POPULATION MANAGER VOLUME 5 Improving Quality of Care
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POPULATION MANAGER
VOLUME 5
Improving Quality of Care
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Volume Five 1997
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County, cnina
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Action Research
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□ Ministry of Health, Egypt
□ Population Services,
Zimbabwe
India
Sri Lanfea
Vietnam
□ ARCH, India
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□ Total Quality Management,
Ministry of Health, Malaysia
Editors
Maj-Britt Dohlie
Jay Satia
■KJ
POPULATION MANAGER
VOLUME 5
Improving Quality of Care
f
A
,
ICOMPJ^
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I
International Council On Management of Population Programmes
(ICOMP)
i
■a'-
FOREWORD
The International Conference on Population and Development
(ICPD) in Cairo in 1994 provided all of us in the population field a
great opportunity to reflect on the imminent challenges that will
shape the contents, forms and structures of population
programmes during this decade and into the next millennium.
The challenge now is how to go from the ICPD Programme of
Action to its practical realization in the field.
It is our belief that the field-level managers, the "front line"
translators and implementors of the programmes, need to be en
abled and empowered for ICPD-envisaged, better and improved
programme effectiveness and service delivery.
The concept for this new series of Population Manager by
ICOMP is based on the above belief. The underlying premise is to
learn from the ideas, approaches and practices of programmes that
have achieved results and some measure of success. Each volume
will identify and group a few of these experiences together under
specific themes and present them in a way that is useful and prac
tical to the field-level programme managers, the target audience
of the Population Manager.
We as population programme managers and professionals
want to be able to learn from each other. Therefore, I wish to thank
UNFPA for providing support to this publication and hope that
the readers of Population Manager, especially the field-level man
agers, will find it a useful vehicle for continuing learning and ex
perience sharing.
Haryono Suyono, PhD
Minister of State for Population/Chairman
National Family Planning
Coordinating Board, Indonesia
v
PREFACE
The underlying premise of ICOMP's journal Population Manager is to learn from the
ideas, approaches and practices of programmes that have achieved results and some
measure of success. Our interest and concern are to identify and group some of
these experiences together under specific themes and present them in a way that is
Nation Ma„4”ChCal tO field’leVel ProSramme managers, the target audience of Popu-
ICOMP has revitalised an earlier series of Population Manager which was dis
continued in 1991, but has re-focused it towards field-level population programme
managers with a different purpose and format.
It is the field-level managers at the grassroots who implement population
programmes and make a difference in people's lives. Population Manager will
endeavour to bring ideas, experiences, approaches and practices from around the
wor d to provide stimulation and learning to programme managers. Ultimately
new learning will enable them to perform their tasks well and even improve their
performance. The journal will attempt to distill lessons where it can, spark debate
when necessary, and raise questions and issues which managers confront in their
daily activities. Experience sharing and information dissemination are important
mechanisms in our continuing quest for improvement.
Population Manager has a thematic focus in each volume. For this fifth volume
the theme is Improving Quality of Care. The case studies and programme examples
are from a number of countries. The case studies from India, Sri Lanka and Viet
nam are the result of a UNFPA-supported action research project executed by ICOMP
in collaboration with local institutions and government agencies that formed a quality improvement team in each country.
We are greatly indebted to UNFPA - both to the main office in New York pro
viding financial support for the project activities and to each country office for its
co-operation. The project would not have been possible without the hard work and
commitment of the QI teams and other officials in each-country. More specifically
we would like to thank the following institutions and agencies for their very im
portant contribution to both the project. In India, Administrative Staff College of
mha Indian Institute of Health and Family Welfare, Department of Health and
Family Welfare, Academy for Nursing Studies, and the AIDS Control Programme
(all in Andhra Pradesh) and Department of Health and Family Welfare New DehliIn Sri Lanka: Family Health Bureau, the STD/HIV Control Programme and the
ancer Programme (Colombo), and the MOH in both Eheliyagoda and KuruwitaIn Vietnam: the Centre for Population Studies and Information of the National Com
mittee for Population and Family Planning (NCPFP) and the Ha Nam provincial
and Duy Tien district population and health officials.
vii
areas for Sir
"S
' ,0 tha"k Pr°S™>rme staff members in the project
active involvememS P '? lmP!e™wi"l5 the project. We also acknowledge the
neXe" „Te re,nS'0P
“"’"’“"■•y organisations - both existing and
woU1dh:v:bS7s;i™=
for SSgS.SeXtoVroSdS0' ‘ b ““ SS’
f°™“d
6 °f thlS ISSUe of the PoPulnl‘on
Manager These case studies are d ' € i''' C
has been doeX7er„S\Ssd„™;ffS S'oPBcZd .SS'"”
latest bttV1°UtSly p.ubllshed in their aotirety in Innovations Volume 1 or SlCOMffs
■XSS—aTs
with ICOMP.
'
t^ie CaSe studles are available in full
No particular preference is given in the order the case
studies and programme
examples are presented in this volume.
CHonf and Pha “
UNFPA forr providing
saXX
PTr°VrinS, the
"■ fub'ish
Maj-Britt Dohlie
Jay Satia
Kuala Lumpur, November 1997
viii
Ti
LIST OF ABBREVIATIONS AND ACRONYMS
p ject
jg the
ig and
ti i, it
? I sis
ih on
imple
u es
’'s
me of
y; in
at >n
Id in
o ic
i II
n
e
i
ti i
AIDS
ANC
ANM
ANS
ARCH
ARI
ASCI
AVSC
Acquired Immuno-Deficiency Syndrome
Ante-natal Care
Auxiliary Nurse Midwife
Academy for Nursing Studies
Action Research in Community Health and Development
Acute Respiratory Infection
Administrative Staff College of India
Association for Voluntary and Safe Contraception
CBD
CDC
CHW
COPE
CPR
CPSI
CQI
Community-Based Distribution or Distributor
Centers for Disease Control and Prevention
Community Health Worker
Client-Oriented, Provider-Efficient
Contraceptive Prevalence Rate
Centre for Population Studies and Information
Continuous Quality Improvement
DHS
DOH
Demographic Health Survey
Department of Health
EC
EDI
Eligible Couples
Economic Development Institute
FGD
FHB
FP
Focus Group Discussion
Family Health Bureau
Family Planning
GOI
GOK
Government of India
Government of Kenya
HCW
HIV
Health Care Worker
Human Immunodeficiency Virus
IIHFW
ICOMP
Indian Institute of Health and Family Welfare
International Council on Management of
Population Programmes
International Conference on Population and Development
Information, Education and Communication
Inter-Commune Population and FP Centre
Infant Mortality Rate
International Planned Parenthood Federation
Intrauterine Device
tine
ICPD
IEC
ICPFP
IMR
IPPF
IUD
IX
MCH
MOH
MR
MTP
MWRA
Maternal Child Health
Ministry of Health, Medical Officer of Health
Menstrual Regulation
Medical Termination of Pregnancy
Married Women of Reproductive Age
NCPD
NCPFP
NGO
National Council for Population and Development
National Committee for Population and Family Planning
Non-Governmental Organization
OC
OPEC
ORT
Oral Contraceptives
The Opec Fund for International Development
(Organization of Petroleum Exporting Countries)
Oral Rehydration Therapy (also ORS)
PCPFP
PFA
PHC
PHI
PHM
PHN
POA
PNC
Provincial Committee on Population and Family Planning
Patient Flow Analysis
Primary Health Care
Public Health Inspector
Public Health Midwife
Public Health Nursing Sister
Programme of Action
Post-Natal Care
QA
QCC
QI
QOC
Quality Assurance
Quality Control Circle
Quality Improvement
Quality of Care
RH
RTI
Reproductive Health
Reproductive Tract Infection
SDP
SPHM
STD
STI
Service Delivery Point
Supervisory Public Health Midwife
Sexually Transmitted Disease
Sexually Transmitted Infection
TFR
TQM
Total Fertility Rate
Total Quality Management
UNFPA
USAID
United Nations Population Fund
United States Agency for International Development
VHC
Village Health Committee
WHC
WHO
Women's Health Committee
World Health Organization
Well Woman Clinic
wwc
X
1
Introduction
The International Conference on Population and Development Programme of Action1
(ICPD-POA) set the agenda for family planning (FP) and population programmes to
broaden their approach to meet clients' needs for comprehensive reproductive health
(RH) care services. The POA states that FP programmes "must make significant efforts
to improve quality of care"2.
The importance of quality has received much attention in the 1990s and is no
committed
themselves to
longer controversial. Although many programmes have
I--------------improve quality, actual progress appears uneven.
|
After concentrating on coverage many FP programmes have concluded that they
should focus on reducing unmet needs for contraception. This requires that the quality
of the services they provide must be improved. It is argued that quality improvement
(QI) will lead not only to meeting clients' needs so that they are able to achieve their
reproductive goals but also to better health status overall. Finally, programmes adopt
QI to achieve better use of resources. This last point is important in an era when
programme managers must confront the fact that they are asked to provide more
comprehensive services to current clients and to groups that previously were not
considered clients. At the same time, they must also be prepared to meet the needs of
an unprecedented number of young people about to enter their reproductive years.
While many FP programmes may have reached relatively high levels of
coverage, this generally does not apply to other components of RH care services. The
challenge in this area will be to provide access to quality services. Hence quality must be
built into the services rather than come as an afterthought.
1 The conference took place in Cairo in September 1994.
2 Chapter 7, paragraph 23.
1
’ 1
WHAT IS QUALITY?
capabiK*y
Quality is not an elusive and intangible concept but
something that may be measured the inf n
and quantified. However, there are multiple perspectives on what constitutes quality of based on ,
care (QOC).
qualit)
Ta
same level of consid a
expectations, but often highlight similar issues related to the dimensions of QOC, for is exce
example, reliability and safety of contraceptive use,
a<.vc;,o to
L services, staff match be
use, easy access
friendliness, cleanliness, good information, reliable supplies, and so on.
provic
There is the concept of customer value. When <a client
‘'
receives medical services (or
M(
uses a product), there are both costs and benefits involved, Costs other than monetary Seven . 'It
ones must be considered. For example, visiting an STD clinic i
may cause efficiency
embarrassment; the client may experience side effects related to the
use of issues ic
contraception; she may perceive a loss of control when using institutional delivery as
opposed to a traditional birth attendant (TBA); or, there may be opposition of in-17ws, care, c J
scope of t
usband or other family to the use of contraception. The perceived benefits of using the
and re rc
services must outweigh the costs to the client.
S
repres_ it
During the current period of transition from MCH/FP to comprehensive RH
’r
programmes, there is considerable need to educate clients on reproductive health- what
define uie
their needs are, what constitutes good medical practices; and even what their
expectabons of the program should be.
id it
dittei
own perspectives
t
Se sertkes
7
“
e> n
have
' a1d‘“‘-bMed
in RH programmes poses
USerS ma>' not be able 10 assess H* technical quality of
.
iQRm pProgrammes
grammes may
may define
define quality
quality as "conformance to specifications" (Crosby
establish^m"naSers ^etermine
level of quality of care to be provided and
developed TheO^
other st^dards, guidelines and protocols are
Shortfall ’
Q°C 1S aS®eSSed by c°mparing actual practices with the standards.
UvaI 11 m COmmunicated t0 managers. Based on such assessments, managers at all
levels take the steps necessary to improve the QOC.
ir^as
syste
This pioc
previous
know
X‘
doing o.
2
I
Quality can be assessed in the process of service delivery, a programme's
capability to provide services at a desired level, and its impact on clients' health. Both
r asured the information provided to clients and the actual technical services provided must be
quality of based on up-to-date scientific knowledge and technology to ensure an adequate level of
quality.
add value,
Taking only the perspectives of the programme and service providers into
i€ ?vel of consideration does not ensure quality because the services - even if the technical quality
QOC, for is excellent and the information correct - may be unacceptable to clients. The degree of
icz'''z staff match between the client's view of the performance of the services and the service
provide/ s view determines client satisfaction (Ishikawa, 1985).
r zes (or
Moreover, RH programmes must consider the needs of society overall. In his
n aetary Seven Pillars of Quality Donabedian (1990) includes the following: efficacy, effectiveness,
iy cause efficiency, optimality, acceptability, legitimacy and equity (italics added). Very difficult
se of issues such as concern for the individual versus responsibility to all, equitable access to
;L ary as care, and so on, are addressed in this framework. Such issues are clearly beyond the
in-laws, scope of this chapter, but must be seriously considered by health programmes. Human
u; ig the and reproductive rights as outlined in the ICPD-POA and other international charters
represent a guide for programmes in doing so.
is e RH
f
Programme managers may combine the multiple perspectives to establish or
’th; what define the level of QOC in their programmes:
■ia' their
• identify through user surveys and qualitative research the dimensions of quality for
I
different services most valued by the users and assess their level of expectations
t€ they*
e nical • examine these through technical assessment and add dimensions which users may
dons of
have neglected
es loses
la^xty of • measure the current level of the dimensions provided by the service delivery
system and establish standards
Crosby,
ieJ and
zc are
ndards.
rs t all
This process has to be repeated periodically as clients' expectations undergo change, the
previous standards have been achieved and higher standards are desired, or new
knowledge makes it imperative to change the standards.
As a guide to developing client sensitive services and measuring their success in
doing so, programmes mayr use existing QOC frameworks and client's charters, but
3
I h
cletermi ?c
a given soc
QUALITY OF CARE FRAMEWORKS
I“e
aspects:
199fn fr^eW°rks refl^ct 1116 «sP^fs ofsennees that clients experience as critical (Bruce
widely a4ted"
016
g
•
elementS °f Q°C Pr°P0Sed by BrUCe
Recogr
cyc1x' a
wic r
consen
pos W
clie s.
Choice of method refers to the range of contraceptive methods available in the
programme. Information given to clients should include, among others, method
charactensbes how appropriate the method is for specific users, details on how to use
it, potenbal side effects and actions required to deal with side effects. Service providers
need an adequate level of technical competence to provide safe services and they need * Ser :e
bt bt r
"atlsfaCtOry interP^onal relations and interactions with clients who must
StrtA.g
.s co t
rT dlgnityai}d comPassi°n- The programme also needs to ensure that there
Priv^c
would van! froT
^tfoll°W-UP is P^vided. An appropriate constellation ofsennees
would vary from setting to setting but generally includes convenient and acceptable * Approj
complementary health care services to FP users.
effe< ' >.
the output of the *
the expected results or impacts of improving the QOC.
8
Availal
refe
Qualit
per >e
manag
tim^y
FP/RH
ensuZ
,Of
ensurmg tne rights of clients.4
>P
q-alily services with confidence while
whi "i
hea i.
Emerging
3
'c'omZt
appropriated
aSP!CtS 316 tHe f0U0WinS: Ch°iCe °f meth0d; formation given to
^ow-up/continuity mechanism; and
4 According to IPPF these needs are the following; training, information, supplies, guidance back-un
spec , encouragement, feedback, self expression, and infrastructure (Huezo and Diaz, 1992).
4
QOC f m
process of
their ra~g€
JI. _
It has been suggested that the level of QOC provided by a programme is
>c_jd to thei
determined by the interface among users, the service delivery system and technology in
a given socio-economic context (Simmons et al, 1997).
The ICPD-POA defines QOC and emphasises, among others, the following
aspects:
ritical (Bruce
b- Bruce art •
Recognition that clients have different contraceptive needs throughout their life
cycle and depending on the individual situation. Access to and information on a
wide range of methods is necessary to meet clients' needs and ensure informed
consent. Hence information on the benefits and risks of the different methods, their
possible side effects and effectiveness in preventing STD/HIV must be provided to
clients.
dJ )Ie in the
ei
method
i how to use
ci providers
d uiiey need * Services must be made safer, affordable, more convenient and accessible.
Strengthened logistical systems must ensure sufficient and continuous supplies.
ts who must
Privacy and confidentiality must be safeguarded.
n hat there
on of services
I "^ceptable * Appropriate follow-up must be ensured including treatment for contraceptive side
effects.
it it of the * Availability of related RH services must be ensured on-site or through effective
referral.
c< ?d, and
knowledge1
? among • Qualitative as well as quantitative performance measures must be emphasised. The
perspectives of both current and potential users must be sought through effective
management systems and other survey techniques in order to evaluate services in a
timely fashion.
la banned
e light to*
co ’'tinuityj * FP/RH programmes must emphasise breastfeeding education and support services
which will simultaneously contribute to birth spacing, better maternal and child
a needs
health as well as higher rates of child survival.
ence while
Emerging Framework for Quality of Care in Reproductive Health
QOC frameworks shift the attention to the client/service provider interaction or the
process of care giving (Donabedian (1966, 1988; Bruce 1990). As programmes broaden
their range of RH services offered, QOC frameworks need to evolve for several reasons:
□n given to
and
:e, oack-up,
1992).
I
5
•
•
RH care involves both preventive and curative care as compared to mostly
preventive care in FP programmes
Interpc-sc
• caring
Referral plays an increasingly important role in RH care services
•
dij it
•
•
•
indivi
ap—o
Many social factors influence reproductive health. Therefore, gender issues and •
social aspects require attention
Social cor
Finally, there is the question of affordability. Most governments provide free FF • so il
services. It is not clear whether they will be able to provide comprehensive RH care • g8ee
services free of charge.
e empo
• ma
An analysis of the experiences of NGOs5 that emphasise QOC and provide a more
comprehensive range of RH care services leads to a discussion of the dimensions of Economic
QOC presented below.
• af re
An Emerging Reproductive Health Framework: Quality Dimensions
Service delivery attributes
• access to and availability of a wide range of RH care services
• effective referral linkages
• follow-up and continuity of care
• range and choice of contraceptive methods
Information
• comprehensive sexuality and RH education
• in-depth information on the service provided
Technical aspects
• technical skills of service providers
• infection prevention
• sound and appropriate medical practices
C
Mana nto son €
have ma
such
c
1995). A<
efficie^c'
and s t(
D
being e
build qu
and st
level, of
instead (
c
ICOMP has documented the following experiences with the support of the Ford Foundation:
Women's Health Care Foundation (WHCF), Philippines; Rural Women Social Education Centre
(RUWSEC), India; Society for Education and Research in Community Health (SEARCH), India;
and Bma Insani, Indonesia. With UNFPA support, a case study and video were developed on
ARCH (Action Research in Community Health and Development), India.
6
time
usua j
needs t<
char ~ ?
(inte ta
ostlj
u
Interpersonal aspects
• caring
• dignity, privacy and confidentiality
• individual acceptability
and • appropriate counselling; listening
| Social context
f e FP • social acceptability
Rn care • gender sensitivity
• empowerment of women
• male participation and responsible sexual behaviour
a more
si is of Economic dimension
• affordability
QUALITY TRANSFORMATION: APPROACHES TO IMPROVE QUALITY
Management theories and practices to improve quality often have different names and
to some extent even different definitions, but they share the same intellectual roots and
have many commonalties in their prescriptions for action. The use of a common term
such as quality transformation has been suggested for the emerging paradigm (Kolarik,
1995). According to current thinking in management literature, client satisfaction and
efficiency happen automatically when organisations focus on improvement in processes
and systems to improve quality.
During this transformation, the approaches to quality improvement shift from
being reactive to proactive. Rather than only inspecting and controlling, organisations
build quality into the design of their services or products and into their work processes
I
and systems. Through strategic quality management there is mobilisation of staff at all
levels of the organisation to be responsible for quality and ensure its implementation
instead of reliance on a quality department or programme (Garvin, 1988).
idudon.
Centre
, dia;
p. „ on
Quality improvement is a long-term process that requires commitment of both
time and resources. Commitment to quality’ at the highest levels of the organisation is
usually considered a prerequisite for quality to improve. Subsequently, the entire staff
needs to "buy into" the concept. As suggested above, implementation of QI implies
change in the organisation's structure and management systems to shift the focus to
(internal and external) clients and to the work processes that enable staff members to
7
1
a
perform their tasks correctly and well and to solve problems. For many organisations, and cc
the initial outlays to improve quality pay for themselves - and more - because QI leads con ic
to more efficient use of resources and reduced waste.
There are different approaches to diagnose quality-related problems and to
can >e
improve quality:
ensure
req re
1. Quality assurance approach (QA). Organisations using this approach establish
standards for structure, process and outcome. Actual results are compared to the
standards. Outliers are investigated to find the causes of the deviations. The reasons
for lack of compliance with standards may be common to all service delivery points
(systemic cause) or tunique
-’ - . to a specific
.
- unit (special cause). The remedial As sue
service
actions required may differ accordingly.
sat a»
c .
the iat
2. Systems improvement approach. The tools for situation analysis were developed by the Thece
Population Council and are commonly used in the population field. However, any pri t
set of tools appropriate to the programme could be used. The assessment can be achiev
done by qualified researchers or as a rapid appraisal by managers. Once the be )t
weaknesses are identified, the programme would begin to improve systems.
the u
..
J • CC
1 •
c
1
3. Teams and continuous quality improvement approaches. Traditional QA approaches tend
to be top-down and often ignore human factors. Such approaches may not be
sufficiently proactive or lead to continuous improvement. Therefore, organisations
have begun to involve staff in the
the problemsolving
problemsolving process.
process. Quality
Quality control
control circles
circles
(QCC) and Malaysia s QI teams are examples of this approach. The COPE6 approach
should also be mentioned. This is a relatively
j si
simple and low-cost local problemso v ing approach. However, in the absence of a stated
stated programme-wide
programme-wide
commitment to and policy of QI, a fair number of problems may remain unresolved.
a conf
avoid
QI
QI ic
Benef
Quaiit
-r
qu-’it
4.
Total Quality Management (TQM) is a relatively recent approach in FP and
t
population programmes to create> aa quality
transformation.
When
Malaysia
adopted
its
such
c
quality transformation. When Malaysia adopted its
Q programme7 in 1989, it built on
on the
the approaches
approaches it
it had
had used
used nrpvinndv
previously and
and an v
incorporated them. For example, the MOH had introduced a QA programme in 1985 in< ?a
with the stated purpose of improving health care and resource utilization as well as
enhancing customer satisfaction (Saha and Dohlie, 1995). In the early 1990s, the
government adopted "Corporate Culture" to encourage increased focus on clients and ad__.ii
to develop its human resources. These steps reflected the gradual shift from inspection terms
th ?
6 AVSC I,nternatl0nal developed COPE (Client-Oriented, Provider-Efficient).
7 The "Q" Programme is another name for TQM.
8
8t-q
j
1
.. -.viaa
>
libdtions, and control to strategic quality management and to an organisational culture more
QT leads conducive to customer satisfaction.
While incremental change may be the realistic option for FP/RH programmes, it
i "nd to can be argued that, from the very beginning, they should take a proactive stance to
ensure that quality is built into the services they plan to provide, into the processes
required to provide them and the systems needed to support them.
?s blish
d ) the
COSTS AND BENEFITS OF QI8
reasons
y oints
ex^edial As suggested above, QI is expected to have a considerable impact on efficiency, client
satisfaction, and utilisation rates. Yet, little is known about the economic costs involved,
the rate of return on such investments, or the extent to which QI can be self-financing.
d oy the These are important issues because advocacy for incremental QI almost always carries a
ze- any price tag. Strategies to minimise costs and maximise benefits can help policy makers
< a be achieve greater "value for money" in a world of severe resource constraints. It should
nee the be noted that economic measurement has been hampered because of the confusion over
the meaning and definition of quality itself and the techniques for measuring quality on
| a continuous basis.
es tend
r t be ’
The experience is that cost recovery and user fees must be accompanied by QI to
;.s ions avoid a significant drop in utilisation rates in the programme. The interdependence of
circles ' QI and increased revenues is illustrated in Figure 1.
•p »ach!
ouiem-' Benefits of Quality
e-’^ide ’
sc red. • Quality should be designed into the programme and services. The three components of
e quality design - structural requirements, process and procedures, and technical inputs T ind may be self-financing. For example, clients often complain of structural shortcomings
its such as irregular supplies and poorly maintained clinics. Experience shows that they
>ti
ly and are willing to pay for improvements in these areas. Such improvements often lead to
n 985 increased demand.
v< as
Improvements in process and procedures imply attention to managerial and
)s, the
ts nd administrative issues. They reduce waste and inefficiencies and increase effectiveness in
>euiion terms of discouraging, for example, contraceptive discontinuation. Research shows that
there is considerable scope for cost-savings in this area.
8ICOMP gratefully acknowledges the contribution of RP Shaw7 s paper to the discussion of costs
and benefits.
9
1
k
Costs of Low (
Similarly, technical inputs can be self-financing. For example, as clients
expectations rise and their knowledge increases, they may be willing to pay (more) foiLow qualit :a
nev\ and improved technologies rather than settle for mediocre or inferior treatments Some of the co
More and better alternatives generally attract more clients, contribute to continuou$
use, and encourage clients to stay with their sendee provider rather than switch to one • Poor qu if
that is perceived to be better.
lower l^ve
there c ?
health car
Figure 1: Flowchart of Cost Recovery and Quality
provid 1 i
higher e,
UL
Increased Value
for Money
•
Poor qi it
and dai g
use of a
effect? c
failure *'a
con tin" ti
resuit
1
for the wc
•
Poor q ih
Interventi
health a
reputa di
a conside
great ( )i
i
increased
Demand
increased
Revenues
increased Willingness
to Pay
Implications
for the Patient
QUALITY
•mpiicaiions
lar
Provider
<
Increased Net
Revenues
Quality Assurance &
Concern for Customer
Satisfaction
Cost-Effective
Standards
efficient implementation:
Oo it ngnt trie first time
lower
Costs
i
I
Poor (”'al
knowk
addition
treatn nl*
client*
Cc si
:i
Source: Adapted from HHRAA’ believe tl
self-financinj
losses du tc
always coot.
be accomrtar
10
K i
Costs of Low Quality
5 lients
more) foLow quality carries many costs both for the clients, service providers and programme.
Ba aentsSome of the costs are reviewed briefly below:
n^iuou'
zh to on( • Poor quality lower-level curative and preventive services are costly. When clients by-pass
lower level health care facilities in the referral system and seek care at higher levels,
there are considerable economic costs and consequences for the efficacy of the
health care system. Relatively simple services tend to be much more costly when
provided at higher levels. For clients, obtaining services at higher levels often imply
higher fees and opportunity costs of time to travel further, and so on.
•
Poor quality commodities and technologies may lead to adverse health outcomes for clients
and.damage the reputation of sendee providers /programmes. For example, in China the
use of a less effective and cheaper IUD as opposed to a more expensive and
effective one saves the programme money at the time of insertion. Yet, the higher
failure rate, the abortions resulting from contraceptive failure, and the lower
continuation rate among women who use the less expensive and effective IUD
result in higher programme costs. Moreover, there are economic and health costs
for the women.
