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Indian Journal of Community Medicine

Continuing Education in Health Care Sector - The Issues and Options

Author(s): S.S. Kushwah

Vol. 25, No. 1 (2000-01 - 2000-03)

Professor & Head, Department of Community Medicine, S.S. Medical College, Rewa (M.P.)

"Knowledge is the acquiring of facts Understanding is the interpreting of facts Wisdom is the application of facts"
Edwin Louis Cole

Training: "To bring a person to certan standard by teaching and practice."

Training has been an integral part of all developmental initiatives of the Govt. of India. The health section is no exception. Training in general requires periodic review as the learning needs of the target audience are constantly changing. Considering the magnitude of the health training programmes, both in terms of human resources trained and financial investment, it becomes all the more necessary to take a sharp look at the training programs in the health sector. Also, training is fast expanding and taking a new shape very often, sometimes even before the earlier strategies take roots throughout the project. In addition, the amount of money spent on training has been multiplying every year during the last more than a decade, there is a constant debate among the programme managers about the benefits of training proportional to the cost, which adds to the need for periodic review.


Training is one of the critical elements of any developmental project. Since it is the process of assisting a person for enhancing his/her efficiency and effectiveness at work, expectations from people trained are usually very high. The controversy about training starts when the actual performance falls short of expectations. Or, the results of the projects fall short of expectations. Despite these controversies and extreme swings of opinion, training continues to play a significant role in most health programmes.

Present scienario of training:

Training activities in all health and family welfare projects are expanding. This expansion is not just in terms of number of people trained or the expenditure on training but also in the scope of training programmes. All bank-financed projects in the population, health and nutrition sectors have had training elements with varying proportions of expenditure and specificity. Projects such as the sixth and seventh Population Projects were also called training projects because their main focus was on developing and strengthening a training system in specific states.

Review of several training programmes by the government and non-government agencies during the last several years has indicated an urgent need for improving the quality and content of training. Although there has been perceivable improvements in the training quality in the last decade, pressures to train a large number of health personnel in a short time often results in devoting inadequate time for planning and organizing training programme. This includes, among others, training need assessment, training design, designing measurable learning objectives and evaluation indicators.

Objectives of training:

In most of the programmes and majority of times followings are the objectives of training.

1. Identify the impact of training policies/strategies on the overall programme goals and objectives in the projects.

2. Assess the impact of training on the health service delivery, with special emphasis on personnel performance and utilization of health services by the beneficiaries.

3. Recommend appropriate strategies for enhancing the impact of training policies/strategies on ongoing and future projects.

Focus area of training:

The elements of training should be training strategies, implementation and management.

Training polices, strategies and factors or issues that influenced changes in training and strategies.

Training goals and objectives.

Relevance of training methods and contents to categories of health personnel and training objectives.

Methods of measurement of learning.

Support system after training.

Number of people trained in each category and duration of training.

Purpose of training - to enhance skills, knowledge or change in behaviour.

Impact of training on performance level of the health personnel and overall programmes.

Budget allocation for various training components (such as buildings, equipment, research, travel, logistics etc.)

Training programmes: Some findings:

During my personal experiences, observations and discussion with friends regarding their observations and experiences, following issues emerged:

There is no system to monitor the quality of training and initiate timely remedial measures.

There is no hand-on or competency based training.

Inadequate training is expected to have contributed significantly to non-achievement of programme/project goals.

Area based community need assessment was not done. Hence, the situation of area was not taken into training. The training is imparted with available modules. Hence, majority of training is not local community need based.

Most of the trainings are being carried out by lectures or talks in the training centres. There is hardly any scope for need based or field based training or on the job training. Hence, the field problems remain unsolved.

Some observations in training programmes:

Multiple trainings in same year : Multiple training programmes are being organized during one year for different programmes for same health care worker, such as NLEP, National programme for Prevention of Blindness, RCH Programme, National AIDS Control programme etc.

Multiple trainings for same work: Multiple trainings are being carried out for same type of work by different agencies during the same calendar year, for same health care worker, for example - syndromic approach in management of STDs by RCH project, UNFPA, National AIDS Control Programme etc.


After review of many training programmes and having a large number of conferences with friends and with our own experiences following issues have been identified.

Lack of foundation training at the time of induction.

No training at the time of promotion or only very primitively/low training at the time of promotion or joining specific programmes.

Diversity in allocation of budget in different programmes.

Vertical versus horizontal versus pyramidal training programmes.

Sustainability of training programmes.

Selection of participants for specific training and number of participants for each training course.

Type/s of training i.e. modular training, skill based training or on the job training.

Training policy status in country. Multiplicity of training.


After review of some training programmes and issues raised from time to time, there are some options which are identified and recommended for on going and future training programmes.

Sustainability of the training programmes is more if district level training instruments are involved and the content of training can also be integrated into pre and inservice course thus it can be more relevant to the learning need of the participants.

Intensive dialogues should be initiated with the government to implement the training policy that will integrate in-service training programmes for all level of health workers and enable development of a training cadre.

Intensive training of trainers should be conducted to enhance training skills of the trainers and establish a system of periodic measurement of performance level of the health staff.

The number of the participants in each training programme should not exceed 15-20 and participatory methods of training should be used for all the courses.

The training programme should be focused on skills development rather than just enhancing knowledge.

Training needs assessment should be conducted and detailed training design prepared during the project preparation phase itself. This design can be modified, if necessary, based on periodic review of the training programme and beneficiary needs.

Trained staff should be given continued support through supervision, on the job training and providing infrastructural support essential for transferring new knowledge and skills to the job responsibilities. Training strategies should be more specific with detailed description.

Qualitative monitoring indicators should be designed to assess the impact of training on the performance level of health personnel and utilization of services.

Enhancement of communication skills including motivational skills should be an integral part of training programmes for all categories of service providers in all the health projects.

Efforts should be made to avoid transmission loss in programmes that utilize a pyramidal system of training, the trainner should be present as observer for at least one course conduct by the new trainer.

Training capacity at the district and block levels should be strengthened so that need based programmes could be designed and implemented at these levels.

Technical assistance to improve the quality of training at various levels should be ensured. Strategies should be evolved to monitor the quality of training programmes and link it with service delivery targets.

During the one calendar year, only one training programme should be arranged and the types of training or training pertaining to all programmes should be incorporated in this single training capsule. All the agencies should coordinate at district level and they should make a common training programme and incorporate their training material/training contents in this training. Thus this will minimize the duplicacy, save the time as well as money and health care workers will not get tired in coming repeatedly for training.

There is a need for development of training policy at national level as well as at state level for the uniformity in training programmes.

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