sample of 60 households from all districts, Hz3600 Cluster sample of 120 households from 5 districts, N=600

Annex 8 TABLE 4 PROVINCE

- 126 -

GROUP INTERVIEWS CONDUCTED . July and October 1992 TRAINED UNTRAINED TRAINED UNTRAINED HEALTH HEALTH PHARM. PHARM.

HANOI' Tu Liem District S!hia Do Comllune City Shat Tan Commune HAl PHONG Provincial Hospital City An Hai District An Lao Commune Do Son District Van Son Commune HUE Regional Hospital Phu Vong District Duong Commune Huong Tra District Huong Xuan Commune HOCHIMINH City Hasp. No 1 Hasp. No 2 City n=2 n=2 n=1 n=1

n=3 n=5 n=6 n=6 n=6 n=4 n=4 n=6 n=3 n=6 n=5 n=4 n=5 n=2 n=5 n=6 n=3 n=2 n=3 n=2 n=4 n=4 18 73 n=5 n=3 n=3 n=4 8 3 3

n=3

n=2

LONGAN Provincial hospital Ben Luc district An Thanh commune Moc Hoa District Binh Hoa Tay Commun Tan Thanh District Tan Lap Commune TOTAL TOTAL N

= 32 RESPONDENTS N = 120

GROUPS

- 127 -

Annex 8 Table 5 Top 3 responses from group interviews on cnn services and activities

-----------------------------------------------------------------------------Trained Health Workers (n-73) 45 (n-3l)

Untrained Health Workers

enD Service Advice to mothers ORS supply Supply of communication materials

-----------------------------------------------------------------------------16

17 3

o 13 1 9

Changes in COD activities in past~ years More communication messages (exclude prints) 23 More printed materials 21 More ORS supply 14 Health workers counsel clients How to prepare ORS Feeding Referral Target for CDD communications Community Parents of sick children/ EPI children Parents of children with diarrhea Most important practices for clients ORS preparation Continue feeding Prevention/ hygiene Verification of understanding Asking mothers questions Asking mothers to do demonstration Asking mothers to repeat Changes seen in communication Morefbetter printed materials New policy from SSS to RW More kinds of channels Told to fellow workers Counselling skills ORS preparation RW preparation Changes in the job Job easier How I talk/ implement Busier/ more" difficult Change seen among clients Parents knowledge/ awareness gained More mothers are convinced Decrease diarrhea cases/ severity 28 21

8 7 6

17 ( 16 11

3 7

22 12 9

4 3

26 26 13 21 17 7

7 9 6

7 5

15 9

24 8 7

29 21 11

o 3

TA8Ll 6

CHARACTERISTIC~

uF COD PATIENT CuUNSELLING FRuN HL .,1 WuRKERS uBSERVED 01' AFTER lRAINING IN INTERPERSONAL CuHNUNICATIONS, BY PRuVINCE. 1990-1992 V[NH PIIU HAl PIIONG [990 [991 1992 1990 1991 In:51 (n:391 (n:101 (n:101 (n:21 39 36 36

/<, .1~.'t'·1 1

~,: I ~.

In,

CHARACTERISTICS uF PATIENT COUNSELL[NG 08SERVED AHONG H.WORKERS Si.~le

THUA THIEN IIUK 1990 1991 1992 (n:41 In:21

~HANAN~

1990

HA tWI 1991 199u 1991 1n: 10 1 (n:21 (n:51

HA NAN NINII 1990 1991 in:lOI )0

LONG AN 1992 In:51

I~ ~ CIO

Language Used

Open Questions Asked to VerifJ Patient's Understanding Visual Aids Used Patient EncourAged to Ask Questions FoclA.ad 'on One hih Message

2 2

3v 28

39 0 39 37 36

10 2

2 2 2 2

16 27

Advice ReAlistic for Patient's Situation Correct Technical content Pat[nt Repeats Advice Accurate 1J Patient Participates . in Discuuion

2 2

28 29 0

CIO N

35 0

THLE 8

coo COMMUNICATIONS MATERIAL. 8Y PROVINCE. HAl PHONG VINH PHU 1990 1991 1990 1991 1992 (n:41 In:391 \n:lll \n:91 \n:41 37 8

CHARACTERISTICS OF HEALTH FACILITY

DIS~LAY ~F 199u-199~

If >c c:D

CHARACTERISTICS OF MATERIALS OBSERVED IN HEALTH FACILITIES ORS Oelonstration Equiplent Visible COO Poster Visible to Patients COO'Wall Chart Visibie to Health Vorker COO Vall Cbart and Palters at Efe level COO FlipChart Vis ible

rHUA THIEN-HUE 1990 1991 1992 In:~1 In:)!

QN-DANANG 1990 1991 In:l0, 9

HA NAM NIHH 1990 1991 In:301

CHILDREN'S HOSP. LONG AN

1m ~

In:21

In:61

29 30

21 8

31 2

21 6

2 2

w 0

...

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Technical Documents

Дата принятия 31 декабря 1992 г.

Источник Всемирная организация здравоохранения