•
Poor quality staff and training can result in misdiagnosis and medical complications.
Interventions to remedy the complications and additional care are costly for the
health care system. Both the programme and service providers may gain a bad
reputation and clients may avoid seeking care. For clients, complications may have
a considerable impact on their health and even lead to death. Clients may also face
great economic costs.
•
Poor quality information, communication, education and outreach contribute to less
knowledgeable clients, non-use and discontinuation of services and commodities. In
addition to less demand for services, incorrect use and non-compliance with
treatment protocols may lead to inefficiency, waste, and complications for the
clients.
s
u.
■
’ Net
J
Considering the benefits and costs discussed above, there are good reasons to
HHRA? believe that incremental improvements in the quality of RH care services can often be
self-financing, and that failure to undertake quality improvements can result in serious
losses due to errors, waste, and delays. It is also apparent that higher quality need not
always cost money or, conversely, that reduced levels of funding need not necessarily
be accompanied by lower levels of quality.
11
6. ^cu
NG(
ISSUES RELATED TO QUALITY IMPROVEMENT
7. QO(
Zany nd programme experiences
to
d
“Cribed “
d,ls i
of
described
in this
OCX
improvement:
e<id '0 be addressed
Programmes imdate qoalli,
c a.
have
1 ■ Mtmtors of qual,ly. Both public and private sector p— programmes
continue to us(8. 1 m
quLXve'in^oTtomeT^
°
rf b»tt’
? anc
pro^
dnt,»x ^mbXd
may “ as the r ?c
measurable units derived L. amo'X^XXeS
are
quality,
Appropriate indicators are jselected for tire process of care as well as forof
has
structure
output and outcome. In this
- context, rt must be emphasised that the search for
^/itata indicators for reproductive health is on-’
appropriate methodologies to measure quahty“‘
°r,’gOing as 15 the search for
2. Learning from the private sector. There is a i
need
for FP
the developing countries to learn from the
private
r and
’ population managers in
ancI to motivate and involve people t0 perfoPrm ? sector,„ to reduce bureaucracy,
•emoving barriers rather
-- —i-monetary
Not all actions to imp:
3 ™“ZXlgtTs^
ZTi„qad1I,y r,equire f“"ds' “““
'»
to improve current training nro<r
deq“ate one’ However, it will take resources
new services, but it may not cosSimific5 HeS°UrCeS wil1 be required to introduce
inferior ones. Cost recovV^iXX^n
“X “b3"
communi^ ^rapKtives’on ^*^7“ dT
fat° aCC°"n' dient "’d
providers which frequently prevailTheC^Cd C,11 °Wn and 111056 of service
among dientsand se’rviee pXers/Xmme,
diVer8mt
QOC
5 P^XXX6XX b' *" —d
-e objectives of the
s"Xdd-/p—
12
[r
J
1
6. Securing commitment to QOC. It is important to secure commitment to QOC among
NGOs. This may be done by forming alliances and through other mechanisms.
pulatio]
ia qualit
7. QOC must be part of the design of the services provided. As new services are added,
QOC must be designed into the services. This is important because inadequate
quality leads to bad work habits. When providers accept low quality and clients
have low expectations, it is very difficult to improve quality.
n to USig.
tative an<
it 1 as thf
1 ney an
quality
s ucture
search foi
^e ch for
Managerial practices must change. Although much has been written on QI in FP
programmes, it may not be sufficiently appreciated that most managerial practices
need to be reoriented. With the shift from demographic achievements to enabling
people to meet their reproductive intentions through quality RH care services there
has been a realisation that current managerial practices are inadequate.
*r yers in
*e—icracy
2rs rather
n netary
t ore to'
’esources^
n aduce
i
i
ic ; than
■.e..v and
" service
oi QOC
2S f the
imunity
e f the
13
•2.7*
1
2
Background of Action Research
Despite growing recognition of the need for quality improvement, the level of action
taken by government FP and population programmes remains uneven. There are many
reasons Programme managers often feel that the benefits of improving quality may not
outweigh the costs; there is no clear roadmap to improve quality in large programmes
and quality improvement is difficult because it requires dealing with people and
processes.
r r
1007
f115 background' an action research project was implemented from 1995 to
1997 wrth funding from UNFPA at one site each in India, Sri Lanka and Vietnam to
explore moderate cost approaches to improve the QOC. The programmes in the three
countries are at different stages of maturity. The contraceptive prevalence rate in Sri
Lanka is high. Although the Indian programme is the oldest, many questions remain as
far as the level of quality of care is concerned. The contraceptive prevalence rate in
Vietnam is relatively high but tins is largely due to the use of one method - the IUD.
JGOMP executed the project with local partners in each country where they
formed a QI team.1 The objectives; were the following:
1. Assist the participating programmes in developing measures of quality through
understanding client perspectives and technical considerations, and in assessing
current levels of quality through self-assessment.
2. Provide knowledge and skills to participants
on how to improve the quality of care.
3. Formulate action plans to translate the
acquired knowledge and skills based on
diagnostic studies to improve quality.
1
New Delhi: Department of Family Welfare.
6
1
Sri Lanka: Family Health Bureau (FHB).
FaXHa^nmg S/NOTP)^"165
Information/Natlonal Committee for Population and
15
L
4.
Provide financial support and technical assistance in implementing the action plans
m areas with a population of around 100,000.
a. Disseminate more widely the learning from the implementation of the action plans
and encourage participants to act as catalysts for institutionalising programme-wide
u u
quality improvement.
b
Ue At the begmr
their undpvst
improven nt
whereas tne
SELECTION OF PROGRAMMES AND SITES
team express
Government service delivery points (SDP) were selected to participate in the project It natUT °f
was understood that the teams would need to stay in continuous touch with the project t0 g°
areas, so relative proximity was considered important.
Pri it
them
more
c
In India, Shamirpet Primary Health Center (PHC) in Ranga Reddy district in
Andhra Pradesh was selected.
f"1’'1 The PHC provides services to a population of about 50- seC°n^ P’ >r
■”
1
reproducu»e
60,000 clients in 33 villages
served’ ’by nine sub-centres. The whole
■area is considered rimarySTD
backward compared to the coastal part of the state, which is also reflected
in the quality
of the health services provided.
After
developer
1 to
In some ways, proximity to a big city (Hyderabad) may affect the health care
services negatively in as much as staff members tend to live in the city and commute to the local o
their place of work. Given that transportation is difficult, this translates into less time assessment v
implemei it
avai a e to ie health care workers (HCW) for actual service provision
r
'
some rep: d
In Sii Lanka, Eheliyagoda and Kuruwita in Ratnapura district were selected. The
two areas combined have a population of more than 170,000. Again, relative proximity
to tire team was important. At the inception of the project, the services provided in the
area were considered to be in need of improvement. The economy is based mainly on
agriculture, but many are involved in the gem industry that is unique to the district. As
ere were many staff changes in Kuruwita, the activities were delayed. Therefore, we
describe the quality improvement experiences in Eheliyagoda only.
to1?™161113131' Duy Tien district in Ha Nam province with a population slightly
over 135,000 was selected to participate in the project. The area is located about 50 km
rom Hano!. The majority of the population is involved in agriculture. Although the
area had previously received some financial support from international agencies, it was
considered to be in need of quality improvement.
T?
programs. 2S
the beginnin
problems v
The QOC p
improver^ ?n
As si
manager: ai
program e,
light on mar
Rapid Asses
After dox±Lg
Kuala L^m
16
i'
the action plan
APPROACHES, ISSUES AND METHODOLOGY
:th action planidfA.t the beginning of the project, the QI teams and the programmes needed to enhance
their understanding of quality although there was much commitment to quality
improvement. The team in India wished to improve the quality of MCH/FP services
whereas the Vietnamese team concentrated on family planning services. Sri Lanka's
team expressed a wish to improve more than just FP services given the comprehensive
i the project j(nature
P1’0?1’3111- Also, because of the Cairo-agenda, it was considered important
Vi the projeci ° S° beyOnd the traditional FP/MCH approach to the extent possible over two years.
Priority was given to review how existing services were provided and to make
h district ‘
m°re clierit’centered. The dimensions of QOC were to be the driving force. A
)n of about 50 secon^ Pri°rity was to brpaden the concept of "client" beyond married women of
i rn j °^reproductive age and to introduce other reproductive health services, for example,
i the quaHtyPrimary STD/HIV Prevention.
After a review of existing instruments available from several sources, ICOMP
developed tools for the rapid and baseline assessments. Each team adapted the tools to
it aealth care
the local context. In addition to assessing the current situation, carrying out the
d commute to
ir ) less tinie‘assessment was considered a learning process for the teams to prepare them for actual
implementation. Moreover, the instruments were considered a suggested standard in
some reproductive health areas where no standards had yet been set.
s ?cted. The
ve proximity^
This was a project for and by managers. The teams would assess their own
programmes, carry out interventions, and then evaluate the results themselves. From
K nainl
beginnin8z a //new" approach to management was encouraged to involve staff in
te district ^jProb^emso^v^n8 and to set motion a continuous quality improvement (CQI) process.
T) efore
-^e
Project made a concerted effort to take a proactive approach to quality
re' wetimprovement rather than a traditional quality assurance (QA) approach.
j. i
suggested above, clients' needs and perceptions of quality were to guide
about 50 km maria£erS
Sta^
t^ie
Processaddition, the perspectives of managers/
ltuo h th Pro8ramrne' service providers and staff were considered important to shed valuable
)ug
e light on many issues.
Hi ?s, it was
Rapid Assessment and QOC Workshop for the Teams
After doing a rapid assessment in their respective countries, the three teams met in
Kuala Lumpur, Malaysia, for an "immersion" in issues related to quality: QOC
17
frameworks and discussion on the various dimensions of quality; comprehensiv,
1
reproductive health; gender; indicators and assessment methodologies; QI approach^ commu
including examples of programmes which have already adopted QI; management tools The -fc
and visits to two different clinics (one NGO and one government SDP).2 Based on thi con LU
results from the rapid assessment, each team developed a tentative plan of action
Finally, the instruments developed by ICOMP for the baseline research ’
were discussec The H
and modified. Each team subsequently adapted them to the respective? country'}
settings.
r
Each cc
imp 'b
staf- w
Baseline Results
preven
The baseline results in all three countries indicated shortcomings - to varying degrees - beyonc
in all dimensions of QOC: insufficient, and sometimes incorrect, information giving imr-rt
limited choice of contraceptive methods; inadequate technical skills and infection beh
prevention; insufficient attention to privacy and sometimes other problems during the
client/provider interaction; inadequate follow-up; inadequate availability of and access
to comprehensive RH care services, sometimes also to contraceptive services; referral The :f<
systems which were not functioning as they should; neglect of groups other than' and ne
married women of reproductive age, and so on.
I ver ei
rela^vf
Data were collected through interviews with female clients (contraceptive users improvt
and non-users); men in the community; service providers; managers; and private like t
medical doctors (PMD). There were also group discussions, observations of service
This is
provision of facilities using checklists. Using different methodologies allowed the teams the-~fc
to see issues from different perspectives.
cor m
FP/M(
Although courtesy bias
and low expectations are very real issues, clients are pre *a
zAiu.uugn
oias ana
definitely concerned about quality. As one team member stated:
During the QOC project I came to realise that people are more concerned about
quality than we providers tend to think. They may not voice their demand so often
because they have few alternatives."
The small group discussions added depth to many issues and the teams appeared to
find them an effective tool both to obtain and impart information. One team member
stated the following: "After a while they (clients) forget themselves and are very open."
" Selangor and Federal Territory Family Planning Association, and National Population & Family
Development Board (LPPKN), Malaysia.
7
18
gei re
req^ir-
quant]
asc^t
wc >
conve
du ?r
he it
• h£4
.....
J
; - Jmprehensiv^
Building trust appears to be a very important aspect in the Asian context As the
- approacne{ community got to know and trust the teams, people became increasingly willing to talk
anagement tools Therefore, as the project proceeded, people provided additional feedback and the teams
)■ Based on th, continued to learn from and about the community.
! . an of actio®'
1 were discusse( The Plan of Action and Action Research Assumptions
e< ve country'
Each country team agreed that its first intervention would be to sensitise staff to the
importance of quality of care through training. Beyond awareness raising, training of
staff was on the agenda to improve different types of technical skiUs and infection
prevention as well as information giving and counseling skills. In addition, staff
required new knowledge and skills to be able to address reproductive health issues
ar ing degrees beyond FP/MCH. Effective supervision conducive to quality was also considered
rmation
'±cn giving important. This included creating a supportive environment to reinforce new
id infectior behaviours and skills after the training.
ei > during the
y of and access
Quality
Quality improvement
improvement requires
requires aa combination
combination of
of "soft"
"soft" and
and "hard" inputs.
?r ces; referral Therefore, the interventions included procurement of needed inputs such as supplies
ip^ o er thar and new equipment as well as repairs and overall improvement of the structure. It is
( very easy to become too preoccupied with structural inputs - maybe because they are
| relatively easier to deal with than "people issues." People are, however, the key to quality
■aceptive users improvement. Improved infrastructure, new equipment and adequate supplies are not
v nd private; likely to improve quality significantly unless the way staff think and act also changes.
01
Servicet 11115 15 Particularly true when staff morale and performance are low The project
wed the teams therefore, focused particularly on the development of human resources. Finally,'
: community outreach was envisaged to reach groups not normally covered by the
j FP/MCH programme - men, youth, and women not generally seeking care (from the
es, clients are programme) - to address STD/HIV prevention and other issues related to RH.
ed about
s often
It should be emphasised that, although the problems faced by each programme
generally were the same, they often varied in severity. Therefore, the interventions
required careful adaptation to the local context.
The action research project worked on the assumption that all the dimensions of
c peared to quality are important and contribute to client satisfaction. There was no attempt to
-am member ascertain, for example, if the interventions to provide more effective choice of method
0} 7."
were relatively more or less important than improving the information provided,
convenience to clients, easier access, and so on. In actual service delivery, the quality
dimensions and the interventions to improve quality are closely interdependent,
1 <! 7amily
frequently reinforcing each other.
19
1
&
In TTie
areas of ci
(NCPFP) has
experieno ii
Access to Quality Services
c"fabi“*are
«
are potentially very divisive but need to be 3^°
^nd aVaUabUity versus quality
The causes underlying deficiencies in these a 16556
quality ls to be improved,
and systems. As discussed, both require seriouTlttentio ^h*16 r6SUlt faUlty processes
QI implies using available resources mor^^
access and availability. The important point is that other (X)C iss1"
not wait until access is assured.
QOC issues cannot and should
‘b'*8 aCtiOnS
m■8h,
X*
"e“ SittS
'
the QOC project Xhf “XXX
outreach to increase access and availabilitv c
-
“Xie,
proc“ses and undertake community
programmes began « eX^^thslrXXX
Final Evaluation and Continuatio
n of the QI Process
aXTXX XX “ XXs A'X8h "
a management perspective for dissemination of learning1'6 °
process
*
OpUlab°n ManaSer fr°m
each cXt^XlndiaX XX PradeX^" '0 ‘’“T ‘
P°rata’8
,ess™
H™«gh the action research in the
project training for’
ad ST’‘riated t0 seIected officials. The initial
traming. The counseHing component has .LotXeZX in other types of FHB
20
j
In Vietnam quality improvement has been included as one of the important
ireas of focus, and the National Committee for Population and Family Planning
•NCPFP) has asked for a workshop to review in depth all the quality improvement
experiences in the country.
I
3l ms - at
sus quality
improved,
ty Processes
initiate QI.
y nprove
a I should
id~*g new
desirable/
3i nunity'
ident. The^
I
report is
* from
01 nuing
xziued to
t r-tputs
tn being
FPA has
•h i the
!
I
ie litial
c. FHB
21
3
India
Improving Quality of Care at Shamirpet Primary
Health Centre, Andhra Pradesh1
BACKGROUND
This case study describes an action research project supported by UNFPA to improve
the quality of care at Shamirpet Primary’ Health Centre (PHC), Andhra Pradesh, India
during the period of 1995-97. Shamirpet PHC serves an area of 52,201 inhabitants (1981
census). The site is an upgraded PHC. It has three medical doctors when it is fully
staffed. Each of the nine auxiliary nurse-midwives (ANMs) attached to the PHC is
responsible for one sub-centre and also provides services to three or more villages with
a total population of 5,000 and up. There are altogether 33 villages. The area has three
male health care workers (HCWs) who have traditionally played a marginal role in the
| FP/MCH program.
;
A local QI team was formed comprising managers who were trained in a
regional training program to sensitise and prepare them to undertake quality
improvement. The team consisted of central and state level officials, two ASCI
representatives, and a member from the Indian Institute of Health and Family Welfare
(AP). Local institutions provided technical assistance with technical backstopping by
ICOMP.
A rapid assessment of the level of quality provided was done in May 1995. A
larger baseline survey followed in Julv/August 1995. The action plan prepared by the
’Contributed by: GNV Ramana, R Devi, M Prakasamma, S Ramidamy, MB Dohlie and J Satia. Other
staff at ASCI, IIHFW and ANS also contributed. The project is indebted to R Chatterjee and I Pal for
their help and support during the programme implementation.
23
1
b..
I
team was implemented from September 1995 to February 1997. Interventions
were
evaluated in March 1997 and a dissemination w
.'orkshop was held in April 1997.
Bothservices nc
The project not only demonstrated that q
uality of care can be improved even in when as_.?c
somewhat constrained public sector health
settings, but also identified and tested
^ev P
moderate cost interventions that were needed to improve quality. In the process, it not like ic
enhanced the commitment of pprogramme managers to improving quality and the f°r steriusa
national capacity to continue quality improvement.
were goM.
Non-usi >
providers, <
BASELINE ASSESSMENT OF QOC
hamirpet PHC has about 8,873 eligible couples (EC).2 For the baseline survey, about
five percent of the couples were interviewed from all the villages using population
< n
poor facilit
underg<
response
uZ^SoTan^th
7'
°f 1116 W°men mterviewed
contraceptive '
users (220) and the rest non-users (244). In addition, a small number of men with
I laP^es of reproductive age and service providers were interviewed. Antenatal care ; services ral
nnicnaidi care [ (ANC), immunization sessions, counselling and medical exam!
inations during the first . suggest4- nf
FP visit, and tubectomies were observed. In addition, there were (
group discussions trust m t
with clients and service providers. Finally, the facilities were rev.etved ustagikCCk
users gave
keep th i
and nor is
Level of Satisfaction among Clients
Clients were asked whether they were satisfied with the services
provided by the
programme. About 57 and 21 percent of users and non-users i
respectively stated that
they were satisfied while the percentage of dissatisfied clients
> was 22 and 6 percent
respectively for users and non-users. When. i
interpreting this data, it is important to
consider issues related to methodology such
as courtesy bias and also the generally low
level of expectations people may have of the sendees provided by the programme.
Another important element in rural India is trust. People may be relatively
--mng to speak to outsiders, or strangers, until they feel they can be trusted. This
may be tire reason why as many as 21 and 73 percent of users and non-users
respectively responded that "they could not say" whether or not they were satisfied
Subsequent contact with the community also indicated that a large number of non-users
saymg so may not have been aware of the services provided by the ANM.
2
Based on an estimate of 170 ECs per 1,000 population.
24
Availabil
PHC, " >c
Imprc 2i
emergent
Suppl of
supplies.
Prope"m
Total
Note: Onlv r
J
J
i
on5; were
Both users and non-users were asked what they did and did not like about the
services and what their suggestions were for improving them. It should be noted that,
1 ''■^en in when asked, only 68 of the 220 users and 20 of die 245 non-users mentioned an aspect
particularly
id ested that they Darticu
^ar^v liked. About the same number expressed reasons why they did
rocess, it not like the services. Generally, the respondents liked the monetary incentives given
a i the for sterilisation acceptors. They stated that their interactions with the service providers
were good. They appreciated services being provided close to home and free of charge.
Non-users mentioned the following positive service aspects: good interaction with the
providers, and services provided close to home and free of charge.
Generally, the major reasons given for not liking the services were as follows:
poor facilities at the PHC; lack of cleanliness, electricity and water; poor health after
undergoing tubectomy; no follow-up services, and non-availability of or nonresponsive providers at the PHC.
y, about
pr ’ation
ac ?tive I
Relatively more clients were willing to make suggestions on how to improve the
en with
t< care services rather than to state their likes and dislikes, an indication maybe that making
tl first suggestions is easier than criticising (Table 1). As suggested, courtesy bias or lack of
:ussions trust must be considered. It is interesting to note that relatively more non-users than
i many areas may possibly
c' Sts I users gave suggestions for improvement. Shortcomings in
keep them from using the services. The suggestion most frequently made by both users
and non-users was to increase the availability^ of staff at different levels of the system.
Table 1: Suggestions by Respondents for Improving FP Services
b” the
e< that
aercent
t t to
11 .ow
at v ely
1 This
i-i ers
asned.
Suggestions for improvement
Number of users
Availability of health staff: sub-centre,
PHC, doctors and specialists.___________
Improvement of service delivery:
emergency, follow-up, ANC and PNC.
Supply of good quality drugs and other
supplies._____________________________
Proper maintenance of facilities.
66
Total respondents.____________________ I
Number of non
users
94
17
10
37
10
12
220
245
Note: Only major suggestions have been tabulated.
25
u
programme amp8rovideerbofelSe AnXT" ’PP“red ,O
expressed hi
““PKhensive RH or primary health care seMc^WeToT^^pX^J a tubectoi /.
XiZbT s “XXT^nti'oTToT “ *em X "8h
p—
Su e
childbirth (L); adviceP„„ the’neXXd bTTTS
views on ^ei
breastfeeding (63); referral of high-risf husband mig
a respiratory other han r
gynaecologil, probLXT-:
RTIS <4>;
vitamin A <
information on
cancers (2); and medical termination of pregnancies;
(MTP, 1 percent).
The Viev\ o
STrI "XX16* T <5°,;
When the se
; services tl y
' The reasons
inadequat t
records to r.et
Group Discussions with Clients
Group discussions confirmed many of the issues raised in rt,o ■ f
■
they conL^er’^^o^to^three-yea^interval^behv^
Clty' S'
not widely us< ' alth
' ' °U8h m°St WOmen exPressed **!
interval
between
preferred four years This rn
L
between pregnancies
pregnancies desirable;
desirable; ofde:
older women Point- 7111
promotion^’ ->*
*=
the programme combined with the i
conception soon after a couple gets marded
■mPorta"“
I"
exmnp.X
the more convenifm method hTevT f,
every day.
have a reversible injectable contraceptive.
"loss of stamina a„d
'U? USe aPFMred to >« considered
SS
h
“
6 conveiuent to
Emergency’£n
wif, Js
reasons why women prefer a noct noin,,,
u
'
e g°od economic
^^ '^I’oat face losr^/income^yway^jnce ^ey°Tre supcio dn^e, t^0Sc W'1° Per^°rm
26
Tc
Interventi is
revealed cuss
Therefore, ve
®aHmg ' n
improvement
their task! w
and traini j
during this pi
S expressed that the "big operation" (hysterectomy) would be necessary a few years after
>v nment tubectomy These statements are a cause of concern and require further investigation.
Subsequent interaction with the community provided the team with additional
a views on sterilisation. For example, both men and women stated that if a wife dies, the
r^. urmg
mjght want to remarry and have children with the new wife. This is, on the
^ra nS ot^er hand' not a likety prospect for Indian women.
k nt siatec
a^xun on
egnancies
The Views of Service Providers
When the service providers (ANMs) were asked about their satisfaction with the
services they provide, four stated that they were satisfied while the other five were not.
The reasons for lack of satisfaction were inadequate basic facilities at the sub-centres,
inadequate transport facilities, inadequate sterilisation facilities for IUDs, too many
a i also
records to keep, and lack of drugs for post-natal care (PNC).
ii g two
don takes
It should be noted that transportation presents difficulties for service providers
ie red.
(and that they are supposed to live in their area of work). In an area relatively close to a
big city, service providers prefer to live in the city and commute to the service delivery
ss^d that
t point This translates into short hours spent there and also in absence from work.
r omen
ult of the1
ta ~hed to
INTERVENTIONS TO IMPROVE QUALITY OF CARE
ic 5 For Interventions took place in many different areas. As indicated, the baseline survey
li
and sealed dissatisfaction with facilities and supplies among both clients and HCWs.
jackache Therefore, various structural inputs were provided early in the project to create
n iered enabling conditions for the workers to perform their tasks well. However, quality
r »rith it Improvement is above all dependent on people. How HCWs and other staff perform
?n-Lnt to!
tasks, what they do, and how they behave are critical factors. Awareness raising
; and training were by far the more important, time-consuming and complex activities
during this project.
li"‘tions
h .t the
conomic
p form
ic Ji. A
ome. As
s. lany
27
1
Structural Inputs
The
AfnXPtheCpHVehadb’CentreH
M
r°OmS ln Vari0US viIlaSes were upgraded laborato s
After the PHC had received a thorough clean-up including unclogging of toX 1 (They were
beds and furniture in the natient ward TArom
°
or toilets, the
were recovered Benches for M I
P
pamted' and 616 mattresses received ~ s
(US$3) i di
provided is
i
|
Develop
le
Observation during the baseline assessment revealed that blood
pressure and As sugg
weight were generally not checked at the sub-centres because
-centres
because
many
HCWs
lacked! n“ babh e
either stethoscopes, blood pressure cuffs or both AHlZS
<
machines) | and maintai
training
ei
AQOC
but a o
inputs Provided m Sliamirpet Project Area---------------------------the Qi te
Clinic rooms and benches for clients.
A tw d
Sub-centres (9)
-
Stethoscopes, blood pressure cuffs and scales.
A tw w
SrriOn ‘ab'eS; tableS a"d ChairSServi“ Panders; storage
Chairs, benches and mats for clients.
Curtains for privacy.
Torchlights.
Bags for carrying supplies.
Uristix; disposable delivery kits.
nmary Health Centre (1)
Hook-up to 24-hour water supply.
Repair and painting of furniture; electrical repairs
1 urchase of mattress covers, torchlights and lanterns
Benches for waiting clients; set-up of counselling area
Drugs for treatment of RTIs and minor ailments
'------------ ^gBEEHg^foLblood^rouping and Rh typing; x-ray film
28
Basic tra
inter n
needt_
urine tes
■
The iiati
and p-o-v
It wa
found th ' £
their ove 11
program wa
the proje . !
HCWs tc n<
were organit
The drugs for treatment of RTI and minor ailments as well as
e
X^SteinTe11^ X
Pgraded
f vuilets, the
h
kiS »XXd
e mattresse?
■h ;hts. The
provided is presented in Box 1.
al repairs. A
F
or me mPuts
Development of Human Resources
•essure and
prob“b^eqtire7to
-V ; lacked
r chines),
osene, and
te s were
°‘
S“ “X™of
SUPPUeS and
-
“fS
- -i'
■
A two-day training in counselling skills.
A two-week training for Child Survival and Safe Motherhood (CSSM) programme.
Basm training in using new equipment. The availability of new equipment and the
nati0"aI, ^IDS PrO?ramme provided the HCWs with training
and provided them with IEC materials for their outreach efforts.
& on HIV/AIDS
' fomd Jb»7? "nSidered =" '«
the traintag on-the-job. However It was
their overall “knfe^aZde
“ Provide
'»>«>««- Moreover.
Program was hired for this task Sh° reqUire,d imProvement. A nurse from outside the
the n™ <- c r 1 f “ t k' She received an orientation on quahty and the £oals of
______ H'
Subsequently, she spent time with the superv.sors ’and each rf tae “mate
r5 and skms-A ““p,e °f
29
'1
i
t
Checklists were <developed
’
for tramers/supervisors to assist them in their task of IEC at
improving work processes. Reaching targets for tubectomy
pr°j< 3acceptors remained a main
i
concern among the HCWs although recognition and prizes
were introduced for those *
who performed well according to the checklists.
c
and f As mentl0"ed above' protocols were developed for recording BP and weight villages
wete dV
nntS' Slmilarly' neW cllent registers and cards were introduced. They info iamore ANC v^t th/ m°^7"“^ for
HCWs and to provide space to record and .H
more ai\c visits, the results of urine tests, etc.
along
500 " Tc
gyn; cc
Both clients and staff identified <access to and' availability of services as major problem
hospita
areas. Interventions to improve access and availability reflected the complex
diverse causes of the problem.
h J and
Access and Availability of Services
commu
no i
n
,lntervc’ntl0n was a request for a bus stop in front of the PHC. Vacant
posts were filled in order to avoid the need for HCWs to cover more than their own
sub-centre area. Steps were taken to create awareness in the community of its rights and
and h 3Vai 1
° HCWs and services- For this purpose, signs indicating the days
and hours of operation were displayed at each SDP. Moreover, madequate supervision
aiailabX0^0^
C°mp0Unded 1116 Problem °f inadequate access and
availability. Some of the interventions are discussed more in depth below
Community Outreach
Because of the apparent mistrust and lack of knowledge in the
? community of the
reproductive health (care
---- services
’
- - - education and outreach were considered
available,
essential to improve the access
and
—to
-----J availability of quality services.
surprismgly, chents presented themselves with a variety of health problems reflect^
stesyd^9
need f°r SerViceS' In the organisation of the camps, the QI team
stressed qualitative aspects related to process such as health education for clients; use of
Coir’Hi
Howev
mob'1' ie
Nur nj;
were es
mal n
the
made
esta is
only « y
IIHFW
effo it
sup >r
1997, a
con ii
amc...g
3 An ._ea
30
; 1
■
■
11 ?ir task' off jgc materials such as inexpensive models of the reproductive system introduced by the
ained a mail/ project3; appropriate disposal of medical waste, and so on.
ze'4 for those
Street plays were also used to reach the community and create awareness about
: reproductive health and the services available. They were organised at night in 28
eight
villages. It was estimated that 6,000 to 7,000 persons attended. The plays presented
a I W(
•d zed. They ’ informationi on wide variety of reproductive health components including HIV/AIDS
ice to record I and STDs.
These were followed by health talks in the community. The supervisory team
along with the female HCWs organized altogether 22 such health talks reaching almost
500 women. Almost half of the women attending admitted to suffering from a
gynaecological problem. One third of the women were referred to government
jc- problem hospitals for further care.
)lex and
3r >lex
The male HCWs were also trained to organise health talks with men in the
community.
H . Vacant
1 their own
s ;hts and Community Mobilisation and Involving Men
ig _he days
supervision However, to improve the quality of care, it is necessary to go beyond outreach to
at ?ss and mobilise the community. This task was undertaken by a local NGO, the Academy for
Nursing Studies (ANS). Village and Women's Health Committees (VHC and WHC)
were established in 29 of Shamirpet's 33 villages. While the VHCs have both female and
male members, they are mostly male reflecting the village power structure. Therefore,
the QOC project prioritised the organisation of the WHCs. Considerable efforts were
made to keep the WHCs apolitical and working for the common good. The
ii of the establishment of the first committee took place in March 1996 and the final evaluation
considered only a year after that.
1C - in the
id g. The
, out, not
r^^lectmg
2 I team
nts; use of
A training curriculum (Box 2) and a participant manual were developed by
IIHFW under the project for the training of the WHCs. The actual training or outreach
effort itself was initially covered by a government grant. The QOC project subsequently
supported these activities and expanded them to involve men to a larger extent. By June
1997, all the WHCs had met twice to share their experiences and to celebrate (each
committee consists of approximately 15 women). The activities of the WHCs included,
among others, providing health education including FP information to the community;
An idea borrowed from the educational programme developed by ARCH which is discussed in Chapter 6.
31
s>i
-
■5
being depot holders for pills, condoms and ORS; growing kitchen gardens- assistin
community members in receiving health care services and referrals, and so on'
?
,
’
and mc*~ s
Box 2: Curriculum for the Training of Women's Health Committees
1. Social Topics (social status, literacy, child marriage, legal aspects).
2. Adolescence (menstruation, sexuality, reproductive physiology,
The Isi
menstrua]!
e
determinati°n' famiIy size' famiIY Panning methodSf The QI tea
succesf d
3. Pregnancy, (care during pregnancy and risks, preparing for delivery, process of two of ^«e
delivery high risks, five cleans - use of DDK (sterile delivery kit), postnatal and pilot cl’nic
to staf o
neonatal care, perineal care).
4. Reproductive Health (white discharge/RTI, STDs, AIDS and care; chronic unemploy
reproductive problems, cancers, uterine prolapse).
?c
o. Child Care (birth weight and neonatal care, importance of breastfeeding, infant
establishec
care, immunisation, respiratory infections, diarrhoea, scabies and skin care time u h
worm infestations, growth and development, nutritional problems and
scale, c d
corrections, weaning foods).
ensure ow
6. General (personal hygiene, environmental sanitation, nutrition, kitchen gardens)
7. Group Activities (registers, meetings, WOMAN project, division of work in the
^if
servicesf<
village among members, health camps, conducting women's health clinics
conducting child health programs, teaching the villagers, monitoring health retired ?r
clinics. iTi
services in the village).
from th'' \
! With : p
I sarpanch
The objectives of the intervention to mobilise the community were manifold:
and erne) COnCePtl°n '
■
Educate and empower village women to become a positive force in their own and
their family's health;
Improve reproductive and overall health including health seeking behaviours; and
Create bottom-up pressure on the health care system to improve the services
provided.
r
The hope was that the VHCs would be sensitive to community needs and
support the WHCs. Some were very supportive, but, from the experience of the team,
community leaders do not always play such a positive role. As the project activities
proceeded, it was felt that outreach to young men through the establishment of youth
groups might increase the support needed by the WHCs. In addition, health education
32
li
supplies i.
salary nc
charge uO
visits ^n<
regula ?c
\f
WHG m
involved
identL d
sifeiH
ens, assisting deluding information on
STD/HIV prevention and contraception - including male
c
methods - was considered a priority in its own right for its impact on both women's
and men's health.
The Issue of Access: Empowering Communities to Organize Quality Services
lenstruaf
% methods' The QI team discussed whether the existing system, even with improvement would be
| successful m providing adequate access. Based on other project experiences in the state,
, ocess of tw0 .t^ie most under-served villages in the project area were selected to establish two
•stnatal and' pllot clmics t0 be run by 1116 WHCs. A local woman - chosen by the WHC- was trained
| to staff one clinic. For the second clinic, the WHC chose an already trained but
,
I unemployed ANM.
•e, chronic
Because of its involvement in the mobitisation activities, ANS had already
„ mtart established good rapport with the community. The organisation spent considerable
skin
-i care, time with the WHCs while guiding them in the development of a client charter, a fee
1( is and scale, and so on. It was felt that these decisions must be made by the WHCs in order to
ensure ownership - a critical element in making a sustainable intervention.
gardens),
Different kinds of inputs were provided by the QOC project to establish the
o in the
th clinics, services, for example, simple equipment, funds to get the clinic started and to employ a
n health retired female HCW to train the local woman and ANM selected to work in the two
c rnics. The WHC in one of the villages (Formal) managed to secure space for the clinic
from the village head (sarpanch), transportation of equipment and supplies, and so on
With support from the community, it was similarly successful in persuading the
sarpanch to have toilet facilities and a wall built in the front of the clinic.
Hold:
I
c n and
■ir
and
--rvices
?eas and
hn team,
k /ities
□f youth
ii ation
Cllents PaY for the services provided by the trained local woman and for various
supplies initially
i
provided by the project. She is an employee of the WHC, and both her
salary and future supplies depend on the income generated by her work. There is no
charge to clients for services provided by the government HCW and doctor during their
isits (once a week and once a month respectively). Neither visited the village on a
regular basis before the project began.
&
After the establishment of the clinics, ANS continued its work to sensitise the
WHCs and the community k) issues related to reproductive health and to issues
involved in irunning clinics. In collaboration, they updated family
registers and
identified women
men with gynaecological problems. They requested the femate
doctorr at
-----------
33
8:-j
. ....
the PHC to provide a special clinic session for the symptomatic women
visits may be organised as needed.
More such
h
From the experience with the early camps, it was clear that there was
considerable unmet need for services related to gynaecological problems. However, the
QI team felt that these camps, or sessions, should be relatively small to keep the focus
on the individual woman and to ensure
------ 2 the highest level of QOC possible.
Improving Quality of Private Sector Services
Registered medical practitioners (RMP) are a major source of care for many Indians
ecause they do not have access to better trained health staff Because of their
madequate knowledge, the RMPs may pose a health threat. For these reasons the
project contacted them to provide information and training on, for example universal
condoms^ "d ™/STD/AIDS- W
served coJect information on”d
RH/STD
?S butl°n' Moreover, they were encouraged to send clients with
RT1/STD symptoms to the PHC for treatment.
ASSESSMENT OF CHANGES IN QOC
Increased Client Satisfaction
leading to
ten viP-'re
most c tl
availabilit
ANC \ n
couple f
performar
place.
a
place.
h d rT1
UabOn revealed that clients did indeed perceive that quality improvement
had taken place in the government programme during the last couple of years. A total
t 22
243 r,On’users were interviewed. Sixhj-nme percent of the users
mtennewed stated that they observed change while almost 58 percent of tlLon-users did Zy
HCWs Tt tb X Z
aVaUabi^ -d ^-iture, more time spen/by7
HCWs
the SDPs, cleaner facilities, and better referrals (Table 2). Compared to the
ellne survey there was a significant increase in the number of clients who stated that
they were satisfied with the services (Table 3). Methodological issues such as courtesy
bias were drscussed earlier, as were low expectation and the importance o^
estabhshing trust. Due to extensive contact with the population in the project area and
establishment of trust, the QI team speculates that people may have become more
willing to communicate over time.
<=cume more
place, nev
baseline a*
and so n.
people noi
4 Both users z
34
• •
!
-
■ 1
■ f.-f
i
i.
More such
d there was
d vever, the
Bep the focus
any Indians
is of their
•e^ons, the
e, universal
c FP and
lients with
movement
n A total
tne users
They
s ?nt by
ed to the
ta d that '
c irtesy
tance of
a. a and
■m more
Table 2. Percent of Respondents Observing Changes in Services
Change Observed
Percent of Users
Observed change
Specific changes observed
Better AN care
Better drugs
Better availability of staff
Better furniture
More time with staff
Cleaner facilities
Better referral
69
Percent of Non
users
~58
~
59
50
48
38
26
19
8
50
38
31
29
11
12
3
Table 3; Percent of Clients Stating They Were Satisfied with the Services
Client Cate^on/
Users
Non-users
Baseline
Final Evaluation
73
57
21
42
The group discussions indicated that
leading to varying levels of satisfaction or W progress was uneven among the HCWs
dissatisfaction among clients.4 In eight of the
r-
-nanon
j —1 or
definitely improved. Increased
ANC were frequmUymeXed Z XwereTfe taXw'4
an<‘
couple of sub-eenne areas w.tb relabreiy lower-per oX^g HcXr XedX i" ‘
P>ace, new S
Paople now saw a need
Witt'
“P—t tatog
at'™
Both users and non-users were represented in the group discussions earned out in ten villages.
35
centres still did not have toilets but some were shifted to better faHliriac d
project. Similarly, more e,lieges provided a r00„ for
miprovements were often the result of community pressure on local
QOC project began and the government health se^ce“^^
Increased Satisfaction among Service Providers
pTrS8xt
x
■
k
u
The last :
though t
projec ?€
they state
1 conce et
suggested that the structural i was a li{:
WHCs w
client; ft-
che;^eMbled
Box 3: Statements of Health Workers Towards the End of the Project
HCW^0^1 made
Services Provided at the sub-centres comparable
finally p
will come
time t‘ r
proba y
to private clinics" (female
"The disposable delivery kits are being used extensively which made home deliveries safer" (female
HCW).
"My work became more systematic after the project" (female HCW).
betwe 11
must also
consu ir
Tha
: project oe
was nr*- a
"Personally I gained by learning the practical concepts of how
to identify high risk pregnant I was al
women" (female HCW).
"The project gave an identity to us. Now the community recognises us with the bag" (male HCW).
"Though we could certainly develop better rapport with
the com:.munity through the project, our
responsibilities have increased" (male HCW).
nrivrrP^00^1^2 t0 1116 HCWS' many areas stm need improvement despite the
i
pregn; t
36
A,..
-■
•-
T'-T--
..
JS luring the f
■r visit These
ic-s once the : Increase in the Use of Services
it n.
I
XX3’ workIoad
•‘Trincreased
*e fact *after
at theHcws
QOC
Xg" “‘2
project began. During the group discusst^n
they stated that the demand for ANC had ’F S6rV1“ Providers at the final evaluation,
Planning was
o with the ': concerned, the providers stated that most peonlT HU
u tubectomy' but
there
e structural was a slight improvement in the acceptance of sn '
S°me VilIageS' 1116
led them to ' WHCs were, according to the providers helnXl'1115
clients after they became depot holders for pile and cTnSme
8
'°
st n client
<"
community
It is i
“ n°te
tow"ds
end of the proici
--------------- ! tae?me Vb”'
(ons“ need^pendT'
longer need to spend
I toe to reKh
ar--
beginning, this
| P-bably still is-met withco^bi^;
-----mistrust
and
resistance.
ics" (female :
According to the client interviews, the
er" (female
■
| consuming due to the addition of tasks during the pro^ert
2gnant|| Was already mTn^ned"thLX’gow^^^^^
t0
m°re time’
successfui (Table 4). It
tO
SUCh kitS when 1116
Project began, so only a small number oTwome
was not asked where they obtained t^e k t"
"
H /V).
Oj^t our |
Table * Peerage D,s,nbu„a„ of Hespi,„dems „„h ,fe
a. Ho„e oe a,
the
f ther
it was
Type of client
User
Non-user
R
M
Baseline
Final Evaluation
17
18
80
68
1
MW
of referral went beyond
□ increase the scope of
37
*1
the programme in spirit with the ICPD-POA
n.
and
the
Health Programme in India For example the b
ReProductive and Chilc
led to a high number of fovn
,ampIe' 1116 heaIth talks for women <’
described abovf Choice f
under the <|oc project ha^^
f
-mps organise^'
needed. Similarly, the increased awareness of the HCW^ tr^atment °r referraJs * The bi 21
increase in referrals from the sub-centres (Table 5).
656
Ied to an exampl-,
available.r
the twcBu
Before the project began, there was no <
consistent
referral
system
so
no
methocS. I
ompanson can be made in terms of numbers of
—' referrals done then and later
However,?t is likely that the majority of the twomen would have continued to ignore!
their problems beca
- -Juse of the lack of attention to
-J reproductive health problems.
Table 5: Number of Referrals
Origin of
Referral
Health
talks
Sub-centre
No. of
clients
seen
436
No. of Clients
with
Gynaecological
Problems
216
^°- °f Clients Referred to F No. of General
PHC or Government
Referrals
Hospitals for
G ^ecological Problems
~~ 69
51 (to PHC)
57 (to hospital
67 (to PHC)
39 (to hospital
23 percm'or"O"‘Pta““lS frt,m 1995 '»
about
reMvely highest among adult women (about 25pe, cemCln Ss™' P” ‘T”’"
make services at the PHC more easilv available f i f ' 1
c°ntext, the effort to
schedule was developed to ensure the availab l e °,Cll™tS must be discussed. A new
opposed to noon earlier) to see clients There w7s stitl
9 a m’ tO 6 P'm' (aS
place, the^f also expressed'tharfu^ther'improvemen^were needed3*
Bas lb
Finai
*p0l
The
method th
of healt s
while that
the imp U
more
k
i fl
at the final
about b*’?!
accordii t
the male F
quickly n
Other L ue
During ^he
informa )r
appeared tc
one me'1 jc
effective es
38
■!
kt
1
ti ; and Chile
escribed abov/ Choice of Method
11 > organise^
c_ referrals a/• The baseline revealed many weaknesses in the information giving process. For
;ues led to as example, the HCWs did not routinely inform clients of all contraceptive methods
available. Table 6 indicates that the relative emphasis on tubectomy decreased between
the two surveys in as much as providers now inform clients more often of all available
sy<^em so no methods. Interviews with providers and group discussions confirmed this.
ie and later.’
med to ignore’
is.
Table 6: Percentage* of Users Offered Choice of Method
Condoms
OCs
Baseline
27
39
Final
34
77
*Rounded to nearest w iole number
Jo. of General
ferrals
phc)
X lospital)
9 > of about'
increase was’
tK? effort to!
ss i. A new!
to 6 p.m. (as ?
a he PHCJ
it allowing
ments at the
ie ’ed.
IUD
Tubectomy
34
59
85
84
Lap
Tubectomy
6
2
Vasectomy
18
14
The users interviewed at the final evaluation were more aware of spacing
methods than those in the baseline sample. According to users, the relative importance
of health staff as the major source of information on contraceptive methods increased
while that of friends, family, spouse and others decreased. It is interesting to note that
the importance of health staff in providing information on contraception increased even
more markedly among non-users.
»• !
Although fewer female contraceptive users received information on vasectomy
at the final evaluation, it should be noted that after at least 2-3 years of no vasectomies,
about twelve were performed in the project area from the end of 1996 to April 1997
according to the PHCs service statistics* This is an indication that the involvement of
the male HCWs and their addressing men's need for information and services can
quickly have the desired results.
Other Issues Related to Information and Protocol
During the intendews, clients were asked about the nature of the FP and other
information they received from the HCWs. After the interventions, the workers
appeared to provide information more frequently on the possibility of switching from
°ne method to another; how to use the method; the scope for reversibility; method
effectiveness; follow-up; re-supply; and appropriateness of the method. Moreover, the
as *«jwest
ion.
39
*
Vi
I
HCWs appeared to discuss spouse's su
pport and preferred family size to
than earlier.
a larger extent
HCWs remained resistant^r^TXT thar^de-tffecte
>r
service: if
p”5®^
areas. The
appeared to be convinced that their clients are more likehTd' 6 dlSCUSSed- They stil1 and mu., r
told about side-effects. Similarly, they tended not to die '
dlscontinue use if they are
tiie method works.
Y
° dlSCUSS contraindications, and how
Other Gab
express^'thHa?X'Vfoeu„d’^dta“kTide
Wl/STD/HiV. The,
Before e
according to clients they were an important'sour'118
lnforn'at]on d,fflcult, but assessment
(34 percent) and non-users (33 percent! indirar d rh ° ]mformation- Both female users evaluati a,
of information. Radio/TV served this role for Stnd^S
Were a ma^or source commit ss
respectively. It should be noted that amona the d
°f USerS 3nd non'users
they had suffered from an RTI 41 n
y8
women interviewed who stated that?
( ie
sought care a, the sub-X
'
Per“n‘
““ “"d 35 P™ of non-nsers evaluation.
their
ZoTuTtV te
1163,01
the men interviewed than for the women M
' ’ atlVe y m°re m’Portimt sources for
than women. Slightly more
h?("( ?,
mOre
a“'are »' HIV/AIDS
HIV/AIDS whileLmo?E « « (“f *he1,nter™»<’d stated they knew about
users did. More men than women
a''' “a ? P"™1' °f U,e "onwhile the knowledge that it spreads from mother (o child^XtmTsX"”' bl°°d'
had
ex™Xp?“Tl m
Although f
WHCsl d
gave the yV
I ei=
Moreover,
commui "y
involvec n
p?!t“'OmC"
about it (users. 24 percent-non user, as P
‘"“I
d,d nothi"S
slight increase in t!e number o! mmen T"(
’17 P““"^ ^re was a
exam (6 percent at the final evaluation versus ’3 pXt atUe'te^r^ ‘
Issues Related to Client Conveni
ence and Acceptability
The a bo 1 <
provider ap
which is * r
consider u
top priority
the final Llu.aon
The
o
of
must ch
40
’ Jci *
£
' ■' J*.
;
... . ...............................
,
f
l?r<jer extent
ILonger time
‘
for providing examinations and possibly more clients receiving
I services appeared to have had a negative impact
on waiting ti:Lines and possibly also on
~
privacy despite the intervention to provide curtains and screens. Moreover, it is
ar reas.
ica&. The
ine^ possible that the HCWs are still not sufficiently sensitive to clients, needs for privacy
if ti-T
and mUSt make eff°rtS tO USe
Provided for this purpose.
n. and howl
Other Outcomes
T V. 'They’ Before the final evaluation, the community mobilisation intervention carried out selfihwult, but * assessment during the less thani one year it was taking place. At the mid-term
Bmale usersd’t evaluation, the team felt that, of the 29 WHCs, five worked very well while four
r source committees failed or malfunctioned, and the rest were deemed to be average.
1 non-users
s'* ted that1
Questions were asked about the WHCs in the client interviews at the final
f )n-users. evaluation. More than 50 percent of those interviewed knew about their existence
Although fewer were aware of their exact activities, the respondents stated that the
WHCs had led to better availability of the HCWs, and of OCs and condoms They also
t< <s were gave the WHCs credit for better ANC.
sources fon
H 7AIDS
Interviews with men showed that they also knew of the WHCs activities.
■new about Moreover, the HCWs appeared to consider the committees a positive force in the
f ^he norp community. Considering the short time they had functioned and the level of difficult
w blood, involved in community organisation, these could be viewed as good results
w.
I
I it they,
CONCLUSION
1 nothing!
ie wasa f The above description shows that quality' can be improved and that both clients and
1 breast Providers appreciate the improvements. However, two years is a very short time for QI
w ich is a never-ending process. Quality itself is a dynamic concept, and what clients
consider quality today, may not be considered so tomorrow. Quality must remain a
op priority on the agenda of managers and supervisors at all levels to be sustainable.
Jstacle at
>e ’ue to
■re links
Many lessons were learnt during the project about quality:
The project showed the considerable extent to which quality required a different way
of thinking and of doing things as well as the critical role of management: managers
must change their approach when they aim to improve quality.
41
t
and proCeSSeSP we found™ZXtiZA'0"1"
labour intensive.
'
h
S Doth 131116 consuming art
SriL
As the benefits of improving quality’
were elt, staff morale improved and tlJ
community became more involved.
aba?,d0''ed “
quality improvement can only proceed to a certain pomt.
n
Focu i
-ith new
Eheli|c
S°
Eheliyaj d.
Colombo. I
the Deputy
health n iv
per monm.
when th~ m
Baseline 3t
Interviews
identifie st
midwife re
expressed i
services f
mortality ra
I u
or good thi
Among ’’ e
cost, use h
1 Contrib'-^ec
S.B. Ab< d<
42
ill
h
k ehaviourj
isuming an/
4
Sri Lanka
ved and thf
Focusing on Clients: Improving QOC at
pd with new1
Eheliyagoda1
- ntil staff
n 3 do so;
BACKGROUND
Eheliyagoda is a part of the Ratnapura district located 80 k:
;m from Sri Lanka's capital
Colombo. Its population is slightly more Ithan 65,000 according to the 1995 numbers of
the Deputy Provincial Directorate of Health Services. Eheliyagoda
covers 23 public
health midwife (PHM) areas with a ftotal
' ’ number
' of' 15 clinics holding about 26 sessions
per month. The programme considered the services in the
------- —! area in need of improvement
when the project was initiated.
^2
Baseline Survey: Strengths and Weaknesses Identified
Wlth contraceptive users and non-users, men, and antenatal clients
entified strengths and weaknesses in the programme. Users were selected from some
midwife areas to represent a mix of contraceptive methods. Overall, client satisfaction
.^pressed m the interviews was high. This may reflect genuine satisfaction wL the
services of a pprogramme that has been successful in reducing infant and maternal
mortality rates andI reaching high levels of contraceptive use.
To understand what creates client satisfaction, clients were
asked what positive
! or good things they had experienced or heard about the st '
services provided (Table 1).
P°Siti?IaSpeCtS mentioned by users were family planning information
i, no
cost, usefulness of the services, and provision of services in the home.
' SXUS
A
c
CD43
* TW
ft
f
The negative things heard or experienced by users, non-users and men in the;
community and their suggestions for improving quality were interpreted as an indirect
way of expressing dissatisfaction and pointing out shortcomings (Table 2). A high percentage
of non-users and men have neither heard nor experienced anything negative, but access
may be an issue for non-users. Users mentioned inadequate access, facilities and
supplies. Having used the services increased the chances that clients had heard or
experienced something negative about them.
')U
rr
| vV
Clients had several suggestions for improving the services provided by the
programme. Suggestions for improvement made by ANC clients are provided in Table
3.
lPI
V
|r«
Table 1: Percentage having experienced or heard positive or good things
about the services *
Aspect experienced or heard
Services are very useful______
Free services_______________
Services provided in the home
Services easy to obtain
Provide information on family
planning___________
Kind staff___________
Don t know____________
12
Non-user
n=159
20
29
31
13
25
User
n=250
49
61
42
39
63
Mer
HIV/A S
should rece
subseqt 'nt
supplie )f
sterilisatioi
admini: ?r
45
9
21
22
17
The
STD/H \
issue
indicated t
public ?a
providers
small ~oi
knowk gt
very limi
inform ic
inform ic
Male
n=52
16
22
7
*Each client could mention more than one item in Tables 1, 2 and 3
Table 2: Percentage of respondents having heard or experienced bad things
about tlie services
Negative aspects heard or experienced
Nothing negative____________
Not satisfactory_____________
Not accessible_______________
Method failure______________
Time consuming (waiting time)
No supplies sometimes
Lack of facilities
Men
(n= 52)
50
17
3
19
7
7
Non-user
(n=159)
61
25
48
6
12
13
14
Users
(n=250)
23
29
30
2_
17
37
38
2 Thripostia
years).
44
-^4'1
1 men in the
ar- in indirect
h ercentage
re, but access!
a ities and *
a heard or*
ia^d by the
ded in Table [
s
’Iser
!
=250
49
51
12
39
>3
?2
.7
rS
I ers
n=250)
3__
z.9
..... ...................................... .......
Table 3: Ante-natal clients- Suggestions for improvement of services
Suggestions made for improvement
Improve toilet facilities
Water to drink
Furniture (chairs and benches)
Syringes and needles - free of charge
Provide services according to arrival
Facilities for blood tests (referral for blood test
was done but not systematically)
Regular issue of Thriposha2
Percentage ofANC
clients making the
suggestion (n=148)
25
18
43
55
13
57
49
Men frequently suggested that they need information, particularly on
HIV/AIDS. Both men and female contraceptive users stated that children and youth
should receive information related to sexuality - a request that was often heard during
subsequent interaction with the community. Moreover, users suggested regular
supplies of contraceptives, more facilities and drugs as well as facilities for LRT (female
sterilisation). Some! users felt embarrassed having the Depo-Provera injection
administered in public.
The programme was interested in learning about the clients' knowledge on
STD/HIV. The interviewers asked the respondents whether they had discussed the
issue with anybody and with whom (Table 4). A surprisingly high number of users
indicated that they had discussed STD/HIV with the public health midwife (PHM) or
public health nursing sister (PHN). This was confirmed in interviews with service
providers but some were concerned about the soundness of their own knowledge. The
small group discussions described below indicated that the quality of the clients'
knowledge of STD/HPV was poor suggesting that the information received may be
very limited. Moreover, doctors played a small role in providing STD/HIV
information. Particularly men, but also non-users, relied mostly on friends for such
information.
QQ
17
' 7
F
Thriposha is the food supplement given to pregnant and lactating women and children (6 months-5
years).
45
W
The ia
of tl *
"safe pe
Table 4: Source of information on STD/HIVfor clients who discussed
this issue with son,nebody (given as a percentage)^
•
Person with whom STD/HIV was
Men
Non-user
User
discussed
n=30
n=76
n=162
Friend
75
32
12
Doctor
7
1
3
PHN/PHM
1
29
79
PHI
1
Others
17
17
7
Cannot remember
__ ________________
12
29
This table includes only clients who stated that they discussed STD/HIV
with
somebody. Each client could give more than one response.
Mos of
that me
the nHI
•
Sorr i
acceptii
„., Son c
; Dep- P
S^and ^ar
S'and c
A.
■...
F '
T' Many t
pro’ ie
Questions were mcluded in the survey to assess clients' awareness of availability k # 110 v b<
and know edge of use of contraceptive methods. Not surprisingly, users were more •, Som- n
i At!'5-.". •
,
smc tr
aware of their availability than non-users. Men had least awareness about female
methods and of the three categories of clients, they had the highest awareness of the I1B” fcnowle
availability of male methods.
\ info u
/ info ic
provide
Nevertheless, the small group discussions indicated that there is a I'
big gap
between bemg able to explain how to use, for example, condoms and to demoM
correct use (Box 1), Actual use would presumably be even more difficult. Similarly,
superficial knowledge of AIDS may be better than no knowledge, but more in-depth
information may be required for people both to perceive a need for behavioural change
den n
and to know exactly what to do to practise safe behaviours.
■ • The me
j
thai ic
,
............................. J < : : and oKi
Box 1. Group discussions with clients in the baseline survey
• •
!i • Fur ‘ ei
In Eheliyagoda, altogether eight group discussions took place to explore in depth
J^owIedge of family planning and STD/HIV. Each group consisted | v behavh
15-20 chents totalling almost 200 people. Four groups consisted of married female h HP et
th,. A.
users and non-users; one group of only non-users; and three groups of married andl i
previoi
unmarried men. The following issues emerged:
|
deF il
I
I....
hi The ne
A malect
■•1
'
? “n
J
„o.
I
■
46
■■
S3
•
The majority of the women knew z/something" about contraception. More than half
of the women had at some time accepted a modem FP method. Those practising
"safe period" often used tire method incorrectly.
5
.
Most of the non-users did not want a child within the next 2-3 years. They stated
that they might have decided on a method eartier had they discussed the issue with
the PHM. Some expressed that they could still select a method.
.
Some users appeared to worry about a possibly negative health impact after
accepting a method. This fear appeared to be behind non-use among some women
Some of the fears expressed included menstrual problems and cancer related to
Depo-Provera; cancer related to oral contraceptives; complications, transmigration
and cancer related to IUD use; unpotence and lack of libido related to vasectomv;
and lack of libido and difficulty with heavy work related to tubectomy.
.
Many users mentioned that they had to obtain Depo-Provera from private service
providers due to shortages at government sites. Most stated that the expense of RS
110 (about USS2) was difficult to bear.
Is
=1 >
12
7
of availability
Some men mentioned that they obtained knowledge of FP from books and articles
since there were no programmes for them. Some stated that they have more specific
knowledge from these sources than their spouses who receive services and
information from the clinics.
They expressed interest in obtaining more
information. It would appear that men could become involved relatively easily
provided the intervention is well done.
'
s ^ere more
ibout female
rt ess of the
s
big gap
) ^monsirate
It. Similarly
oi in-depth
?ural change
Tire majority of men had inadequate knowledge and negative attitudes towards
male contraception and towards vasectomy in particular. Knowledge on correct use
o condoms was poor, for example, the difference between explaining and
demonstrating correct use.
•
The majority of both male and female participants had heard about AIDS, but less
than half knew that AIDS is incurable and that it is transmitted through sex, blood
and skin-piercing instruments.
•
Further exploration revealed that clients have little in-depth knowledge. Thev did
not understand how transmission of HIV occurs; what constitutes high-risk sexual
behaviour; and how to practise safer sex. Moreover, they did not understand the
HIV test and the window' period; the difference between HIV and AIDS; the fact
that- AIDS is a syndrome; and what tire symptoms are. The few clients who had
previously attended HIV/AIDS programmes also expressed lack of specific and indepth knowledge on these issues.
I
re in depth
:p Dnsisted
rLJ female
:arried and
47
‘ HlVVt„CfeZr’<PreSSed T"0” 'k’' ''■°“ld >* cond-dvetodiscrindratartagainst
• written j
i n
enter the
saloon or tire tea-kiosk; touching an HIV infected person; allowing one's
' ' barber adequate
2nc's
children
to (not f<•nr !»
play with the children of HIV-infected
b
persons, etc. These misconceptions were abou 'O
discussed. Efforts were made to analyse concepts such
as personal responsibility
and choice.
othe^than
articipants' male and female, had no basic knowledge on STDs
Other
than AIDS^Th
aibq tCdllu remaie, nad no basic knowledge on STDs
° be
1 anv
*a"AIDSH:. ’’T V‘lla8e lerm f" STD
STD 1S
is
‘Jfease".
There did
did -t
mt appea
appeal
to
disease
'' There
to be any distinction between STDs and other RTIs.
1P
aaPP
PPei
ei ;c
they are
.
they
SUpp]
s,
health*1118 FP ?d HIV/AIDS frequently led to discussion of other reproductive 1116
health issues and even overall health.
F ^ucuve
A majority of clients expressed a wish for written health information including
ObsCx .a
verXoune 6
m"
fOr
h°mC
pe°ple °f a11 a8es' even
Both tire baseline group discussions and tire small group sessions subsequently
organised to reinforce the skills of the newly trained staff offen ended wSJ ai request
with d6 COmmUni7 t0 C°Ver the entire teena8e and adult population in tire village
with tire same information. There was appreciation among people that X
seriousness of HIV makes it impossible to consider sex the taboo subject tliat it has
1
f i1S' (:°nSldered according to cultural and traditional values Clients
diatetliev th1^ 1
i31*
are aVailable t0 C°nti,1Ue tO provide formation, and
to attend tT
J
" reSpOnsibilit)’ to help ^ganise and request health staff
o attend. The participants were also encouraged to discuss their new knowledge
both with family and other community members. It was emphasised tliat STD/HIV
can be brought up everywhere to spread tlie word among people.
7
Interviews with Providers and Managers
U
?
.
.
Conti
IE n
N n
No cl
St if
T1
did n b
done be
iirimi
iz
risk; c d
Ten service providers and hvo managers were interviewed. Group discussions were
also held with providers. Staff were very open and willing to identify problems such as:
Bias in discussing methods with clients
• Inadequate FP counselling and information on m
mode of action, side effects, risks
and benefits, and how long the method is effective,
Clients were often not told that
method change is possible
• Inadequate screening for contraindications and no checklists used
• Problems with supplies and equipment
• Sometimes breakdown in referral system for family planning
48
y
infon_„iti
syringes i
n
assessme
methc o
r-
■
.
....
■
nation against
■id ’ bathing i^
t( the barber
e's children to
dons were
r< ponsibility
ponsibilitv
__
e< e on STDs
P
m not appear
I
r ’reductive
o: including
geo, even the
written protocol. The service provider explained that they take medical history before
providing a method, but felt that they did not know whether they perform tiiis task
adequately. Furthermore, they stated that a pelvic exam is done only for IUD clients
(not for Depo-Provera and OC clients). They did not routinely ask IUD or other clients
about possible RTI/STD symptoms.
While the, providers
Pluvluer!’ stated
statea that
mat they
mey provide
provide STD/HIV
STD/HIV information, they
appeared to think that it is madequate. Finally, four of the ten providers stated that
they are not satisfied with the services they provide because of lack of facitities and
supplies, and because of the heavy workload they have, The same issues were raised in
the group discussions.
Observations and Facility Checklists
Only four family planning counselling sessions were < ‘
observed. They were very timest sequently consuming because the observer must be i
---------------in
the
right
place at the right time. The
4th a request problem areas identified included:
n he village
31 that the
• Contraceptive samples were not used
ct that it has
• IEC materials were not available
■ie
Clients
• No information was given on STD/HIV
nation, and
• No checklists were used
health staff
• Sterilisation consent forms were not available
1 owledgi
itaTD/HIV
did
°bSe™erS °f
five immunisation sessions noted that some refrigerators
done b t e 3 therm°n?eter; th" Ejection site was sometimes incorrect; recordlg was
imm
6 °Je glVing F16 mjection'’ inadequate instructions were provided after
munization; unsafe handling of needles and syringes sometimes put providers at
nsk; and some providers were unsure of age-appropriate immunisation ?
ssions were
-ni such as:
ffe^ts, risks
ot jld that
Observers of the four ANC clinics noted that clients received inadequate
svnnXs aTd " a^dlbOn' Some equipment was not in working order, clients had to buv
syringes and needles, and there was a lack of IEC materials.
asse« They !b°rr
Sh°WS
method T if°J
m°St Pdrt
Methodologies validated each other.
616 Pr°blem areas identified by each
Same' S° overaU 1116 results ^of the
49
« ■ y
!
8f
INTERVENTIONS TO IMPROVE QUALITY OF CARE
Interventions Begin: Creating Staff Awareness
and staff in the FP/r'
new concept for both managers
and staff in the FP/MCH programme. The QI team consisted of managers fron,
different levels who were sensitised to QOC issues at a regional workshop early in th
project ^rey felt that awareness raising of all staff to issues related to quality was J
precondition for proceeding with the project.
Problems
Lack oJ he
Irregular
(Depo
Provic rs
that some
more t ai
of a
Local hos
sterilif tic
provic rs
. needed to go through these steps m order to have ownership of the QI process.
All sites c
tempc ir
Box 2: Elements guiding the project:
The training stressed the critical role of service
• Choice of methods.
providers in each of the dimensions of quality
• Information given to clients.
and the extent to which their behaviour and
• Technical competence.
actions determine whether clients choose to use
• Interpersonal relations.
the services provided by the programme. For
• Follow-up mechanism.
example, they were encouraged to be very
• Appropriate constellation of conscious of interpersonal relations during
services.
interactions with clients. More specifically, staff
were told to be kind and polite also when
• Availability of essential
clients make mistakes
such1 as arriving late for
supplies and equipment.
-------------• Accessibility and availability appointments, forgetting to bring their
appointment cards, and so on.
of services.
Inadeq
ANC die
inforn ti
Clients re
inforn ti
InsufE^xe
provided
effect ii
long med
possib’Ht
Tire importance of showmg clients respect and considering their opinions was
equaUy emphasised to staff as was ensuring that clients understand the information
and instructions provided. Service providers were, among others, encouraged to use
same words as clients and to ask questions. Moreover, staff were requested to pay
more attention to unmarried clients and to those with domestic problems The
JZTnte'to d^"7
Was hWted to create a sah environment
for chents to discuss sensitive and difficult issues. As discussed below, subsequent
supervisory activities have continued to focus on these dimensions.
q
Lack c. II
materials
Inadequatt
inject! is
The problems identified and the interventions are shown in Table 5.
50
" in
tc
' ■!» "“v T-'................ ...
■
Table 5: Problem Areas, Indicators Selected and Interventions Done
1 managers
aj rs from1
eany in the'
ah’^y was a
d' 'on of a
ei
(Box 2). ■
; to analyse J
a he staff
;s.
?
service
; ox quality
iv’our and
o< e to use
amme. For
o ’ >e very
n during
ically, staff
a] ) when
no late for
ing their
in^ns was
if mation
ged to use
:t( ’ to pay
. The
vironment
u equent
Problems identified in the baseline
Interventions
Lack of choice
Irregular contraceptive supplies
(Depo-Provera).
Providers and managers state
that some methods are promoted
more than others.
Manager/staff meeting at the end of each clinic
session to plan for adequate supplies for the next
clinic session
Local hospital does not provide
sterilisation due to lack of trained
providers.
Sensitisation of staff (through training and
subsequent support) to the importance of
method choice; training to ensure all staff
members have correct and sufficient knowledge
about the methods
All sites do not provide all
temporary methods.
Efforts to train doctors at local hospital in LRT
and vasectomy
Training of IUD service providers
Inadequate information:
ANC clients do not receive
information on warning signs.
Clients receive little or no
information on STD/HIV.
Sensitisation of staff to importance of adequate
information; review of correct information
Training in various components of RH including
STD/HIV, communication and counselling
STD/HIV prevention message to be provided to
all clients
Insufficient information
provided on methods: side
effects, risks and benefits, how
long method is effective,
possibility for method change.
IEC provided to clinic sites and to PHMs for use
at home visits (including bag for carrying IEC,
contraceptive samples and penis model)
Lack of IEC materials or IEC
materials not used.
One penis model provided to each field level
staff and to every clinic site
Method specific information introduced
■;
!S
s
Sensitisation of need to use IEC materials
Inadequate privacy: Depo-Provera Sensitisation of staff through training (and
subsequent support) to importance of privacy,
injections provided in public.
confidentiality and good interpersonal relations
with clients
Procurement of screens/curtains
f
I
51
I
06655
0C
k*Vooc'
d
1
Problems identified in the baseline
Interventions
ensure privacy during counselling, exam and
provision of method
Inadequate technical skills and
infection prevention:
IUD providers state they do not
feel confident about their skills
and midwives state they are not
sure they screen correctly for
contraindications.
IUD clients not routinely asked
about RTI/STD symptoms.
All supplies used for IUD
insertions not sterile.
Provider safety.
Inadequate technique for
administration of immunisation.
Training of service providers in IUD insertion,
infection prevention and all contraceptive
methods
Pre ei
pregnar
refei dpregnar
Lacl 'f
Training in maintenance of records; more
systematic "flagging" of high-risk mothers
Continuous training and supervision: all staff
have to demonstrate correct use of steam
steriliser ; other infection prevention measures
taken to protect staff (and clients)
Separate area for sterilisation to ensure supply of
sterile supplies/equipment to sites with no
electricity
Access!
serves
Foci m
Sterilisation log in use
Complication log introduced
Inadequate follow-up/ continuity on
occasion.
Referral system sometimes does
not work.
Sensitisation of staff through training and
continued support on-the-job to the importance
of follow-up/continuity
Development of referral system for well woman
clinics
Systematic referral of all high-risk mothers and
follow-up by midwife
Systematic review of ANC records to ensure
timely PNC
Inadequate constellation of services:
STD/HIV information not
routinely provided.
Men and youth do not receive FP
and STD/HIV information
Training of staff on STD/HIV followed by onthe-job training & supervision to support new
STD/HIV knowledge
Well woman clinic introduced with attention to
qualitative issues including information
STD/HIV
52
r.U-
Trail
Mamr o
knov ?c
training
weel ac
beca e
member
routi d
the r x
and
;a
Problems identified in the baseline
Interventions
Pregnant women not routinely
referred for blood typing (first
pregnancy) and VDRL.
Training of service providers in performing Pap
smears
Blood testing of clients attending the ANC clinic
reintroduced
h rtion.
Lack of supplies and equipment.
ic
!
thers
a staff
am
n sures
Accessibility and availability7 of
services.
Adequate supplies planned ahead of next clinic
session
Needed furniture and equipment procured (Box
5)_________________________________________
Introduced FP services at two new sites and six
clinic sessions added
Saturday polyclinics for working mothers
introduced
Polyclinics rather than single service clinics
offered to increase convenience for FP clients
e supply of
tl
Outreach sessions to men and women of all ages
10
Focusing on clients' perspectives.
Suggestion box installed
11
Supervisor checklist developed to include
interview with clients to assess their level of
satisfaction
ai
ip ^rtance
ii.
Question included in the tools in the final
evaluation
/Oman
h s and
Training to Improve Skills and Knowledge
tn
ire
iT
on-
di
lew
ei
on to
n
Many of the problems identified in the baseline were the result of inadequate
knowledge and skills among service providers. Therefore, a comprehensive RH
training lasting five days was among the first interventions (Box 3). It took place on
Weekends in order not to disrupt daily service delivery. Staff were not paid to attend
because it would be impossible to replicate. Approximately 60 percent of the staff
members attended the training. The training included some topics or sessions not
routinely provided to staff such as communication and counselling. They were among
the needs expressed in the interviews with service providers.
53
-mainsr
routinely provided to staff such as communication and counselling Thev
were among
the needs expressed in the interviews with service providers.
Strengthei
Box 3: Topics Covered during the Staff Training:
• Components of reproductive health.
• Adolescent health.
• Temporary, permanent and natural FP methods
• STD/HIV.
• Communication and counselling (with special emphasis on FP
and STD/HIV).
• Clinic management
• Maintaining records and returns.
• Infection prevention.
Strengt ;r
Monthly s
Lanka'; Fl
! meetin^ e
of how to f
The m
new k
lec rc
impor
use t
Eac s
Th. n
In addition, some training took place on-the-job in the field It
was planned that staff
would be trained 1) by observation 2) by performing the task
themselves and 3) by
continuous training and exchange of experiences, for example
at the monthly staff
meetings.
r
. i
issues
suf rv
that in
The skills available in the STD/AIDS programme were utilised to train local
and Sw7XS1 TV"1 •8r°U? discussions t0 increase community awareness about FP
d
?1S frammg/mtervention is discussed in greater detail below By the
TheVffl/PHM
abOn began'
‘T1118 SeSSiOnS h3d been or^anised ln Eheliyagoda.
1 he 1 HI/PHM sessions organised independently numbered 15.
In < d
Health=
suf rv
ini I ti
The en
rec d
that Ji
A hands-on training to improve their technical skills and aseptic techniques was
provided to four service providers who perform IUD insertions. Two service providers
were trained in taking Pap smears
F
On oi-
Although no systemic problems were found in the baseline, overall
improyement m infection prevention was seen as important. An initial training session
took place with continued on-the-job support as discussed below.
import
ene1 lii
suj rv
purpoj
doi t
Overall, su
initiatic c
systems uxC
54
I
were among
Strengthening Supervision to Focus on Quality
Strengthening supervision was considered a high priority when the QOC project began,
Monthly staff meetings to discuss and review activities are not a new feature in Sri
Lanka's FP/MCH program, but chang<,es have taken place in the way the monthly
meetings are conducted to cencourage staff involvement and problem solving in terms
of how to further improve the services:
a
iTcZr^HSsE/T^
important
QOC issues Wh ? H
imPortant in keeping alive" staff awareness of
QOC rssues. While the word quality was rarely used previously, quality of care
issues are now routinely discussed at the monthly meeting, during oZ
n<
i «<at staff
and 3) by 1
it y staff
upcrvu.or/staff interactions, and during staff interactions. The team strongly feels
that in order to sustain the QI undertaken, QOC must be internalised by staff
’
Ti I local
about FP
By the
11^ igoda. |
n
qu^s was
Providers
pverall
J! ssion
Heah^T H mTS
t0 1116 m°nthly Staff meetmg' 1116 ^31 Officer of
tli introduced weekly local conferences - meetings between the immediate
uperyisor and a small number of midwives - to strengthen supervision after the
initiation of the project. All the midwives attend one such conference per month.
The emphasis is on identifying problems both
in the field and in the clinics. Clinic
records and returns
--------J are reviewed to ensure that theyJ are complete and correct and
that they are done in
ir a timely fashion.
One-on-one supervisor/staff interactions have increased, or, perhaps more
importantly, changed m nature, reflecting the emphasis on supporting staff and
nablmg them to perform their work better than before. In Eheliyfgoda the
supervisory public health midwife (SPHM) has been completely released for Jhe
purpose of doing field supervision. Her reports are the basis for field supervision
done by the MOH and the public health nursing sister (PHNS).
i MhT"'
KtiVi“eS "e
,n • more systemafc fashion than prior to the
mhatron of
QI efforts. staff men,bers have a|so become
“ o
syslemabc follow-up. For example. after each clinic sesslon
°f
55
The supervisory checklists developed have a provision that supervisors mm
talk directly to clients to assess their level of satisfaction with the services provided
Hence, the lists represent an additional mechanism for continuous feedback fro^
clients.
*
Interventions Related to Structural Inputs
Box 5: Examples of Furniture and
Equipment Provided
Benches for waiting clients
Curtains for screens
Tables and chairs for providers
Lockers
Cupboards
Test tube holders
Examination bed stools
Spot lamps
Wooden racks to dry gloves
Buckets for water storage
Hot plates
Bags for staff to carry supplies and
IEC materials.
I
Common <complaints among both
clients and programme staff were related
to inadequacies in structure. Staff at each
clinic site helped identify shortcomings at
the time of the sensitisation workshop,
This included structural inadequacies.
Some furniture and equipment were
provided based on the plan of action and
also as subsequent suggestions were made
(see Box 5). Since many essential items
were provided by a different UNFPAsupported project, the QOC project
focused its interventions on many items
which are very noticeable and make a big
difference to clients and staff.
For example, screens to ensure privacy, benches for waiting clients, buckets for
water storage, and so on were considered particularly important to ensure a high level
of quality. However, the provision of the physical inputs was only a small part of the
quality improvement interventions.
Improving Access and Availability
All the stakeholders - clients, service providers and managers - identified access and
availability as a jproblem in the baseline survey. Several steps were taken to address
this problem:
There were two health facilities that provided no FP
F~ services and where expansion
of such services was possible. The QOC project providedI some physical inputs, and
the time of existing staff was reorganised.
u
58
T1
t<
e
ar__ I
that t
th r
cl ..,ic
C de
w^/k
for th
rrn H
Two
TF’S
ncapi
n
selects*
sterilisatii
workc y
because c
keeping e
at the k
not negle
availaR1e
orl
TI
existii c
has a jr.es
clients.
bLM
receive s
whicl la
interv at
improvec
....
pervisors mus) •
d“s provided
fe Iback fro^ •
............ ,
The total number of clinic sessions pi
'er month was increased from 26 to 32.
More clinics became polyclinics
simultaneously providing ANC, child welfare
and FT services - rather than single-service clhui. rr cltents appear to indicate
-------- FP clients
they
among both . Clinic hours have been changed to cater to clients' needs. A special polyclinic for
working mothers was introduced
7 me related
on Saturdays to make services more convenient
for this group.
buff at each
ortcomings at
Two well woman clinics (WWC) per month
•n workshop
were introduced at the end of 1996.
This was a modest start to address the needs of
inadequacies.
women who are neither pregnant
nor in need of contraceptive services.
:p’"?nt were
31 chon and
In addition, steps were taken to improve the client flow
j
is were made
selected activities and clinic snarp Fnr Z
i
r H
Staff reorganised
st dal items
3r UNFPAOC project
n ny items
i-.ake a big
■
buckets for
a Ngh level
-1 ] rt of the
The space available at each
service delivery point (SDP) varies greatly. Within
existing constraints, there has been
an effort to use space better, and each activity now
has a designated place. In some
o the clinics, signboards have been put up to guide
clients.
a ess and
to address
evnansion:
-di
is.
interventions2 began^Tt staff state ^at^th SerV1?6S after 016 cluality improvement
improved and chLges ^eldX^™^ is
" easier
“ after the facilities —
59
■''f-
-
OB
Well Woman Clinics: The First Step towards a Cradle-to-Grave Approach
The government is planning Well Woman Clinics (WWCs) for the entire country for
women aged 35 and above. Some areas in the country have begun to offer these services
while others have not. Well woman clients in Ehliyagoda receive a breast exam and are
instructed in self breast exam; a urine test to screen for diabetes; a blood pressure check;
a pelvic exam and visual inspection for possible abnormalities (cervix/vagina); an
STD/HIV prevention message, and other information and referrals as needed.
Although the focus is on women above 35 years, younger women are also encouraged
to come for services if they do not already seek FP or antenatal services. For example,
women in their early 20s have sought services for, among others, menstrual problems.
Among the issues emerging with the addition of WWCs are the effectiveness of
the referral system and of client follow-up. Management and staff are currently in the
process of exploring possible solutions. As discussed above, two service providers
received training in doing Pap smears, but they have not yet been introduced. Other
steps envisaged to improve the quality of the services provided include a client flow
chart to be used as a simple standard, client cards, and a reproductive health leaflet.
Problems during Project Implementation
Although the provincial level staff was most co-operative and allowed the team much
flexibility, a key member of the provincial staff - the medical officer/MCH - obtained a
transfer soon after the QI team attended the training programme organised for the QI
teams. This constrained province-level involvement and increased the burden on the
other members of the team at the central level.
Some delays occurred in the implementation because of procurement
procedures. Transport breakdowns affected the programme activities. For example,
vehicle breakdowns made it difficult to reach the clinic sites to provide services; field
staff lacked transportation facilities to reach the SDPs; and due to restrictions on the use
of vehicles, it was difficult to perform supervisory duties on Saturdays.
60
El
It is too < rl
improvemer
Privacy« d
Some cl itreceiving De
to this findiiseparate x
examinauor
Similarly cc
efforts.
u
high score c
courteoi s»
Choice of h
Several te
was introdi
overall ic
correct udc
method cpt
and inci is
EFFECT OF THE QUALITY IMPROVEMENT INTERVENTIONS
c tntry for
e; services
am and are
»s e check;
Velina); an
as needed.
?r >uraged
>r example,
>r^blems.
tiveness of
n’’ r in the
I ^viders
id. Other
?li it flow
e< et.
It is too early to evaluate the impact of quality improvement interventions. However
improvements are visible.
'
Privacy and Interpersonal Relations
to this finding and reviewed this issue in relation to all services. Every clinic now has a
separate room or area that allows privacy for IUD insertion, Depo-Provera, and other
exammations. Screens and curtams are widely used. Only one client is seen at a time
Similarly counsellmg takes place in a private area. Chents do appear to appreciate the
e or . During the final evaluahon, 52 women seeking ANC gave the programme a
high score on the issue of privacy. They also appeared to be satisfied with the k“d
courteous service that they received.
a
Choice of Method and Comprehensive Reproductive Health Information
Several interventions were made to enhance method choice although no new method
was introduced: problem solving and planning for adequate clinic supplies improving
coTrec
°f Staff
motlva^g them to provide more comprehensive and
much
btained a
o ‘he QI
?r >n the
aj
:u ment
example,
-e field I
i uie use '
method
f
°n ^Pr°ductive health including FP methods, and introduction of
J
PeC^ couns*ning- These measures altered the method-mix in Eheliyagoda
and increased
thej number of new acceptors (Table 6).
---------&
Table 6: Number of New Acceptors and Method Mix in Ehehyagoda
Method
~OC
Depo-Provera
IUD
~LRT
Vasectomy
% increase over previous
year
1995
236
255
161
78
4
40
1996
176
319
267
68
__ 0
13.4
61
j
is
In the baseline survey, both staff and clients complained about Depo-Provera
shortages. In the fmal evaluation, neither providers nor clients reported shortages of
or other methods. During the project period, the demand for Depo-Provera and
UD increased rapidly while the demand for pills declined. Relatively fewer acceptors
selected tubectomy. This may be because of the inconvenience to clients of not being
able to receive sterilisation services locally. The number of vasectomies remained
unchanged despite the outreach to men. This issue requires further exploration.
Technical Services and Infection Prevention
Both service providers and managers state that this area improved as a result of the
training, the equipment provided, and so on. Sometimes relatively small steps were
taken by managers and supervisors to improve technical aspects. For example, to
ensure that correct amounts of reagents are used for urine tests, the test tubes were
marked to facilitate the task of running the test. Moreover, there is now a system in
place to ensure that antenatal clients receive blood testing (typing and VDRL).
CONCLUSION
HI,
In conclusion, the quality improvement in Eheliyagoda focused on client needs. There
is much evidence that the word quality has taken on a new meaning for both managers
and service providers. The concept has been internalised and work behaviours have
changed. The word quality is frequently overheard at monthly meetings, during staff
interactions and supervisory activities. The following statements depict the changes
taking place:
62
security
ques >r
I \
QI te
"Dui g
quality t*
they a’
impr ze
manager
I /
Q- te
"Staf ir
quesuun
Dr. C
( te
"This nr
on F e
sexuanty
when wt
be cc si
acceptat
print’ k
exam le
S.B. i
C LU
Quality improvement is more time-consuming and slower than I initially
thought. I have seen a significant difference in the attitude of field staff. They are
enthusiastic about the challenges implied in this kind of project. Change has also
taken place in the way the team members think."
Dr. K. Wickramasuriya, Director, FP/MCH, FHB, Ministry of Health, Colombo
QI team leader
Service pro
place.
4i
commeiius:
Quality matters! My attitude has changed. Now I start the different types of
training I conduct with an introduction to quality of care. I talk in terms of the
elements of quality and I take a more comprehensive view of reproductive health.
"The w k
(clinic) tor
stays op a
I have also changed the way I interact with clients. For example, I discuss
STD prevention with sterilisation clients because they often have a false sense of
"The traini
Providt
J
p Provera
:hi tages of
rovera and
r xeptors
f )t being
J remained
■ic
sru of the
>t s were
cample, to
ul s were
'dem in
is. There
managers
> have
ring staff
? ’ anges
ii illy
e7 are
is also
security (after they become sterilised). I do not lecture to them, but ask them
questions to see what they know and then give them the information they need."
Dr. V. Karunaratne, Principal Investigator, FHB, Ministry of Health, Colombo
QI team co-ordinator
“ During this project I came to realise that people are more concerned about
quality than we ]providers tend to think. They may not voice their demands as
they have few alternatives in fterms of receiving services. I feel that quality
improvement needs the help of all types of "staff
starting with top level
management to the grassroots level service provider."
Dr. A. Fonseka, FHB, Ministry of Health, Colombo
QI team member
"Staff are more active at the meetings than they were before,
questions and bring up more problems."
Dr. C. Gamage, Medical Officer of Health, Eheliyagoda
QI team member
They ask more
sexuality. For example, we discuss not only condom use, but also masturbation
when we explain safe sex. We may discuss different sexual practices- what may
e considered dirty - while also exploring the fact that different practices are
acceptable as long as both parties agree and derive enjoyment. We use the same
principles as for one-on-one counselling and we always ask permission For
example, we ask permission before we do a condom demonstration."
S.B. Abeyakoon
Counsellor and Trainer
Providers Speak
Service providers also had an opportunity to express their views on f
the changes taking
Pace. Midwives at a monthly staff meeting in June 1997 made the
—
following
comments:
?eb of
of *he
a.
The work is easier now because I can more
AC;Ci
can more easily refer clients to the MOH office
(clinic) for family planning. Rather than being open until
,
---------- o
noon only, the clinic now
stays open all day so clients can come at any time."
,s<
The training made me understand the importance of access to services for clients.
IS
ss
of
63
---
Because we have begun to do pre-clinic preparations at the end of the day after ou.
le
field activities, we imanage to start clinics on time the following morning. This is better
Gradually,
for both the clients and us."
regular re
project re
"Patients have told me tl-iat the clinic is really clean and nice and that they like to come
sector, FT
here."
purpos a
Kandy ^.s
"All people benefited after we started to improve the services, Earlier
f
we also
understood that we should treat people well, but we did not take it as seriously,
During this project, we learned to consider clients opinions. We also began to provide
family planning services in two remote areas.
"Before there was sometimes bias. Now we give information on all methods and
emphasise no method in particular."
"The mothers come to me more often now- sometimes even in the evening."
"Now we cannot even show anger to clients when there is too much work because we
were told in the training to always be kind."
Views of the Male Public Health Inspectors
11.
"Earlier the PHIs were not involved in family planning and reproductive health. We
learned a lot of new things during the project: to demonstrate condom use, and so on.
We like to be involved in family planning because it makes it easier for the wives to
make decisions when the men also have information."
"Maybe contraceptive use has gone up because we have removed fear of the methods
among men."
The workload is heavier because of the increase in the number of clinic sessions. It
would be nice to be paid for increased workload."
When staff were asked about their preferences in terms of providing services the new or the "old" way - they expressed that the advantages of the "new" approach
outweigh the disadvantages, heavier work load, because of increased client satisfaction
and interesting challenges.
64
■
ar
ft
day after our
T‘ s is better
'1 e to come
li we also
as seriously,
n provide
The pilot project has begun to influence the training sessions provided by FHB.
Gradually, the QOC component developed for the project is becoming part of its
regular training. The counseUing component developed for the staff training in the
project area has subsequently been used for training of health staff in the plantation
sector. FHB is also aiming to replicate other lessons learned in Eheliyagoda. For this
purpose, a workshop was organised for central, province and district level officials. The
Kandy district is beginning to explore the process of problem solving.
k ‘hods and
because we
h'-ltli. We
, - d so on.
he wives to
le methods
;essions. It
y —rvices •proach
satisfaction
65
---
..
,
5
Vietnam
Improving Quality of Care in
Duy Tien District1
BASELINE ASSESSMENT OF QUALITY OF CARE
lit
I
it
3“ —is=~ S- =antenatal clients were also interviewed
Since th? Vipen
'
distnct and some
ted to"ards
■
I
i
i
1 Contributed by HP Hoa, ; ''
JJ.Tand J Sftia- We WouId hke t0 thank VQ Nhan and NQ Anh, past and
present Directors, CPSI, for their guidance. We
2 are also grateful to VA Dung, PD Vi, VD Doan for
their contributions.
67
Ii ?r
indicated
the fa< t
health ver
Accordmg to both users and non-users, there is relatively little choice of method in the use
^o.
programme. Condoms, IUD and tubectomy are available, but not always easily percen )f
accessible, while oral contraceptives often are not. Although clients stated that th any more
taggingCXPlain h°W t0 USe 1116 meth°ds'
knowledge of using them was vvomer w
were b as
of protect!
Observation of the client/provider interaction revealed weaknesses in this area, pregna y
short time spent with the client; no separate area for counselling and information
givmg; insufficient information; and lack of IEC materials. The educational level of the
Ther
clients is quite high so an important opportunity is missed to offer needed information clients it
through appropriate IEC materials to this literate population. A relatively high Among
percentage of clients stated that the provider addressed issues such as follow up visit of ten
( ), sexual customs (63), contraceptive preference (84), method switching (67) and contrac >t
domestic violence (47). Overall, relations between client and provider appeared to be in the nic
Among the
and mi
■ Less
haIf
Ghents stated that they had privacy during the counselling husbana aisession while the number was considerably higher during the exam. Box 1 indicates
the medical services provided to clients and the extent to which universal precautions
M ;t
were taken. While 25 percent of the clients had symptoms of RTI, 21 percent received programnv
treatment. Eighty two percent of the clients stated they received information from the the 9th o
provider on STD prevention while 52 percent had received such information through IEC ma ri
mass media.
b
Observatio
for rout e
Durmg the group discussion with users and non-users, several problem areas appears t(
emerged. In practice, a client cannot easily receive an IUD because the method is not
provided at the commune level in Duy Tien district. IUD insertions are the
e
responsibility of a mobile team that visits the commune only once a month. Screening
or the method appeared to be inadequate as was the information given Health a- Therp \
workers and commune coUaborators seemed unable to provide correct information and
cons le
to address clients’ fears and concerns as a result of their own lack of knowledge.
improve
was 4-ha
Othe i
rarely n
Contraceptive Users and Non-users, Men and Antenatal Clients
1
1U
i
I
b- Thei v
quality.
I'
II
68
■
■
.. .
•
......
O®-
■
...............
Interviews
with
non-users
Box 1: Before providing the method, the
indicated a high unmet need despite
the fact that 95 percent stated that provider:
health centre staff motivated them to
Percent
contraception.
(Seventy-one
n hod in the use
• Took medical history
always easily percent of the non-users did not want
88
a
ny
more
children.
Ten
percent
of
the
• Did a pelvic examination
a 1 that the
60
ir them was vvomen were pregnant and 32 percent
• Washed his/her hands
59
were breastfeeding with varying levels
• Put on gloves
57
of protection. The rest was at risk for
• Explained reasons for
pregnancy).
5 — this area:
examination
63
1 information
• Did a Pap smear
7
The number of men and antenatal
al ?vel of the
• Took blood pressure
30
I information clients interviewed was very small.
• Did breast examination
24
la^vely high Among tire men interviewed, nine out
• Taught self breast examination 21
II v up visit of ten used some method of
• Asked about history of STD
72
ing (67) and contraception (either the husband, or,
• Provided a user card
30
>p ired to be in tire majority of cases, the wife).
Among the majority of users, non-users
and men interviewed, contraceptive use or non-use was a joint decision by both
unselling husband and wife.
x indicates
precautions
Most of tire antenatal clients were satisfied with the services provided by the
:e received programme. Four of the six women interviewed sought ANC late, between the 6th and
ic_ from the the 9tlr month. There appeared to be a lack of both information given to the clients and
tion through IEC materials. Overall, service providers did not encourage clients to ask questions.
Observation revealed shortcomings in tire following areas: lack of laboratory support
for routine tests, inadequate facilities, and no antenatal cards for clients. Overall, there
owem areas appeared to be insufficient capacity to care for all pregnant women.
e od is not
The field visit by the QI team established for the project revealed the following:
>ns are the
=i. "creening
ei
Health a. There was an almost universal perception that quality improvement requires
:mation and
considerable financial resources. When asked the question "What can be done to
improve quality?", tire answer from managers and community leaders invariably
was that technical training of providers, new equipment and facilities were-needed.
Other interventions, however, such as IEC or informed choice of methods were
rarely mentioned.
b- There were no quality assurance mechanisms and supervisors did not check on
quality.
69
I
(full timu
c. Service providers generally treated clients well and provided the service requested a counsellir
A large proportion of clients used an IUD, and there were concerns among clients two mid i\
clinical ^ai
about gynaecological problems related to its use.
technical sk
d. The supply of pills and condoms at the health care facilities was inadequate (or availabil /■
stockouts occurred) because of lack of co-ordination between the Provincial] vasectomy
Committee for Population and Family Planning (PCPFP) and the health system, number s
There was an apparent division of labour; CPFP (Committee of Population and
AtteiFamily Planning) providing non-clinical methods of contraception and the health
and MR ht
system providing clinical ones.
monitor g
Mass orgai
Associat n
INTERVENTIONS TO IMPROVE QUALITY OF CARE
the spec: lj
In November 1995, after the completion of the baseline survey and analysis of data, a
A b
QOC workshop was organised for various representatives from CPSI (Centre for
Population Studies and Information); the District Committee for Population and Family counsel!*, .g
Planning (DCPFP); the inter-communal and communal levels; the district health In additio
bureau, the general hospital and the Party. At the workshop, the results of the baseline collabor.
assessment were discussed along with QOC frameworks. There appeared to be general Commune !■
support for improving quality as well as agreement that the assessment results reflect (ICPFP) Q?r
of Obs tr
the real situation in Duy Tien district. Possible interventions were also discussed.
attended th
represer' d
Appropriate
interventions
were
Box 2: Topics Covered in the
problem tf
designed to address the weaknesses
QOC/Counselling Training
faced
wF
identified in the areas of counselling and
counsell g
information
giving,
technical
skills,
•
The
importance
of
QOC
cards de ?1<
universal precautions, IEC materials,
• The need for developing a protocol
infrastructure
and
equipment.
• Counselling steps using the
S ii
Interventions were also required in the area
GATHER
methodology
training
.or
of supplies/logistics.
• Use of checklists and counselling to supervis
for each method
progran ai
• Recording and reporting skills
at SDRs wit
Training Related to Technical Aspects,
• User cards for improved follow-up
Integration of Services, Follow-up and
I ?
Continuity
• Reproductive health dhd
reproductive rights
AVSC's i-an
^hich v?r
This intervention began with a three-day
• Brief overview of
WNOV, 7
QOC workshop, which also included training
RTI/STD/HIV/AIDS
in counselling (Box 2). A total of 240 persons
70
•r re requested]
a"d rKeiVed
IS among clients tiv° midwives were trained in IUD insertfo*"
J™8' ten femaIe asslstant doctors and
dinieai trai^ng fo,lo “d by ZZX “
b gUlato’(MR) lhr0“gh a
technical skills. This intervention wa.
f ?? ,Ob trauunS to improve their
inadequate J availability of these services. Moreover, two providers wereT^ d^^h
t0
t ? Provincial vasectomy services. However clinical nra rH™
j jpframed in the provision of
health system number of acceptors for this me'thod in thrpXtaroa
°f
1OW
■
Population and
iZ a^° cour a—g * - -
a 1 *e healttl and miXS-
monitoring and evaluation was orgaSs^^^^i’^^ently, a two-day trainmg on
Mass organisations - the Youth Union thn w
and other mdividuals.
Association - also particinated Th.
Women's Union and the Peasant
the specially developed managers' checklisT
3513 °f 1116
was how to use
1} s of data, al
SI (Centre fori
A two-day refresher training on
o and Family! counselling and QOC- was also organised,
Box 3: Convenience to Clients
d rict health! In addition to
full time staff and
of the baseline* collaborators from
communes and InterTraining of service providers in
be genera
PoPulation anti Family Planning
IUD insertion at the commune level
r^ults reflect (ICPFP) Centres, staff from the Department
improved access to services and
scussed.
of Obstetrics and two mobile teams
client convenience. Clients
attended the training session. The training
comment that they are happy to
represented an opportunity to discuss the
'ie
have IUD insertion available in the
problems the service providers might have
community and that it is easier to
faced
when
practising
their
new
understand the new user cards. A
counselling skills and utilising the new user
DC
broader range of choices became
car s developed under the project (Box 4).
available because of increased
ir a pro toco
information.
ng che
Similarly,
similarly, a one-day refresher--------------training for managers was organised on i
' ’
cc nselling
supervision, the introduction of key^dicators^ eValU3tlOn' Problems related
1
h skills
•ISDPs withta
e< ollow-uf
hd
projKt area wsre diXed ’
■>» qoc“md ME
s
6 Pr°ViSiOn
cX«,r„iri70UH JHpiEGO
*he's traming
Infection sessions
Prevention, both of
'Vhich were provided^by the Jand
a«
71
!
A four-day refresher training in IUD
insertion and MR was offered to all service
providers. The FP mobile team from the
District health office and the Department of
Obstetrics at the district hospital were
previously the only providers of these
services. After the inception of the QOC
project, trained service providers at selected
commune health centres began to provide
them. In other words, women began to
receive IUD and MR services at the local
level.
The p
knowledge
increased oi
training.
1
Service providers state that they feel
treated at the
more confident in doing their job as a although n
result of the training provided in the
commune a
project area and the improved
MCH/FP mo
supervision and support offered from of Obsteta s
the district hospital staff. They also
result of me
indicate that they appreciate being able screened or)
to share their experiences with other
specimenj o
providers.
for diagnosis.
In addition to introducing the IUD_______________
__ reported.
and MR checklists, the QOC project introduced IUD and MR complication logs to
improve the monitoring of these services. IUse
’ of the logs will assist programme
managers in spotting possible areas in which service providers need additional Developn n
training, or even individual providers who may need improvement. In this context, it
should be mentioned that a log for pregnancy follow-up was also introduced. Clients
in either logbook will receive a (follow-up) visit by the collaborator if they do not return Pamphlet w
vasectoim a
for their follow-up appointment
User cards fo
A six-day vasectomy refresher training was organised for two male medical a pamphl a
doctors. The overall low demand for vasectomy was a problem when the initial training done to er^ui
took place. Again, training of local providers has made vasectomy services more easily
accessible for clients in as much as they no longer need to go to the district hospital or Structural n
to a hospital in the neighbouring province.
Five SDP* v
Finally, several steps were taken to address reproductive health issues besides interventi i
contraception and menstrual regulation. Two female staff members (one female planning cen
medical doctor and one female assistant doctor) from Duy Tien district hospital were used for r m
sent to the National Institute for Skin and Venereal Diseases in Hanoi to learn to various ec if
diagnose RTIs and STDs. Subsequently, these doctors and two other service providers
Th ii
organised training for service providers on diagnosing STDs and RTIs at the
tiles, elecl Cc
community level (Box 5).
of Obstetrics,
for guidir F
the labor „_o:
example, M
laborator ;u
72
Box 4: From the Point of View of Service
Providers
The participants' awareness and
Box 5: Training on RTI/STD diagnosis
knowledge
of
STD/RTI/HIV
have
at the Commune Level
increased considerably as a result of the
training.
RTIs/STDs were previously
they feel
• STDs and RTIs.
treated at the province - or higher - levels
j eir job as a although some RTIs could be treated at the
• HIV and AIDS.
ovided in the
commune and district levels by the
• How to diagnose STDs, RTIs and
3r^ved
MCH/FP mobile team or in the Department
HIV/ AIDS at the commune level.
■t fered from of Obstetrics at the district hospital. As a
• How to take laboratory specimen
f. They also
result of the training, 16 providers have
and transfer them to the district
ci e being able] ----------screened 90
- J women to date and sent 72
hospital.
?s zith other
specimens to the district hospital laboratory
for diagnosis. Of the 72 specimens taken, 65 were positive for RTI while ho STDs were
reported.
Cation logs to
st nrogramme
e additional | Development of IEC materials and User Cards
this context, it
u-?d. Clients
r ( not return Pamphlets were developed on oral contraceptives (OCs), IUD, female sterilisation,
vasectomy, and on general information on all the methods as well as on HIV/AIDS.
User cards for the various methods were also developed. Each client now receives both
a
pamphlet and a user card pertaining to the method selected. The interventions were
n le medical
initial training done to ensure informed choice and better follow-up.
2S lore easily
ic lospital or I Structural Inputs
View of Service
I Five SDRs were identified
i
by the QI team and received structural inputs. (The
besides!
intervention
took
place
at
Mocbac
health commune,
’.Sbu*es besides! mtervention took place at Mocbac health
commune, Dongv.
Dongvan intercommunal family
(one female planning centre. Yen Bac and Tien Hiep health communes and also included two rooms
h< pital were usecl f°r family planning at the district hospital). Repairs, upgrading, and supply of
)i ro learn to! various equipment were among the actions taken to improve the structure,
providers
The inputs include linoleum for the floors, ceramic tiles, replacement of roof
F Is at the
tiles, electrical wiring for lights, and replacement of ceiling boards. In the Department
of Obstetrics, the family planning and counselling rooms were upgraded, and boards
for guiding FP service providers in the counselling process were provided. In addition,
the laboratory was upgraded. Equipment and supplies were also provided, for
example, MR and vasectomy kits, electrical sterilisers, cupboards, microscopes,
laboratory supplies, and so on.
73
The awareness of local leaders that they have responsibilities
A‘
appears
vase
oi
procurement of. microscope, a new ceiling, a cupboard for storage, a^o^n S“Cil ”
condom
intei it
Checklists
to the Fp
XToS’ssrr maTr t deveioped'»
- . COTpsidered f
Efrons to Encourage Male Participation and Responsible Sexual Behaviour
i
*
Male doctors conducted the activities
developed to address men's needs. In
collaboration
with
the
Peasant
Association, PCPFP of Duy Tien, and
the CPSI QI team, male group sessions
were organised. From October through
December 1996, a total of 16 sessions
were held reaching a total of
approximately 200 men. The men (or
their partners) had either never used
contraception or had discontinued use.
Box 6: Misconceptions among men related to
reproductive health expressed at the sessions:
Family planning is the responsibility of
wnmen.
• Vasectomy may cause both physical and
psychological problems for men.
• Condom use is inconvenient.
• SI Ds and HIV/AIDS appear in urban
areas and not in rural areas.
•
Outi
ic
Two as
and i€
in
yc
conduct
activ Oh
meeting
CPSI T
evah
and 64 b
E
and STE
same ie
encoi aj
question
worr ; ’
Supp rt
Provide
The main topics at the sessions---------------respo"sibilit’’
<^y
development of agricultural products DnHna L "accmatl°n programme and the
some questions to the oarticinanK
° eaC. session' t^'ie facilitator would pose
answering the questio.ri posed (Box 7). e"C0Ura8<’lhem ,O S1’are
“P“es white
Diffe ntradio r
inform at
durir tB
but were
A
on repro
care a is
raisin _ e
local net
74
Li .
-
----
2S to the Fp
As a result of the sessions, it
w^“eness was appears that two men chose
k 1g such as vasectomy
while
45
chose
o on.
condoms. Other men expressed
interest in the IUD.
Outreach to Youth
d 'eloped to
mid assist the
■ir staff. The
oi _are.
<ur
3n related to
te ^ssions:
Box 7: One Man's Choice:
During a meeting in Tien Hiep commune,
one man commented that he previously
thought that women have the responsibility
for family planning because men cannot use
the IUD. After gaining increased
contraceptive knowledge at the session for
men, he stated that he now understands
that the husband should share the
responsibility for contraception with his
wife. The man chose to have a vasectomy.
Two assistant doctors (one male
and one female) received training
in
youth
counselling
and
conducted the youth outreach
activities.
They
organised
in collaboration with 1116 local youth union and a female medical doctor from
Crbl. 1 he groups were organised
<
’
‘ for
' boys and girls. At the time of the final
separately
evaluation, three meetings had been organised fo/ each addresskig
j a total of 59 girls
and 64 boys.
6
^risibility of
p sical and
men.
t.
r urban
same methodology as those for men. The facilitators would pose various questions and
encourage the participants to share their experiences while finding answers to the
questions The participants were also encouraged to discuss possible concerns and
worries while the facilitators attempted to answer questions as needed.
Supporting the Radio Network to
Provide RH Information
1 r family
ptions were
Df’ ?r topics
-K and the
w<ould pose
ei es while
Different activities to support the local
radio network in providing RH
information were to have taken place
during the first six months of the year,
but were delayed to August 1996
A one-day information session
on reproductive health and quality of
care was organised with the purpose of
raising awareness and educating the
local network.
The DCPFP of Duv
Box 8: Implementing the ICPD POA at the
Grassroots
Mr. Le Co, head of the district radio
broadcasting, stated that, after 1994,
advocacy for the ICPD POA had been
one of his concerns. However, neither he
nor his colleagues felt that they
understood the issues of comprehensive
reproductive health and quality' of care.
According to Mr. Le Co, their hope was
to provide better information as a result
of the information session.
75
■
/
Tien, the district QOC team, and the Information and Cultural Cd
Office of Duy Tien
/ h
joined forces to develop the session for the heads of the radio network
i
— in 22 communes the counse
and for 15 collaborators, four journalists and editors in the district broadcasting (Box 8).
clients
commi it
After the training was organised, the radio network in Duy Tien District has During the
featured 12 special programs on population, development and reproductive health, anc
approx' tie
42 reports on the activities of the QOC project. In addition, a cassette tape on the QOC
1,985 i ?r
project was developed. It has been broadcast also on Ha Nam province radio station.
seven, 41
contrac
ACHIEVEMENTS OF THE QUALITY IMPROVEMENT PROJECT
Several process improvements have taken place since the inception of the QOC project
The additional 12 providers who underwent IUD insertion and MR training, for
example, received intensive skills-based training. They inserted a total of 968 IUDs and
performed a8 MR procedures with no serious complications during approximately nine
months. Each room where FP services are provided is now equipped with a board
containing step-by-step instructions on how to insert an IUD; how to perform
menstrual regulation; and how to solve serious complications if they should occur.
*
There appears to be consensus among the district level managers that the
training organised as part of the QOC project is better than that offered in the national
programme. Therefore, these managers have decided that more service providers must
receive the training introduced by the project. They have also decided to offer yearly
refresher courses. It should be added that neighbouring provinces have expressed
interest in the different types of training which took place in the project area.
Similarly, there is consensus that the level of co-ordination has improved among
CPFP, the Ministry of Health, and the Ministry of Education and Information at the
provmce and district levels. During the QOC project, a monthly planning meeting was
introduced at each of the three levels (commune, district and province). The meeting
aims to monitor the progress of the project and to continue the improvement process
This meeting will be institutionalised.
The IUD checklists discussed above are used at three different levels: by
collaborators, service providers and imanagers.
--------The lists would ensure that clients
undergo thorough screening before they have> an IUD inserted. Finally, the programme
keeps track of possible complications in its newly introduced complication log
facilitating systematic corrective action.
Final E il
In order tc
16 man ;e
delivery w
Ir
66 percent
percent fe
interes’ ig
service pre
to clien (
T fl
Chan^
ILiJs
comn
B< ei
Do nc
tr e
se_ /ic
It is e
rc n
boarc
O’’ ei
76
-1
■
2 vi' Duy Tien
2? communes
a; ng (Box 8).
?r District has
v health, and
>e on the QOC
d’ station.
e
Durmg the last six months of 1996, for example, providers and coUaborators counselled
approximately 3,000 clients; distributed 2,500 method information sheets; provided
1,985 user cards for IUD clients (of which 968 were new contraceptive clients)- and
ZVep “e dienT'
VaS“,0,ny'
»»
r
Final Evaluation
QOC project
lining, for
9l^ IUDs and
ximately nine
v h a board
T io perform
Almost all the respondents felt that quality had improved (Table 1). In addition,
d ^ccur.
66 percent
. , . of , the ^ers felt that 1116 quality of counselling had improved. Fifty-seven
percent felt that STD/RTI diagnosis and treatment had improved. However it is
gers that the interesting to note how some aspects appear to be more appreciated by cliento than
i LUe national service providers/programme and vice versa, for example, in the area of convenience
o ders must to clients (travel long distances to receive services).
) offer yearly
/€ expressed
a,
Table 1. Percentage of Respondents having Observed Quality Improvements
•o ?d among
on at the
meeting was
T meeting
iGxil process.
lc
t levels: by
tHt clients ;
p gramme
lication log
!
i
Change Observed
IUDs are inserted at all
commune health centres.
Better equipment and facilities.
Do not have to wait long or to
travel long distances to receive
services.
It is easy to find FP service
rooms because there are sign
boards.
Other
I
Users
Providers
Managers
Men
88
80
93
73
72
90
40
53
33
59
27
87
32
93
47
27
27
20
33
13
K
Contraceptive method choice also improved. At the baseline, only 41 percent of
tire users mentioned that pills were available. This proportion increased to 92 percen of policyn
instruc >r
at me final evaluation, thus improving choice.
the con-.ti
The interviews also indicated that clients received more comprehensive
information after the inception of the project, particularly on how to use the methods
on follow-up, side effects and what actions to take should side effects occur. In this
context, it should be mentioned that more than two-thirds of the respondents at the
final evaluation mentioned these issues without prodding as compared to less than 15
percent at the baseline assessment.
The respondents also received more information on RTI/STD screening and
treatment because of the project. More than 95 percent of the contraceptive users
^ad iheard ab0Ut contracePtion' quality Of care, reproductive health,
bl D/HIV, and male responsibility in reproductive health through radio broadcasts.
u. , m M?fre dla z 75 percent of 1116 managers felt that work methods had improved and
that the efforts of various institutions were better co-ordinated for the benefit of clients
Moreover, better equipment became available as a result of the project.
LESSONS LEARNT
Ki.
Several lessons have been learnt during tire course of the QOC project. It is interesting
to note that there may be congruence between the ICPD POA and the interests of the
national FP/population programmes. In Duy Tien, for example, many demographic
md.cators have reached "good" levels. Hence tire challenge for the programme in the
uture will be to maintain these levels. Leaders at both the commune and district levels
understand that an adequate level of QOC may be both an effective and wise strategy
tor tlie programme at this stage.
67
To improve quality the following are required:
•
•
•
•
•
78
Commitment from the leaders.
Basic and relatively inexpensive equipment.
Co-ordination among agencies.
Effective training, supervision and monitoring.
Follow-up and appropriate research on a continuing basis.
___
The action research project, along with other such projects, increased the interest
y 1 percent of of policymakers in QOC. QOC was incorporated in the recently issued executive
d uU 92 percent instructions by the Prime Minister to the MOH and NCPFP. The instructions state that
the conditions for providing all contraceptive methods must improve.
comprehensive
e *he methods,
c ur. In this
ondents at the
t( ’ess than 15
s cening and
a< ptive users
iuctive health,
or idcasts.
im oroved and
n t of clients.
t interesting
nterests of the
» mographic
jr nme in the
1 district levels
1 se strategy
79
6
Review of Experiences in Improving Quality of Care
IMPROVING QUALITY OF CARE: EXAMPLES1
1.
Use of Situation Analysis in Kenya.
2. Introducing COPE in Asia: Kumudini Hospital in Bangladesh.
3. Continuous Quality Improvement Programme
(CQI) at the Catemaco Logistics
Center, Mexico.
4. Quality of Family Planning Services in Taicang County, China.
5. Quality Improvement Programme
(QIP) by Ministry' of Health, Egypt.
6.
ZtatabLe™*'5 related to H‘ln’an R<!S0UrCe
Populaaon Services.
7. ARCH, India.
8. Total Quality Management in Malaysia's Government Health Services.
! 1
r™X’ore'ctaX"1'ThcKen>ah“b“"^u™„Kdwiih
r"ua,s "“h unfpa s"pp"1 ™Xec“X„”:
Quahty of Re^roduTtiw^eMthaCaTeTs6 ±^6 \vaSy™^rwa°rd'
December 1995.
7 horward heId m Kuchmg, Sarawak, Malaysia in
81
%
IMPROVING QUALITY OF CARE IN KENYA
USING SITUATION ANALYSIS2
BACKGROUND
I
i
!
Kenya's population has gradually increased from 5.4 million in 1948 to 21.4 million in
1989. It is currently estimated to be 29 million (Centre for Bureau of Statistics, 1996). The
Government of Kenya formally accepted population and family planning (FP) as part of
the National Planning Strategies in the Sessional Paper No.l of 1965. Two years later,
the National Family Planning Programme was established within the Ministry of
Health. Family planning services were to be integrated into maternal and child health
(MCH) services. At this early stage, however, the success of the programme was limited
because of many deficiencies in the existing health infrastructure, human resources and
quality related factors. This situation continued despite the high priority placed on
family planning.
I jl'TSt
ifel1
w
The Government of Kenya launched the National Council for Population and
Development (NCPD) in 1982. The Council's mandate was to formulate population
policies and strategies and to co-ordinate the activities of ministries, non-governmental
organisations, the private sector and the donors involved in population and
development. Two years later, NCPD launched Sessional Paper No.4 of 1984. It clearly
stated the demographic, education and clinical services goals, and defined current and
future population activities and the roles of the stakeholders.
The Ministry of Health continued to address the identified quality gaps in the
service provision of the integrated MCH/FP Programme. Between 1978 and 1986
several reports rated the overall Family Planning Programme of Kenya as "weak" and
"poor" (Ministry of Home Affairs, 1984; Henin, 1986; Lapham et al, 1984). However,
the 1989 population census showed that the total fertility rate had declined to 6.9. The
population growth rate had also declined to 3.3 percent per annum, and the
contraceptive prevalence rate had increased to 27 percent for married women. In the
same year, the Chogoria Report clearly suggested that a decline in the fertility rates was
possible through the provision of high quality integrated services (Goldberg, 1989).
The Demographic and Health Survey of 1993 clearly indicated that Kenya was in
a demographic transition. The contraceptive prevalence rate had increased to 33
percent and the total fertility rate had fallen to 5.4. Over this period of change, the
2 Written by Achola Ominde, Ministry of Health, Kenya with support from the OPEC Fund.
82
popula )r
determ^.ec
the last net
xer
1995. Tue
reorien
ofMCH/F
With th_ as
in 1989 wit
prograi n
Delivery P<
overvie1*7 c
improv ic
and quality
the pro; ar
Operati
is
1. Logistic
then w
SDP.. /
less thai
2. IEC. T
base J o
SDP k
have a s
not. ai
only .6
Howeve
som- zb
3. Manage
perc t
population programme studies <___
continued to provide key information that not only
determined the progress made, but,
, more importantly, facilitated future planning over
the last nearly one decade.
- a„d
1W5.
y 4 million in
st s, 1996). The
5 (FP) as part of
> years later,
h< Ministry of
nd child health
m was limited
i resources and
ri^T placed on
reorienting facility-based clinical services with an overall ami of m reorga™smg “d
of MCH/FP services offered by the programme.
^proving the quality
SITUATION ANALYSIS IN 1989
improvements. The study focused on Kv
■ man^ lnsights into possible areas for
fUnCti°ning of subsystems
’o ilation and and quality of care A^ummaX of *
7
re- A summary of the major outcomes of this study and the rating of
it population
the programme are as follows.
-governmental
)f lation and
It -1 It clearly
Operations of Subsystems
?d current and
ty gaps in the
9' and 1986
s "weak" and
4) However, 2. IEC.
to 6.9. The
am, and the
3i ?n. In the
li y rates was
•g, 1989).
However, it was noted that the weakness in thn /h
2
i
7
V1Slt
Kenya was in
somewha, balanced by (he
clientcounsellingPro8r™D’e Was
reused to 33
' ange, the 3.
Management and Supervision. "
These sub-systems were rated as "low" as 60
percent of the SDPs had two or fewer
i.
supervisory visits in the previous six months.
83
r
The recommended number of visits is one per month, which was reported by on],
14 percent of the SDPs. Only half of the SDPs had a FP workplan or schedule 0
responsibilities even though all workers were trained to prepare these managemej
la
aids. Record keepmg was rated as "moderate" as 87 percent SDPs kept FP record care________
even though there was a variety of record systems in use. Referrals of MCH client Choice of Meth
for FP were rated as "high" as referrals took place in 81 percent of the SDPs Th«
did not take place in 13 percent of the SDPs, and the situation in the remaining si
percent was unclear.
6 w
4
^nrpSOunel and 7raininS- ™s system was rated as "moderate" with 92 percent o
clinical nursmg and nurse midwife staff available in the SDPs had ever received the
seven-week training in FP, but continuing education in FP had been provided to 16
percent of the nursing and midwife staff.
5. Number of Clients Served by Method. Oral contraceptives were the most common
method offered to the clients. Seventy-one percent received oral pills and 19 percen
of the clients received Depo-Provera. Four percent of new clients received an IUD. Interpersor^1
relations
Situation Analysis in 1995
\e objective of 11115 1995 situation analysis was to assist the MOH, NCPD,
I
The situation analysis suggested that the Keny;
ya programme was functioning
better and the quality of care had
J ’ improved
'
since 1989 although there is still room for ,
further development
hformatioi
^change b ve
By 1995 the methodology used in the situation analysis study had undergone clients and prov
substantial revision but there are several critical issues in the sub-systems and the
quality of care that allowed the researchers to compare the study findings (Table 1).
84
■
—
?p ted by only
or schedule of________ Table 1. d ?mr?SOn °f the FindinSs of Situation Analysis
>e lanagementKien^nt of: quality of Situation Analysis 19899
Situation Analysis 1995
;eFc FP records
------------- —
of MCH clientsp0*6 of Methods
Researchers reported that 94 percent Almost all facilities provided
of new clients observed received
it >DPs. They I
combined pill, the progesterone
information on two or more FP only pills and injectables while
? remaining siJ
i 92 percent of
] rcenthada,
} rcentofthe
ar received the
/ided to 16
st common
ma 19 percent
Interpersonal
vp'4 an IUD. I
it
methods and the mean number of three-quarters offered the IUD.
methods clients received instructions Most new clients were told about
was 3.8. Nearly all clients were told six methods on average. The most
about orals and Depo-Provera. frequently imposed restriction on
About three fourths of the clients providing a method is requiring a
were informed about IUDs. Fewer client to have at least one child.
women
were
informed
about
condoms (60 percent and foaming
tablets 50 percent) and very few
clients were told about tubal ligation
(17 percent) and vasectomy (4
percent).
Researchers observed that the
vast majority of both family
planning and MCH clients were
satisfied overall with their visit
and felt that they received the
information and services that they
wanted. Although most clients
felt that the consultation time was
satisfactory more than 20 percent
of MCH clients and 11 percent of
family planning clients felt it was
too short.
relations
4OH, NCPD,
F and other
s nctioningl
s Ln room forL___________
information
(exchange between
d undergone clients and Providers
and the!
Tc le 1).
Information given to clients was
judged as "moderate" as 87 percent
of clients were informed how to use
FP methods. Benefits were discussed
with 77 percent of the clients,
Possible
complications
were
discussed with 60 percent of the
clients, contradictions with 50
percent and the management of
complications with 44 percent.
The methodology and categories
used to code the information
provided to clients in this second
situation analysis was very
different from that of the 1989
situation analysis. Nevertheless,
most new clients were asked
about
their
reproductive
intentions. In 75 percent of the
consultations, clients were asked
about their knowledge of and
experience with family planning.
T i most cases the provider
In
85
'r
explained to the new client how
to use the selected method.
However, many women were not
being properly informed about
the side effects that they should
expect or about switching methoc
if they have a problem.
Clinical procedures
performed
j ‘‘
In terms of the technical competence,
the study providers were relatively
competent. This component was
rated as "high". For example, 96
percent of the new clients observed
had their gynaecological history
taken. Blood pressure was checked
for 85 percent while a pelvic
examination was performed for 73
percent of clients. These findings
had limitations, as an objective
measure of the providers' skills was
not carried out.
W!
‘I >' :
Mechanisms to
encourage
continuity and
follow-up
Integration of
services /
constellation of
services offered
I ■
86
U.I.
Relatively little integration of other
health care services was observed
during visits by new FP clients. In
85 percent of the 49 new client
provider interactions observed, no
other health issues were discussed at
the time of FP service provision.
Similarly, no other health topics
were discussed in 85 percent of the
24 revisiting clients observed
(although such discussions may
have taken place prior to entering
the FP service areas).
Most new and revisiting clients
had their weight and blood
pressure checked. A substantia
proportion of new clients had
breast and pelvic examinations.
When providers were asked
which procedures they should
perform
prior
to
offering
combined pills, progesterone only
pills, the injectable, and the IUD
to new clients, more than 75
percent recommended a number
of clinical procedures indicating
that they knew which clinical
procedures should be performed
prior to offering various FP
methods.
Almost all family planning
providers (98 percent) were told
when to return for resupply or
follow-up. In addition, over 90
percent were given a written
reminder of when to return______
During 35 percent of the
consultations with all clients there
was some discussion of at least
one or more health issues. This is
a very encouraging result
indicating a more integrated
service delivery programme.
At *^e
imp v
couplet
Plar Ji
situ; o
asce. vdi
to note
care e
I P
r )V
post
1 p
k__ll
The
h >n
E
man ;e
increasii
C
underta.
are j rr
man^oe:
Integra ti
Com^o
With st
estal ’ ’st
addr si
Kenyan
asses n(
logis_js;
r client how
thM.
STEPS TAKEN TO IMPROVE QUALITY
en ,vere not
med about
th
should
lii „ methoc
At the policy level, the Sessional Paper No.4 of 1994 clearly recommended
improvement of the quality of FP services offered. The situation analysis studies
coupled with other documentation indicated the progress that the Kenyan Family
Planning Programme has made towards this recommendation.
7
ti
clients
and blooc
s hstantial
cl its had
aminations,
e]
asked
ie should
offering
te-~ne only
k he IUD
e than 75
a number
i Heating
cl. clinical
performed
ai us FP
anning
v re told
esupply or
n, ver 90
a vntten
urn______
f the
ie s there
at least
es This is
g
result
integrated
nrna.
to note that the exishng programme strategies and interventions to address quality of
care were basically already in place. They included the following4
7
O"
•
•
•
.
•
Improving
the supplyor
and
distribution of contraceptr
—r------ uKjuiuuuun
contraceptives
Providing extensive education through production of core materials, e.g., flip charts
posters and workshops specifically for the Ministry of Health
Improving and strengthening MCH programme with the aim of improving the
health of the mother and the child
E
K
The Development of FP policy guidelines for service providers
Monitoring and improving the quality of management, personnel and facilities
Despite assurance that the programme's course of action was right, programme
managers realised that there were still major challenges in terms of meeting the everincreasing FP needs while at the same time addressing the quality gaps identified.
Over the next five years, efforts to improve the Kenya FP programme were
n er a en along several fronts and the progress made varied widely. The following
are some of the key steps that were undertaken in four key areas: commoditie!
management and contraceptive method mix; IEC; training of service providers and
integration of services; strengthening management and supervision.
Commodities Management and the Contraceptive Method Mix
ith support from USAID, the Family Planning Logistic
Management Unit was
established in 1988 within the Ministry of Health with the
primary objective of
addressing commodities management problems that were
being encountered by the
enyan FP Programme. Initially, the major tasks of this unit were to conduct a needs
assessment; develop a curriculum to tram programme managers and implemented in
logistics; conduct training activities in selected pilot district and thereafter expand
87
V
tfiese training programmes. Over the five-year period, the Logistic Managemeni
Programme expanded rapidly in order to meet the ever-increasmg programme n7ed address e
r contraceptives and related commodities and supphes. Staff and supplies officers a;tpproach. T1
PrimaX^e^ltTc
COnducted between *e^Division of various c ir
ary Health Care and the donor agencies to address issues related to contraceptive MCH/Ff s
curricula; u
supphes, contraceptive method mix and other related logistical issues.
MCH/Ff ar
Addition
n
Currently the programme addresses its contraceptive needs and distribution
issues through a computerised system. An additional long-term method, the implant ever increasi
distrkUeve^5
mtr°duCed mtO 1116 ProS™mme and is currently available a^ the of servic c
sectors.
De ?r
Information, Education and Communication
To facilitate the production of adequate IEC materials, the programme was to set un a
to set up a
media production centre within the Ministry of Health. The establishment of this unit
as, however, hampered by a number of constraints and difficulties. Thus the
He 1th 3
P°puIatlOn and Development in collaboration with the Ministry of
Health undertook the same activity through the Family Planning Association of xSwa
(a non-governmental organisation in Kenya) with the materials produced privately The
project includes IEC materials such as calendars, posters, T-shuts and pamphleta In
ifaon to materials produced by this project, other FP projects, i.e„ the Family
Planning
Private
Sector the
working
i
aterials to
supplement
abov^^nXt^
7^
m<‘
‘
impact a NationaMFC nneC"SSary duPhcab°n - and therefore to maximise the
NCPDbH
\ ? committee was put in place under the chairmanship of the
NCPD to discuss and plan the various IEC activities including the design, production
distribution, follow-up actions, etc. The Government and a number of Stilaterarand
L lateral donors funded the activities. In addition to the IEC materials produced for use
duX
P'Xd1
channels/apples that were bnplemented
the in-service
meant th< ‘ r
existing c rr
various aspe
managem it
To rr
Contracej o
Updates o*. c
introduced a
concepts < i t
wider covera
a result of ‘he
the client- ie
At ’ e
of Health)
programme n
Management
Training Of Service Providers
At the facnit
introduction c
°{ HeaIth With suPP-t of a number of bilateral and
bas c traiX^™ Z38
7 “P1™^
activities
covered both the
training and the in-service training of service providers. Again, interventions to
Plannii
selected h( pi
Training < d
88
M 1 >"
vlanagement
ii ne needs
officers
Division of
oi raceptive
c tribution
the implant
il ’ de at the
set up a
Oi this unit
Thus, the
* i nistry of
in of Kenya
b tely. The
n ilets. In
the Family
ii >nal IEC
5
a; nise the
isiup of the
production,
il eral and
iced for use
Q] ’ ?mented
address the gaps in the basic training of service providers adopted a multi-pronged
approach. The components of the approach include review of the existing curricula for
various cadres of service providers to include practical management skills related to
MCH/FP, strengthening and upgrading technical aspects of various issues in the
curricula, upgrading the clinical area; supervision by supervisor in the area of
NiCH/FP, and logistic and managerial support to all existing medical training centres.
Additional medical training centres were constructed and made functional to meet the
ever increasing demand for trained service providers that was created by the expansion
of service delivery outlets within the public and non-governmental organisation
sectors.
Decentralised training centres (DTCs) were established specifically to address
the in-service training needs and expanded ongoing in-service training further. This
meant that more trainers must be trained to staff the newly established DTCs. The
existing curriculum used for the in-service training was also reviewed to address
various aspects on quality of care including counselling, technical competence,
management and integration of services.
To make permanent methods more accessible, the Voluntary Surgical
Contraception Programme expanded training of medical officers on these methods.
Updates on counselling and the provision of quality surgical sterilisation methods were
introduced and became part of the focus in the doctors' training programme. Newer
concepts on quality of services were also piloted with the aim of adopting them for
wider coverage. This included the Client-Oriented, Provider-Efficient (COPE) tool. As
a result of the successful introduction and implementation of the trials, the expansion of
the client-oriented services was undertaken with USAID funding.
At the national level the Division of Primary Health Care (formally the Division
of Health) addressed managerial and supervisory gaps by training and updating all the
programme managers at this level.
Management and Supervision
At the facility level, efforts to improve supervision were undertaken through the
introduction of quality improvement techniques.
il ?ral and
Planning and Voluntary Surgical Contraception Committees were created in
eu ooth the Selected hospital facilities in order to improve the provision of family planning services.
v^ntions to Training and deployment of additional public health nurses at the district level
89
%
M ;t
w d
STI/F
Sc ei
visitir
• Tb^u;
co ;u
integi
strengthened the supervision by the District Public Health Nurse of all the service
delivery points within his or her catchment areas. However, the ongoing expansion
added service delivery outlets as well as responsibilities and logistical difficulties that
continued to be a major challenge to the improvement of supervision.
At the provincial or regional level, training aimed to develop facilitative
supervisory skills of the regional supervisors. Logistics and materials support
complemented dieir training and helped improve effective performance. The support
to this initiative has continued through the Government of Kenya and USAID funding.
n
becomes
progr m
the cf ij
At regional level, the emphasis continues to be on the consistent monitoring of
tlie following activities:
•
•
•
•
•
* :
I-:
Quality of counselling.
Introducing client oriented services.
Monitoring record-keeping and referral procedures.
Ensuring that providers have up-to-date knowledge and skills.
Helping providers address their service related problems effectively.
The i ;u
province
essen*1 1
imple e:
short-ten
the N ic
to 20i .
following
The Family Planning Policy Guidelines and standards for service providers were also
developed and distributed to all service delivery outlets. However, the number of
copies available could not keep up with die ever-increasing demand by service
providers for diis important document. The guidelines assisted bodi die service
providers and dieir supervisors in meeting die needs of dieir clients widi the provision
of all die approved FP choices and widi appropriate counselling/information.
P v
tlic e
imnr
Il '.c
the fi
LESSONS LEARNT
While the general quality of services offered continued to register significant
improvements, there were several programme weaknesses at the facility level that will
need improvement if the programme is to achieve its desired goals. For instance, the
following are some of the weaknesses on interpersonal relationships:
REEL Ej
•
•
11
Revisiting clients felt die consultation time was inadequate.
Service providers imposed restrictions on the provision of nearly all methods
requiring the client to have at least one child. This was in keeping with the
restrictions according to the Family Planning Policy Guidelines and standards for
service providers that have since been revised.
Centre fc
and ? ti
Centra fc
Minis y
I
90
I
'MS
1 e service
ig _xpansion
:ficulties that
9 ^acilitative
ia support
Tne support
IP binding.
lonitoring of
Most new FP clients were not asked about the nature of their sexual relationship;
whether they had discussed family planning with their partners, or the presence of
STI/HIV symptoms.
• Screening for cervical cancer seemed not undertaken on a routine basis for all clients
visiting the FP clinic.
• Though the proportion of clients who hear about other health issues during their FP
consultation increased from 15 to 35 percent, the numbers still indicate that full
integration of services is an issue that has not been fully addressed.
,
Therefore, the situation analysis study, when conducted to assess quality of care,
becomes an extremely important tool in the implementation of reproductive health
programmes. It provides both programme managers and implementers insights about
the changes unfolding within their programme performance.
FUTURE ACTIONS ENVISAGED
rs vere also
? imber of
by service
I ? service
ic provision
»n.
significant
vc1 that will
it ince, the
The results from the 1995 situation analysis study have been disseminated to all
provincial and district teams countrywide with the primary objective of providing the
essential feedback to regional and district supervisors as well as programme
implementers at these levels. After discussions, the district teams then developed
short-term plans that will address some of the quality gaps identified in the context of
the National Implementation Plan for Family Planning Programme for the period 1995
to 2000. Over this period the Kenyan MCH/FP programme priorities are in the
following areas:
provision of reproductive health care
the expansion of services
improvement of the quality of care
IEC and advocacy; and
the financing of the Family Planning Programme.
REFERENCES
ill methods Centre for Bureau of Statistics. 1979. “Kenya Population Census". Ministry of Planning
tg vith the and National Development, Republic of Kenya.
an^ards for
Centre for Bureau of Statistics. 1996. “Kenya Population Census: Population Projections".
Ministry of Planning and National Development, Republic of Kenya.
91
Goldberg HI, M McNeil, A Spitz. 1989. " Contraceptive use and Fertility decline in
Chogoria, Kenya." Studies in Family Planning20,l:17-25.
Henin Rushdie A. 1986. "Kenya's Population Programme, 1965-1985: An Evaluation". The
Population Council.
Lapham J et al. 1984. "Family Planning Programme Effort and Birth Rate Decline in
Developing Countries".
International Family Planning Perspectives 104, 109-118,
(December).
Miller R et al. 1989. "Situation analysis of Kenya's Family Planning Programme".
ii- ■
Ministry of Home Affairs and National Heritage. 1984. "Population Policy/Guidelines".
Sessional Paper No. 4. Office of the Vice President. Republic of Kenya.
Ndlovu L et al. 1997.
Kenya."
I: <,-• t
jU,
#4.
"An assessment of clinic based Family Planning Service in
The a< ?s
the hand*
respoi b
afford I
knowledg
daily.
A\
and ii ?r
Hospital i
from Pua
CC
evalua (
requin tl
(1) the sei
the ac >n
they ia^nt
h
specific rij
use on1” s
’i,
As
about n
knowl g
client inte
basis, 1 -1
Cli
develc bc
States, ih
registe* fc
Miom
I
3Summ y
Pati.
4 Internatioi
92
.fir
»«»<••: “.-■’r-v-;' ..
ity decline in
INTRODUCING COPE IN ASIA:
KUMUDINI HOSPITAL IN BANGLADESH3
aluation". The
The assessment and implementation of strategies to improve QOC have remained in
the hands of programme managers and senior level officials. The people ultimately
responsi e or the QOC provided to clients, the service providers, are not often
afforded the opportunity to review and improve QOC even though they are the most
knowledgeable about the services provided and the ones who interact with clients
te Decline in
U
109-118,
daily.
//
y/^uidelines”.
ig Service in
AVSC developed COPE (Client-Oriented, Provider-Efficient), a self-assessment
and improvement tool to improve QOC. In 1993, it was introduced in Kumudini
Hospital m Bangladesh. This is a private hospital located approximately 70 kilometers
from Dhaka. It has 750 beds and is the largest private hospital in Bangladesh.
i
f reIativeIy simPle instrument administered at FP facilities. It aims to
evaluate QOC also from the clients' perspectives and to use resources effectively. It
requires the participation of clinic or hospital staff to evaluate the QOC using four tools:
h 6 Self'a®sessjPent Suide (2) the client interview (3) the client flow analysis and (4)
e action plan The same staff members develop strategies to address the problems
they identify and to implement the strategies.
iS 3 ten'part Ust °f ^hon*- Each part addresses a
p ific right of the chent based on IPPF s4 framework for QOC. The staff may choose to
use only some or all parts of the guidelines.
Ab t tAS rP? Of
COPE assessment, staff participants volunteer to interview
bout ten clients on (a) their opinion on the services provided by the facility (b) their
knowledge about the services provided and (c) their suggestions for improvement. The
client interview also encourages staff members to ask clients informally, on a regular
basis, for feedback on the QOC they receive.
8
da i C1.7? fI°rW ^nalysis is a low technology version of the patient flow technology
S^10^ by v6 Cei?ers for Disease Contro1 and Prevention (CDC) in the United
fates. The staff members are to chart the client flow through the clinic using client
gister forms. The clients are mstructed to present the form to each providfr with
om s/ e has contact. The provider fills out the form with information on the type of
S™mary of a case Study published in Innovations, written by AB Faxsel, M Ahmed, KJ Beattie, BP
’International Planned Parenthood Federation.
93
visit, and the beginning and end of the contact. The information is analysed to identify
problems and waiting times.
From the information collected with the hellp of the above three tools, staff
members develop a plan of action to resolve the problems identified. The plan of action
includes a statement of the problem, a plan for resolving the problem, assignment of
responsibility for carrying out the planned actions to appropriate staff members, and a
target date for completion of the planned action and resolution of the problem. The staff
members also agree on a follow-up workshop about six months later.
After the head of Kumudini Hospital decided to introduce COPE, AVSC
facilitators held a two-day introductory meeting. Staff members then used the COPE
tools to identify problems. During the one-day follow-up meeting after the first round
of using COPE, 14 of the original 25 problems identified were solved.
ft
j. ■
fjjp’i-W*;
i
4
<K
Several lessons have been learnt from the application of COPE in a large number
of settings all over the world. First, in order for it to be successful, staff members must
be willing to be involved in the process. They must see it as a problem solving process
that focuses on work processes, and not on personal shortcomings or management
deficiencies. Secondly, although the experiences suggest that several problems can be
solved using the resources already available, some problems will require additional
resources and/or higher level involvement for their resolution. Third, social and
cultural factors will affect the implementation of COPE. In some cultures open criticism
is considered inappropriate. Therefore, care should be taken to use it as an
improvement rather than faultfinding tool. Finally, COPE is a continuous QI tool
involving follow-up and periodic repetition of tlie activities.
cor
The con it
Mexican* j
concerned v
but reali ;d
the deliver}
CQI wa< ' li
The
providec tc
assure c__ei
functioning
commur y
clinic/ho^pi
service doli\
For c
(See Box " f»
by a mi )r
convened tc
supervis a.
maintain _ _1.
To ac
developed
impleme at
various serv
reached I t
5 Summary ^f c
94
—
■■'.-J,
sea to identify
CONTINUOUS QUALITY IMPROVEMENT PROGRAMME (CQI) AT
THE CATEMACO LOGISTICS CENTER, MEXICO5
■ee tools, staff
f‘ nofaction
a; gnment of
embers, and a
i. The staff
C PE, AVSC
sew the COPE
h^ *irst round
L je number
k ibers must
jiving process
i magement
)b_ms can be
ire additional
d, iocial and
Dpen criticism
is° it as an
a is QI tool
The continuous quality improvement approach has been used by MEXFAM (Fundacion
exicana para a
aeacion Familiar, A.C.) of Mexico since 1991. MEXFAM was
concerned with
of the
the delivery
delivery of
medical services to the rural popXtZn
ith the
the quality
quality of
of medical
but realised that the lack of resources and remoteness of many communities^mpered
the delivery of comprehensive service provision to them. Therefore, a programme of
CQI was initiated and the Catemaco Logistics Center (CLC) was chosen as a pilot.
°kfCtives were t0 continuously improve the quality of the medical care
pr vi e to the target population, to prevent and control possible mistakes and to
assure client satisfaction. Tire strategy comprised two steps: (a) establishing a
functioning service delivery system with well defined tasks at the four levelscommunity health assistants, community health technicians, medical brigade, and
serviceMelivery^ '
" Pr°CeSS t0 aChieVe desired standards of
n
For each of the levels, factors to control and results to expect were identified
(See Box 1 for an example at the field level). Operation and quality standards were set
by a majority vote. Monthly general meetings and extraordinary meetings were
convened to resolve problems. The different departments instituted internal cross-
mamtamed'
conArning minutes of all agreements and solutions was
To adapt the approach to MEXFAM's particular needs, a training manual was
5 Summary of a case study published in Innovations, written by AL Juarez.
95
Box 1: Level Field Attention: Community’ Health Assistants (CHA)
Factors to he controlled'.
QUALITY (
The CHA should have the correct and recognised profile. She detects the problems and
identifies the relevant individuals, and has the contraceptives and materials necessary
including leaflets and documents.
The CHA should be ready to receive training and can conduct talks. She should
also have all the manuals necessary to handle medication and medical procedures. She
should be able to determine the appropriate time to request the services of technicians or
the brigade.
The expected results:
The FP methods and medication suggested by the CHA are appropriate for the client.
And she has,’available and ready, the outlets where the technicians or the brigade can
work safely. Her referrals should be correct.
The talks given by CHA have an impact. There is a feedback on the training she
has received from the community health technicians. All the potential users of the
medical brigade services are attended to. Last but not least; the CHA is self-financing.
The CQI approach is a departure from tradibonal management improvement
techniques in that it seeks improvement in the performance at all levels of the
organisabon and not just at those that are not funcboning well. Each level has its own
set of standards to which is must adhere. A conbnuous cycle of measuring current
performance against the set standards takes place. Once achieved, the standards can be
revised upwards. Because it is a conbnuous process of improvement, it requires long
term commitment and teamwork.
Using the Bi
County in C
improve
e
c
province
very close to
total popi ib
92.75 percent
Chi :e
choose their
IUDs, piT (
withdraw
minimises u
lactabng i )r
and womi e
Inf i?z
couples i^pr
informabon. i
conductec b<
progressea fr
a survey ^ui
average.
Tec' ii<
follow tw r
Various Cont
Commissi i
Secondly, ^ie
of Public Hee
and supp] d
and pass a (
programme k
rates, the i zi
6 Summary of a
96
p Diems and
iai& necessary
. ^he should
cedures. She
:e< nicians or
or the client,
gade can
J I ining she
u rs of the
financing.
- ------------- 1
QUALITY OF FAMILY PLANNING SERVICES IN TAICANG COUNTY, CHINA6
Using the Bruce elements of quality as a basis for strategic interventions, Taicang
Cou ty in China has adopted a series of programme-wide management actions to
improve the QOC. Taicang County is located in the southeastern part of Jiangsu
province m southern Chma. In 1993 the natural growth rate was 0.92 per thousand
very close to zero increase, and the total fertility rate was 1.2. At the end of the year the
total populafaon of Taicang County was 448,784. The contraceptive prevalence rate was
percent.
Choice of methods. According to the national FP policy, married couples are free to
choose their preferred method of contraception. The following methods are providedIUDs pills condoms, vasectomy, tubal ligation, injection, spermicide, rhythm and
wi drawal methods, diaphragms, cervical caps, and Norplant. The programme
minimises unwanted pregnancies by providing specific guidance to newlyweds
lac atmg women, couples who have only one child, couples who have two children
and women experiencing climacteric.
imicn.
Information and counselling. IEC has played
an important role in changing
1 els of the a survey found that the people in the area knew seven methods of contracep^on on
el has its own I average.
st ng current I
n irds can be I
Technical competence. The medical personnel providing FP clinic services must
requires long- follow two regulations. First, they must adhere to the General Clinical Standards of
Various Contraceptive Methods formulated in 1989 by the State Family Planning
^mm^smn (SFPC)> to provide the principles for standard management of FP services
■
of P°nm y'i?e . u
and
1 T
°peratlOn Climc Routme Standard laid down by the Ministry
SFPC mUSt be
f0ll°Wed- AI1 facmties -e well equ"2
I anH rnjcc a
i
'
°rs and nurses must be certified
nd pass a clinical exammation before they are allowed to provide services. The
ratokJePS ™P°rtant data on'for example, contraceptive acceptance and failure
rates, the mcidence of abortion and side effects.
6 Summary of a case study published in Innovations, written by X Sun.
97
Interpersonal relations. In the course of providing FP services, the relationship
between providers and acceptors has improved. The FP workers have continued to
deliver services during home visits. They are concerned not only with the acceptors'
contraceptive choices but their general health. Therefore, the acceptors like to see the
doctors and FP workers when they have problems hoping to obtain advice.
Follow-up mechanisms. Traditionally, the reporting system is done by collecting
data on women's reproductive history such as the number of children, current
contraceptive methods, continuation of contraceptive use, and so on. A computer-based
MIS was set up in 1993 to improve follow-up by providing HCWs better data.
! fei
pl!
I
In 1993, th
goverm it
was the b»
teamwork
will pre o
ri-»0
Appropriateness and acceptability. The FP services are provided by well-equipped
county and township hospitals. There are strict regulations concerning the clients'
rights to privacy and confidentiality. Clients face short waiting time to receive FP
services.
of the s ?e
comprises
supervi rs
and unc n
monitoring
are proj rl
Appropriate constellation of services. In Taicang County, FP is integrated with the
MCH programmes. In 1993, the Taicang County decided to establish a new service
network for health promotion called Family Health Service Center from cities to every
township and village. The services will cover three groups — children, couples and the
aged.
Each ur
Manual > I
judged, inc
Thus, a variety of mechanisms are used to ensure QOC including formal
regulations of quality services, provider attitude and competence, monitoring, and use
of the primary health care system.
MANAGEMENT ACTIONS FOR
QUALITY OF CARE ELEMENTS
i
MANAGEMENT ACTIONS
QUALITY OF CARE
ELEMENTS
including:
Method Mix
IEC
Types of Services
Where Services Offered
MIS
Client Feedback
4. I
ec
5. Clie.
6. f !tl
7. L_C
8. Hon
9. I zc
10. Ciin
Choice of Methods
Training
1. ( n.
2. Clin
3. C n
>
11. Targ
Information & Counselling
12. (
ei
Technical Competence
Interpersonal Relations
Follow-Up Mechanism
Appropriate Constellation of
Services
Eacl Q
units sb il
where the s
delivery si
assessment
Accessibility
7 Summa:
Improving Infrastructure
9^
■
,1!
IIU.UI ,!
’’ • '■’rnw-iTWW
o
lationship
ci itinued to
he acceptors'
J< to see the
j
b collecting
Iren, current
rr~’iter-based
QUALITY IMPROVEMENT PROGRAMME (QIP) BY
THE MINISTRY OF HEALTH, EGYPT7
In 1993, the Egyptian Ministry of Health System Development Project began a twogovernorate, nine-district study to improve the quality of the FP services provided. This
was the beginning of the Quahty Improvement Programme (QIP). It emphasises
teamwork and leadership and tries to inculcate positive organisational attributes that
will promote quality of care.
it
The most important feature of the programme is the formation and maintenance
of the supervisory team at the governorate and district levels. At each level the team
re equipped comprises a FP director, a clinical supervisor and a nurse supervisor
All the
; ie clients'
supervisors must pass a supervisor orientation course designed to provide awareness
o receive FP and understanding of their supervisory skills and responsibilities in applying the QIP
monitoring system. The supervisors must make extra efforts to ensure that the clients
are properly informed and satisfied with the services they receive.
itpd with the
i w service
Each unit receives the Clinic Procedures Manual and the Service Delivery Resources
ties to every Manual so that they know the indicators according to which their performance will be
if 1ns and the judged. The indicators selected cover twelve technical and administrative categoriesd g formal
•ii , and use
C S FOR
-E_ JENTS
J
is
elling
1. Clinic equipment/furniture.
2. Clinic facilities.
3. Contraceptive commodities.
4. Infection prevention.
5. Client registration, FP information, history.
6.
specific counselling, physical examination, method provision.
7. IEC activities.
8. F
Home visiting/Dropout follow-up.
9. Records/reports.
10. Clinic operations.
11. Targets.
12. Client satisfaction.
n(
ons
is
ic.. of
ach QIP category comprises a number of individual indicators that the service
units should achieve. Using a checklist, the supervisory team awards a mark of "1"
ere the standard is met and a zero otherwise. The supervisory team visits a service
dehvery site once every quarter and spends about three days conducting the
assessment through observation, interview, role-play and demonstration. At the end of
’Summary of a case study published in Innovations, written by EH Gebaly, C Brancich, ME Shaffie.
99
the visit, the team discusses the score with the clinic staff as a whole and sets targets for
performance improvement.
The monitoring system has resulted in considerable improvement in the QOC
provided. At the beginning of the QIP, in one governorate with 102 units, 42 units
received scores below 70 percent, only four units received 90 percent and more, and no
unit met the minimum standards of 100 percent. After three-quarters of QIP activities
five units met the 100 percent required, and 31 units achieved 90 percent or more. Only
24 units remained below 70 percent.
B
It !.
ii -
The providers complied with the standards of practice and the indicators for the
facilities and equipment are improving. The QIP uses an external, pre-determined set of
standards as a reference point on which reviews and recommendations are based.
Establishing clear standards and assisting clinics in achieving them through effective
supervision is pivotal to the success of the QIP in improving the quality of the FP
services. It is expected that continued problem solving, decentralisation and teamwork
would lead to further improvement over time. In view of the positive results of the pilot
project, the QIP is gradually being expanded to cover all service delivery sites
throughout the country.
I,
’t.
EFFECT!
Not onlj h
attention if
manager-1
inductioi pe
feedback, tv
member; in
innovate
Recruitn.^n
Sustenan ‘
recruitment,
professional
selection k.
recruitment
be quit
selection;
interview cc
needed 1 tl
and it mu^t
period.
The
inconsiste^c
opportur y
the applican
about it? Is
Converse ',
objectives so
TL_
performance
candidate e
phone or in
references m
8 Taken from I
100
b J
•
‘t ■:-
.W
s j targets for
EFFECTIVE PRACTICES RELATED TO HUMAN RESOURCE MANAGEMENT8
it I the QOC
units, 42 units
1 ore, and no
QxP activities,
or more. Only
lie tors for the
te nined set of
3ns are based.
*c *h effective
il / of the FP
and teamwork
il of the pilot
livery sites
Not only the service delivery system but also the people who provide services deserve
attention if the QOC is to improve. Population Services in Zimbabwe pays attention to
managerial practices m the area of human resources, for example, staff recruitment,
induction period, training to enhance competence, commitment to team work frequent
feedback, two-way appraisal and adequate incentives. The organisation involves staff
members m the planning process and encourages them to continuously learn and
innovate.
J
Recruitment
Sustenance of motivation begins with staff
recruitment. It must be carried out
professionally and efficiently.
Various
selection skills are required to make good
recruitment decisions. Job applicants can
be quite deceptive resulting in bad
selections. A thorough, unrushed job
interview conducted two to four times as
needed with each candidate is important,
and it must be combined with an induction
period.
Effective practices that promote QOC:
•
•
•
•
•
•
•
•
Staff recruitment
Induction.
Training to enhance competence
and commitment to team work .
Frequent feedback.
Two-way appraisal.
Adequate incentives.
Involvement of staff in planning.
Encouraging staff to continuously
learn and innovate.
The
interview
may
reveal
inconsistencies. It also represents a good
opportunity to become acquainted with the candidate, It is important to find out why
the applicant wants to work for the organisation. How much does the applicant know
about it? Is there commitment Ito its
’* goals, or does the candidate just want a job?
Conversely,
it is important to brief
,. .
'r applicants
Tx'1
on the organisation's mission, goals and
objectives so that they make an informed decision.
The interview should discuss remuneration including the organisation's
performance-related incentive scheme, and so on. It should closely examine the
candidate s education and qualifications to ensure that they fit the position. References by
Phone or m writing should be sought from past employers. Refusal to give written
references may indicate a possible problem. Length of time in the previous position is also
8 Taken from ICOMF s seminar report, contributed by A Rugara, Population Services, Zimbabwe.
101
library
. ’■
l
(
> 0'1
AND
I r-
documentation
) r
06655
important The induction/probation period should be at least three months, six for key
posts, in order to provide ample opportunit}- for interaction, training, exposure to the
organisation, and to determine whether the person can deliver.
The role of appraisal
■
I’
I/
t
If
•1
| 'I
1%
The candidate and line manager must agree on appraisals throughout the induction
period. Weaknesses and strengths may be discovered to assist in the final hiring decision.
If the candidate has many strengths, but is lacking in some ways, the induction period
may be extended, but this may also cause problems. Appraisals should continue after the
candidate is permanently employed. A two-way appraisal was at first controversial in
Population Services, but is now well accepted and has improved staff/manager
relationships. It is important to capitalise on the strengths of employees and improve on
the weaknesses.
i
Actio R
serve? a
among o
activi ?s
the nc<.d
efforts th
educe di
their xno
healtl v
contir o
n<
reseai i
intervent
servic ;
Training and other issues
services »
Training is also very important in enhancing commitment to teamwork and QOC. Both in illnesses
house and formal training is provided, for example, FP and STI updates are done and treatn n
contribute to staff motivation. Training needs are assessed on a continuous basis. Staff
members are always involved when change is taking place. They must own the change
^h
organ t
which, after all, they will be responsible for implementing.
workers,
Similarly, Population Services has a GAP (good action planning) process which partic a
provides staff with an opportunity to do a SWOT analysis, consider the organisational
environment, and participate in the planning process. This has increased motivation
A
through increased knowledge and organisational transparency. Other important factors are tl
contributing to staff motivation include tu^o-way motivation, staff meetings, frequent specifx^a
feedback, adequate incentives, staff setting their own objectives, and continuous learning CHWs a
the cc ir
and innovation to avoid stagnation.
• br‘Jg
• pi zi
• encoi
• he >
ar t
9Takei o
is alsw Jt
102
5,
O
x for key
re to the
ACTION RESEARCH IN COMMUNITY HEALTH AND DEVELOPMENT9
Action Research in Community Health and Development (ARCH), founded in 1°82
serves a rural community near Baroda in the state of Gujarat, India. Founded bv'
among others, a husband and wife team. Dr. Anil and Daxa Patel, ARCH began its
activities by studying the problems and diseases most prevalent in the area. It explored
the needs and wants of the community as well as its beliefs and misconceptions efforts that enabled the organisation to develop effective service, counselling and health
education programmes. It is also interesting to note that the founders acquired much of
their nowledge of the area as a result of their informal relations with the community
health workers (CHWs), their emphasis on two-way communication, and the
continuous learning/training process to which they committed themselves.
ie induction
ir^ decision,
cl n period
nue after the
ti ^ersial in
if manager
improve on
Since ARCH's inception, each and every intervention developed is based on
research and a carefully developed plan of action. This process continues also after the
intervention has been launched. ARCH offers comprehensive primary health care
services to a project area with approximately 12,000 population. Over the years tire
services of ARCH have grown from meeting community's needs in the areas of acute
Both in- ^atalnt'of RtXtd
t0
reProductive health' deluding diagnosis and
e one and Ulv.CXLlILV.llL vJl L\ 11/ O 1 Lz.
basis. Staff
I’ ? change
The use of the CHWs in providing services has proved to be effective because the
organisation provides adequate training, supervision and technical back-up to the
workers. This programme also offers a strong educational programme aimed both at
X s which
particular target groups and the community at large.
& isational
motivation
ARCH attributes its success in ensuring a high level of QOC to the CHWs who
t t factors I arg the core service
ice rproviders. Specific approaches to staff management, or more
JS, frequent specifically to the CHWs,
, are considered essential in developing their potential. The
>u-learning CHWs are iparticularly
- effective
in performing some tasks because they are rooted in
the community. Some of their tasks are as follows:
•
•
bridge the gap between tradition and medical science.
provide culturally acceptable and low cost health care services.
encourage women's participation.
help evolve a tentative body of knowledge about women's concerns, their wants
and their apprehensions.
’hZtZXTS.0»’ p‘per "inen b> MB “"e “ The
103
help prepare acceptable health education materials and conduct health education to
the community.
•
ARCH has currently fourteen full-time and six part-time health care workers in
addition to two doctors.
2. Curr itl"
rema d
accept c
estat ;h
apprene:
3. The c
Selection of CHWs
4. Weel
ARCH prefers to recruit women from either the project villages or the village of
Mangrol where the clinic is located. The selection of a worker is largely based on her
communication skills, her willingness to learn new things, and her ability to interact
with all women irrespective of caste or community. All the current CHWs started as
part-time workers. Many outstanding workers were selected to work full time
Training of the CHWs
"As iue worked with women in an atmosphere of friendly informality, we learnt a lot
about the worries of the women, what they really wanted, what they were apprehensive about
and what were their hidden, unspoken shames," says Dr. Daxa Patel. It is from this
understanding that a tentative body of knowledge was developed. It was further
checked and tested in large, formalised and structured meetings. The training materials
were a result of these experiences.
’K
' I
5. The trair
diagr st
The re
point at 4
behind it all,
internalised
a thorou; t
exceedingly
commun” j
commun r
Dr. Patel un
years for ie
Training at ARCH is a slow and ongoing process. The relatively low levels of
education of the CHWs presented a challenge. Not only did the health care workers
need to learn the complicated and unfamiliar concepts of modern medicine, they also
had to overcome their own traditional beliefs. All the new concepts had to be
internalised and accepted.
In ad
their ind id
community,
covered b^ t
unless re li
the village.
The process of teaching the CHWs new concepts and about illnesses, developing
their skills in diagnosing, making correct interventions and providing appropriate
treatment took a long time. The following methods and factors facilitated the training of
the CHWS:
Managemen
1. CHWs learned on the job by examining the patients with the doctor. In this way,
they learned to take the medical history, to diagnose, to explain the disease and
treatment to the patient, to administer treatment, and to document and keep
records.
Di A
organisation i
to call it i a
differences rla
articulated.
104
”
... ..............................
1
1
’;
...............................
■■
K.
.. 1
i ducation to
ai
workers in
2. Currently, the CHWs can manage 70-80 percent of the cases on their own. With the
remainder, they need assistance from the doctors. Clients have gradually come to
accept care from the CHWs. Working alongside the doctors at the dispensary
established their credibility in the eyes of the villagers who are no longer
apprehensive of receiving care from them in their homes.
3. The categories of illnesses were introduced to
the CHWs
------------. ini an incremental manner.
4. Weekly meetings and case discussions have contributed to the training process.
e village of
r based on her 5. The training of the CHWs in various laboratory procedures further increased their
li to interact
diagnostic skills.
II. 3 started as
time.
The relatively slow process of training the CHWs allowed them to move from a
P0^ at which they were supplying drugs, but understood little of the reasoning
behmd it all, to a point at which they understood the concepts of modem medicine and
internalised this knowledge. Firmly rooted in the community, they had at the same time
a thorough understanding of the cultural beliefs existing there. For this reason, they are
we learnt a lot exceedingly effective educators and also constitute an important link between the
n ’ msive about community and the doctors at ARCH who continuously strive to understand the
■t
from this
community and respond to its needs. After the training, the CHWs worked alongside
t was further Dr. Patel until they were confident enough to treat minor illnesses. It took another 1-2
n g materials years for them to gain confidence to treat more complicated diseases.
In addition to the dispensary work, all CHWs are responsible for health care in
r w levels of their individual villages. They also collect vital data, conduct health education to the
i cure workers
"in. they also COmm^' dlstnbute iron f°Hc tablets, and immunise children who have not been
;t had to b J6
y **
VeTen? ANM- 1116 health Workers d0 not do door-to-door visits
unless required but rather diagnose and dispense medicines from their own house in
the village.
as ieveloping
g appropriate Management of staff
tl training of
Dr. Anil Patel, one of the founders of ARCH, says, "ARCH values a democratic
organisation in winch communication flows freely up and down. It may indeed be a misnomer
i this way, o call it up and down as there is little hierarchy; it is expected that socio-economic and caste
e disease and
interactions'" These as weI1 as other expectations are clearly
2n*- and keep articuHted’
105
...
Employees have much flexibility in terms of how, and, to some extent, when M
per orm their tasks, but tasks are expected to be performed correctly and well On th
other hand, it is also accepted that mistakes are part of the learning process. Th,
precondition is that staff must own up to their mistakes and learn from them.
All ARCH employees participate in the decision-making process. At weeklv
meetings attended by all full-time staff members, issues and decisions related to the
orgamsation as well as client cases are discussed. Thus, the meetings constitute an
important part of the continuous learning/ training process of the CHWs.
Quality
MaL si
Directoi
QuaK*y
Supervision is supportive and positive feedback is frequent. Part-time staff in
the villages are supervised by senior CHWs as well as by the doctors who visit the
villages regularly. Part-time staff also attend meetings and training sessions at ARCH
■,...
h
I’B TO
? '' •?
■■
y'
&
'
When enquired about their motivation to perform, a worker said, "tltere is an
open and friendly atmosphere here and we like the opportunity to learn and develop skills"
Another mentioned, "/ like to work at ARCH because 1 know what is expected of me and we
can work on our own without somebody looking over our shoulders or scolding us" The
workers feel that they want to give back to the community because they have had an
opportunity to learn and develop. In addition, the CHWs tend to emphasise the fact
that the community appreciates their services and that clients often express gratitude
The friendly atmosphere observed among staff carries over to client/provider
interactions.
r
I
agen es
sevei. st
< a
qua
C”a.
( a
qua
( a
( a
JL
''I: ■ '
While many factors have contributed to the success of ARCH, three deserve
particular emphasis: (1) the strong groundwork, research, and intensive planning
before starting an intervention (2) ARCH's ability to learn from the community and (3)
the critical role of the CHW's in providing RH care services to a traditional, poor society
through their dissemination of ideas, information, and knowledge.
The < jc
By 1 15
proviair
QuaF^z
the n m
health Cc
Ir
optimun
gove. rr
apprc^cl
encouraj
10 Summa
106
J
Xucnt, when to
d well. On the
j xess. The
tern.
TOTAL QUALITY MANAGEMENT
IN MALAYSIA'S GOVERNMENT HEALTH SERVICES10
!S At weekly
related to the
> nstitute an
Quality is the most important item on the agenda for the health care system in
Malaysia. This is reflected in the following comment made by Dr. Abu Bakar Suleiman,
Director General of Health, Malaysia, in his recent address at the World Congress on
Quality of Health Care:
■rt me staff in
Vvxio visit the
dons at ARCH
Quality, as perceived by consumers must be the number one priority for
any health care system that strives to excel."
In 1989, the Malaysian Government introduced the "Q" program into all its
agencies. The program is a Total Quality Management (TQM) approach which relies on
seven strategies, the 7-' O' s :
id "there is an
d elop skills."
'd of me and we I *
di ; us." The •
y ive had an •
hasise the fact •
n ; gratitude. I •
liLx<t/ provider •
•
three deserve
si’r? planning
ni dty and (3)
1, poor society
quality day.
quality slogan.
quality information system.
quality feedback system,
quality suggestion system,
quality process system.
quality assurance system.
The Quality Assurance Program
By 1985, the Malaysian Ministry of Health (MOH) felt that it had succeeded in
providing extensive coverage of health care services to the population. Therefore, the
Quality Assurance Program (QAP) was initiated to achieve the optimal benefits from
the resources available to the programme. The QAP had three objectives: (1) to improve
health care (2) to increase resource utilisation and (3) to enhance customer satisfaction.
Initially the National Indicator Approach (NIA) was used to set standards for
optimum achievable levels of quality of care and to assess the quality of care in all
government hospitals. By 1992, the approach covered all the MOH activities. As this
approach created an awareness of quality’, hospitals and districts were increasingly
encouraged to set their own standards (with hospital and district specific indicators).
10 Summary of a case study written by J Satia and MB Dohlie, ICOMP 1995.
107
pnorthX0^
’n,
analysis,
actions
hhi.
The prOg[am Is orSanised by the steering committees specially established to
ied rrp“7 J miniStry leve1' a‘the d,"sima'
quality. It
has led tc
expect n
care facilit
“d state levels ms appmacb
led to considerable improvement in quality as mdicators continued to improve ov«
conditions
considi d
Quality Control Circles
Bi
I - If
Quality Control Circles (QCC) have been . ’
a feature in Malaysian government agencies
since the early 1980s. These activities focused
on solving many day-to-day problems or
those that cause customer dissatisfaction. The
groups
are decentralised and each facility
has its own QCC.
I
TQM: Building a Corporate Culture
o create a philosophical foundation and
an enabling environment for the
programme, both a vision and a mission statement
were formulated after consultation
with key stakeholders. To further develop the c
organisation and its focus on clients, the
programme adopted a "Corporate Culture" in’the
early 1990s. It has the following
three core values: (1) caring services (2) team work and (3) professionalism.
108
. —
.....■
Id itification,
e
analysis,
tedial actions
stablished for
nh approach
.mErove over
The client's charter developed is used to empower clients and institutionalise
quality. It enables the public to evaluate the service performance against the charter. It
has led to increased expectations on behalf of clients in terms of what they should
expect and can demand. The client's charter defines the responsibilities of the health
care facilities and service providers as well as the client's obligations.
In conjunction with higher per capita income, better socio-economic
conditions, and rising expectations amon^
ig clients, prioritising quatity of care has led to
considerable improvement in the health status of the population.
lent agencies
’ j obiems or
i i ch facility
cits to make
er efficiency
2 tivities of
/ resulting in
ir s, and on
n< t for the
c isultation
n clients, the
i( oilowing
)r: is given
, guidelines,
le 1 )cal level
fi 11 states:
>p. Now we
h
j."
109
. ..... ..;)ais?<\ .....
7
What Would Managers Need to Do?
The importance of improving QOC is widely recognised. Now the major issue is not
why quality but how to improve quality. As the action research and other examples
documented m this issue of Population Manager show, quality improvement (QI) is not
an autonomous process. On the contrary, it requires well-planned proactive actions
Based on these experiences. Chapter 7 discusses the lessons learnt and QI approaches
used. The role of leaders and managers in QI is also discussed along with actions
required to initiate and sustain this process.
LESSONS FROM ACTION RESEARCH
Many lessons were learnt in all three countries since the inception of the project.
Moreover, several issues arose in the move towards comprehensive RH care services.
Quality can be improved, even in constrained settings. The cases demonstrate that
quality could be improved despite the many constraints faced in the public sector At
the project sites m the three countries, clients perceived that improvement took place in
the services provided. However, quality improvement is a slow, time consuming and
labour mtensive process that must be allowed the amount of time required by the
individual programme depending on the cultural, social and organisational context as
'veil as the maturity of the programme.
Rapid assessment appears to be an effective tool for managers to assess the QOC of their
programmes in a relatively easy and inexpensive way. The action research in the three
countries - India, Sri Lanka and Vietnam - showed that involving managers in carrying
out a rapid assessment in their area quickly sensitised them to address some of the
Problems identified. Once the problems are identified, managers and staff may explore
Ways to correct them. However, a rapid assessment will only uncover the nature of
problems and not their scope.
111
Ir
I
Jr
i -'
Although there are many similarities in the
quality-related problems identified, their
extent and nature maiy differ fn
I
one( Programme context to another. Therefore, many action
taken to improve the quality of
At
t
care were common to the three
Box 1: Possible Interventions
Addiho
action research sites. These
avai bi
Common Interventions:
activities included sensitisation of
staff tm
staff to quality of care, training to
• Training in QOC, counselling and
improve counselling, information
i
technical skills
giving and technical skills, and
relatively
the use of supervisory checklists
• Supervisory check lists
for li
to assure quality. They also
• Modest investment in infrastructure
bloo p
encompassed relatively modest
• Community outreach
Even if
investments to improve the
• Attention to mundane details
circi is
infrastructure and to establish
such xie
new
community
outreach
Context Specific Interventions:
little Ml<
arrangements both to improve
access and availability and to
C
• India: Community mobilisation through
address broader RH care needs.
make
women's health committees and village
Improving quality of care
HCV v
health committees
requires attention to mundane
that ma'
issues such as cleanliness,
have
n
• Vietnam: RTI screening and treatment,
availability of water, functioning
their ic
IUD insertion at commune health centres
toilets, curtains to ensure privacy,
sub-cent
and overall maintenance of
supp ?s
• Sri Lanka: Organising quality well woman
facilities.
whei^ d
clinics,
improved
organisation
of
responsi
community clinics, group counselling on
However, activities to
sexual and reproductive health
improve the quality of care also
C
differed at the three sites. In
partible
India, for example, there was considerable emphasis on f
of
m< a
forming women's and village
health committees and on educating them on reproductive and child health In while su
Providers were fr^d in IUD msertion at selected commune health centers, parti
RTI/STD screening was introduced at two sites, and selected providers were trained to abilit
do group education for youth and men. In Sri Lanka, several changes were made to
better organise community clinics. Service providers were trained to do group
counselling sessions on sexuality and reproductive health in the community. Moreover, progn-.at
quality-related issues in relation to the planned well woman clinics received attention.
interven
addn ;e
Hence some interventions were common whereas others were specific to the other rej
programme and cultural context.
skills m
112
......
is lentified, their
re, many actions
11 iiZk imPromng quality, the issues of access and availability often must be addressed.
L
iZV1^' 1SfUeS °f aCCeSS
availability arose and had to be addressed.
Ad -Zu3 fa“ lbes and staff are often thought to be necessary to improve
access and
availability. However, the action research shows that reorganisation of the work
; and of
staff time can play an important role in improving access and availability.
ai
and
Many of the structural inputs required to improve the quality of care are ven/ basic and
relatively inexpensive. Some of the examples include curtains to ensure privacv benches
for waiting clients, stethoscopes and/or cuffs to enable providers to record clients'
blood pressure, scales for babies or adults, follow-up cards, IEC materials, and so on
Even if many of these mputs are relatively inexpensive, it may under normal
circumstances be difficult for managers and staff at the service delivery level to procure
such items. Centralised procurement processes often do not include the items and make
little allowance for possibly varying needs at different sites.
3r through
ar... village
Change in work behaviours and improvement in staff morale must take place in order to
make the improvements in infrastructure, equipment and supplies sustainable. The female
Tre. pr°V1.Jd.Wlthuvanous equipment and supplies at Shamirpet PHC in India
diat made it possible for them to provide better services. The interventions appear to
have improved their relations with clients and community and to some extent boosted
their morale. Gwen the fact that the female HCW is the manager and provider at her
sub-centre, it is Possible.to make her personally responsible for the equipment and
pphes provided. This has been more complicated at the primary health centre (PHC)
msponslbdity111
°f
leam tO W°rk tOgether 35 a t6am and to tak" j°int
elling
ire
tieatment,
th centres
rell woman
;a ’ )n
of
"U ling on
n's and village
iiJ health. In
health centers,
ve*e trained to
v re made to
to do group
iif Moreover,
e< attention.
sj zific to the
___require
____ programmes to adopt a more
i e success in improving_ the quality of care will
Parhcipatory style that allows for involving staff at all levels to tap th<
ability
°----- uicir creativity and
ahl1’Hr
Staff sensitisation, training and monitoring become major interventions when
programmes confront quality improvement. The QI teams at the three sites identified these
addressed Tou^Zg
er reproductive health issues and sometimes also primary health care, technical
S,
ec on prevention, clinic management, and recording/reporting. However, a
113
one-time training is not enough. New skills need to be practised on-the-job under close
supportive supervision.
I
fete
I. . mI
There is a need for reviewing training modules to ensure that they are conducive
to a high level of quality of care. At the same time, it is important not to forget the
basics. At the project site in India, the team found it necessary to train the HCWs in
using the scales, stethoscopes and blood pressure cuffs provided by the project. In
Vietnam, improving technical skills in IUD insertion, MR and vasectomy was an
important issue that was addressed along with improved counselling and information
giving. However, it is not necessarily easy. Bottlenecks emerged in the vasectomy
training in both Sri Lanka and Vietnam because an insufficient number of men wanted
the service.
:■
lli®
I
The earlier comments of the HCW worker in Sri Lanka may guide programmes
in their quest for better training programmes ("Now we are told to be kind"). It is not
enough to take for granted that staff will exhibit good work habits. Programmes must
introduce their expectations in their training programmes and provide subsequent onthe-job reinforcement of good work behaviours.
Bot tf
probably de
educatioi ar
programme
whereas in I
generally rc
Th^ ac
different i y
approach wne.
of manage m
Mana^
managers t
managers, tc
important. 1
the conce o
easier to L<cu
may already
each othe is
be frank a do
sometime^ n
compoun th
at higher lev
issues.
Programmes need to consider community education in their efforts to improve and
increase the information and prevention messages clients receive. Many HCWs already carry
a heavy workload. Much of the information which programmes need to communicate
could be given in a group setting rather than to the individual client coming for
services. Traditional FP programmes generally do not reach non-users, men, youth of
both sexes, and women past reproductive age. New innovative approaches are required
for this to happen. If, indeed, programmes offered comprehensive community
Commi
education programmes, more target groups would be reached, and HCWs might have
more time to focus on the individual client requesting services at the clinic for her/his at the top vt
quality in.rrc
problems.
down throug
The community outreach interventions at the Indian project site contained FP and programn ,
other reproductive health information (in addition to primary and public health place to cuar
information). In the context of Sri Lanka, the public health midwives themselves came ^ords, create
up with ideas for new subjects in their information sessions for the community after Perform ti ir
have a demor
they had been sensitised and trained.
take place * i e
The QI team in Sri Lanka used the male public health inspectors to communicate situation t :o
with and involve men. Similarly, the Indian team increased the role of the male HCWs
Roh f
in the areas of FP/RH.
the-job >a
^ith the new
114
-
PPM
.
_____ '....Tij-
jc
under close
/ — e conducive
Dt to forget the
n ie HCWs in
tne project In
ct^my was an
ni information
the vasectomy
of nen wanted
programn.e^ooseTtopro^.'
either mab or ,e"a,e
Mmagiml Styles md Systems Cmducive to Quality. An Important task of
managers
at all levek becomes that of mentor and „f enabling staff (aXLerted
te rogrammes
ir__"). It is not managers) to perform their work belter than before. Problemsolving“w * staff f
grammes must tmporlant This requires open two-way communication. It is inleresZ” not^
st sequent onconcept of quality with its implications for systems and managers seems to be much
easier to inculcate m a less autocratic context or system Managers and staff at all 1
I
may a ready be more used to ,datively more openness^n7Tqua^ i^ dX w^
tc tnprove and
s already carry
) c mmunicate
n zoming for
men, youth of
2S re required
e zomm unity
Vs might have
li for her/his
“
XT Srith X h thiS “nKXt “
gtTstaffto
be trank about problems they encounter while in a more autocratic context staff are
cover-up.
• compound the problem. If there is no
te:± - - • Lack of <accountability
may further
faith that appropriate action can or will be taken
at higher levels, staff at lower levels will
J not bother, maybe not even dare, to raise
issues.
down XgTX system Xs^X“TX
X
^ot Twtil not take
itc led FP and P acTto XneXT aPpr°Priale aC“°nS by
puolic health tori
1 8 work behaviours sufficiently. In such situations, one can, in other
*ir''elves came Perforate3 6 til
C°ndltions for 111056 who want to work while those who do not
n unity after perform their duties may continue to do so with impunity. The latter will /eneralv
have a demoralising impact on all staff. If, in addition, the efforts to improve qualite
situation bm 3 Settmg
there relativeIy little accountability to the commumty tte
c nmunicate situation becomes even more difficult.
me
e male HCWs
on th
t ^fS^sors. Current supervision is often inadequate or insufficient for the
Mth^th°
mg and monitoring
need to take place after initial trainmg In line
the new management approaches described above, supervisory behaviours need
115
to change. The COPE programme example highlighted the fact that criticising is more
difficult to do in some cultural contexts than others, and that a positive rather than a
negative approach - problemsolving, rather than fault-finding - is essential to success
Similarly, the example from Zimbabwe emphasised the importance of building on
employees' strengths while improving weaknesses. The CHW at ARCH also indicated
that a positive enabling approach works better than a negative approach such as
"scolding."
the QI a
break a a
le
Vietnauies
behaviours
AS
I 1 I
I: I-1^''
wf
’H
The QOC project encouraged supervisors to go beyond their customary
inspection and monitoring of, for example, targets. The project developed different
types of checklists that were adapted to the local context by each team. The lists are
training tools that might eventually serve the workers directly as an aid to remember
tasks and to do them correctly. They can be used as a basis for discussion and problemsolving between supervisor and supervisee or among co-workers. Moreover, the
checklists
-------- are a useful aid for supervisors who often perform their tasks inadequately
prepared.
Given the emphasis on reorientation in management approaches, work behaviours and
processes, we found that quality improvement is both time consuming and labour intensive. It
may be tempting to fall into the trap of spending too much time on structural inputs
because they are so much easier to deal with than issues related to people and
management. In addition, some settings require relatively more input than others do.
Some programme contexts also will have more difficulty in dealing with the
implications of the concept of quality. As emphasised above, the mere existence of
brooms, waste containers, and so on will not alone ensure a cleaner site unless staff
begin to think differently and change their work behaviours accordingly. Even under
the best of circumstances, however, re-orientation does not come easily.
In addition, most FP/RH programmes are already involved in many activities
and some may find it difficult to spend the amount of time and effort required to
improve quality, or they appear to need to spread the effort over a longer time.
Considerable investment of time is required to sensitise staff and provide
appropriate skills-based training. Both are critical to bring about sufficient change to
improve quality. As discussed above, the QI teams at the action research sites spent
considerable effort on staff sensitisation and training - or retraining - to improve staffs
skills and level of knowledge.
becomes mo
initiativ I
to the new
already il
applies >
different ai
India a i
improveme
programme
will pre n
on the healt
1
’>
vary considc
various u
universe a
issue of prix
7 J
improvement
implies. v
pilot preset
Improvi™ (
project s ?s
Q- al
successfi v
level and fie
others, si v
receptive c
The extent of sensitisation required to improve the QOC may be under A and B iiestimated. The effort must be on-going until new behaviours are internalised. Similarly improve ?r
116
ic ing is more
? rather than a
ti to success.
)f uuilding on
also indicated
rc zh such as
*e QI teams themselves required both time and sensitisation to become prepared to
break away from "old" ways of thinking and performing tasks.
P P
The very heavy emphasis on or ____ 2____ 1
promotion of some methods in the Indian and
Vietnamese programmes illustrates well the need for
---- reorientation and change in work
behaviours.
As the benefits of improving quality are felt, staff morale improves the community
becomes more involved and local managers take many actions to improve quality on their own
initiative. In the achon research project areas, the early indications are that staff respond
ei customary
oped different
retlnrkClrTStanCeS enabling 1116111 tO dO a better i°btransformation hat
. —he lists are
1
remember
y
^en p ace m many of the NGO experiences described in Chapter 6) This
and problem- app ms to better physical work environment, improved skills and knowledge and a
rt
SUpPOrhve aPProaCh on behalf of supervisors/managed In btth
vl ’eover, the tndte
> ^.adequately
commur^ty/commune also responded to the -pemeived
improvement by providing funds, better space for the clinic, and so on 7ott
,
. P ingXTeS H "h Veiy pr°aCtive in encouraging this to happen. The local involvement
»n ufe
’ P0S,,iVe
nO,Ot,Iy
“he
W, ako
u( iral inputs
a people and
The perceptions of quality - perhaps particularly in terms of interpersonal dimensions
la others do. vary considerably among countries and among providers within a country Alihn t, n,
in with the
quality frameworks developed elnuin dimeXs of Xfr X h
s existence ol ™versal appbcauon, their interpretation may vary greatly in different Contexts ThZ
e nless staff lssu^ °f privacy is interesting in this respect.
ven under
The potential for pilot projects to play an important role in terms of advocacy for auality
mprovement may sometimes be overlooked. Moreover, aiming to provide quahty services
m.y activities
advocating for other RH services to meet clients needs effectively £X
t squired to Pllot projects played an important role in sensitising the top managers toXalitv U
" ■
XZr11'’’ °f
Pvogr'mm™ XXXe
a" i provide
>n :hange to
Quality efforts are generally driven from the top, but the efforts are trulv
trulye
:h sites
XTX f X? qiUaHty beC°meS ever>’one's value
responsibility. Some midd
if we staff s level and field level supervisors are more effective in inculcating this value in staff tiln
r thers so within a programme quality will vary. Similarly individual staff membersXe
H
A andTte a^
’ t0
^e65makeS * difficult to comPape sites
y .e under- A and B m a particular programme. When evaluating their progress in auaX
au. Similarly, improvement, they should, above all, compare their current performance agXsTXir
117
past performance while using better performing sites as a Ibenchmark. There may also be
external factors that make it more difficult to improve quality at site A than at site B.
Sometimes site B's reaction to quality improvement at site A is "we are already
doing that". This is not an approach or attitude conducive to QI. The point is that site A
- and maybe the majority of other sites in the programme - may not be, and they need
to improve their performance. Instead site B could pick the same or another area to
improve against its own higher standard. That is continuous quality improvement as
opposed to meeting a set standard.
LESSONS FOR THE SHIFT TOWARDS
COMPREHENSIVE REPRODUCTIVE HEALTH SERVICES
■
u
Current QI efforts must deal with the improvement of existing services as well as the
difficult transition to more comprehensive RH care services. The project worked on the
premise that current services should be improved with a gradual addition of new
activities and services depending on the programme's ability to introduce them
adequately and safely.
it: Kt j?
I
The experience to date shows that if comprehensive quality RH care services are to be
introduced, then the knowledge and skills of staff and service providers must improve greatly in
many settings. Staff in all three programmes required considerable training to perform
tasks that their programmes have normally not addressed such as STD/HIV
prevention. Inadequate technical skills may represent a problem area even for existing
services.
Given the fact that both medical doctors and different types of HCWs sometimes
appeared unprepared to perform, for example, pelvic exams, it is important to examine
the curricula of medical and nursing schools along with those of training programmes
for HCWs. With a view to the services implied in the ICPD-POA, are existing training
programmes sufficiently skills based, relevant and up-to-date?
There is, and will probably continue to be, a considerable demand for service
providers who can perform different types of procedures related to RH. This is due to
tlie heavy burden of disease related to this area of health and its relatively large impact
on overall health. Moreover, many clients may currently not even seek care for such
problems because of their low awareness of RH. On this background, the question must
be asked whether general practitioners are sufficiently and adequately trained to
perform many of the most common procedures. These include pelvic exams, treatment
118
.
-
of RTJ 33
pregn^.c}
of pregnai
/ir a
STD or ST
and S'. >/,
STD/HIV
traditic al
questic s
I n
integrator
understaff
the nu is
emphasis
strong ’ne.
does, h ve
I
activitif I
disruption
with ar m
HCWs _._iv
want to st
bureauc ic
appropnat*
e
with client*
other is ie
degrees n
present sigi
activitie tc
expressL c
most it app
willing >
individual
interaction
find inc d
(counselling
.
■
............. <
hi ? may also be
h l at site B.
—rrdated to
of pregnancy, b-ealment of post-abortion complied^, aSLoa
s ve are already
)ii^ is that site A
2, and they need
< )ther area to
inprovement as
te'programme
Pr°i‘ct madei UK
STD/A/DS5'mutml
<ais, k„mi,ledge
and stuff
stalfoftk
>^^
dsemd
of
- - programme personnel to cooperate. It is
! :=?;%T
hTo“
traditional FP/MCH programmes because they
ti
Xss,or
questions that often cause quite a bit of embarrassment amo'ng other seS pmvidLs '
ZES
tamgra^oTlX^
understaffe'd and maMy
Preferably
»“ve!y
the mainstream popuiatton. The inherent conffict betw^ fee ^ces “'“th
3 well as the
t worked on the
d tion of new
nuoduce them
js
does, however, raise many different issues.
programmes
The first issue may be one of coordination. How can STD/HIV
activities be closely coordinated or integrated with FP/MCH arK h ? S13™1116
disruption of daily activities/service provision’ How can oth^H
lheS Wth no
services are to be
nf ' ive greatly in
ii ; to perform
as STD/HIV
for existing I hrea„cracy? T'the^Xs^deXedfor fce
V(
o’f S
appropriate for the deitvery of more comprehensive reproductive helfear'eZTeZ
21 > sometimes
u
■ta*^
to
examine
c
u
ents
$
h11 to^ducfeheZ
S to be raised whether
theb^S^ZvTm
barriers to discuss difficultva”
issues
tg programmes Lr issues related
’S
'”
xi ing training
ar for service
. This is due to
-ly ’ irge impact •.lling to discuss the above issues with dSZ X of a “et
T^11
re for such individual clients questions about their sexual WstoX d,
^°UPS- AskUlg
question must interaction appeared to be more difficult. It should also Z addeZiatlt "ent/Provlder
el trained to
"l“’“1,inS SkillS' ™S
-ue
treatment (X^g)"^
119
The difficulty staff may have in discussing various issues with clients reflects the
fact the traditional FP/MCH programmes have shied away from issues of sexuality. As
programmes aim to implement the ICPD-POA, however, it will become increasingly
difficult to continue to do so. Secondly, sexuality and gender are inextricably linked
Women's roles are socially constructed and only partly a result of biology. Effective
programmes must take into consideration not only of women's biology but also of their
overall low status.
How to operationalise gender sensitivity at the field level remains to some
degree an open question. In the project, the Women's Health Committees in India are
very much based on the concept of empowerment. The community outreach activities
in all three project areas aimed to encourage responsible male sexual behavior and male
method use. Men appeared very interested in the opportunity to gain information.
II
■
t *'■
1
IF
i
/
L
j.
i
acces bl
private .
techrira
encoi
The C’ 6
qualit
1. Qi lit
sb v*ct
to exis
rei )r
(systet
rec”ir
Mi st
to asse
the h
see c
Introduction of new RH services will increase the pressure on referral points. The
critical question is to what extent they are prepared: Are already overcrowded hospitals
prepared for new waves of clients who earlier had an unmet need? For instance, as RH
services are added, the programmes must face issues such as cancer screening, services
for infertility and for older women. Some will require interventions at higher levels.
Many difficult questions must be considered in this context: To what extent should and
can governments pay for such services? What priority should new activities be as
opposed to improving the quality of other important prevention activities?
2. Syj m
ilhuje
The introduction of new services will challenge programme capacity not only to
the Po
provide more services at higher levels or in terms of providing continuity of care. How
cot I
should the process of referral be managed in an orderly fashion? Referral will need to
provid
take place both within and outside programmes. How do programmes follow-up on
sup^w
these clients? These are some of the issues that received attention in all three project
AR d
areas.
r J
related
res( rc
There is a need for developing adequate standards and guidelines for all RH services.
the »n
Most of the services which programmes have committed themselves to making more
generally available after Cairo are provided in some fragmented form or another in 3. Que y
most countries. However, adequate standards and guidelines were generally not
trac lo
available.
J
elemen
proc >s
In this connection, it should be emphasised that the private sector plays a
app^^at
considerable role in providing medical services in many countries. Clients often appear
that reli
to prefer these services because they are perceived to be of better quality, more easily
of c st
120
T----- ----- --------
'
'....
'
“-
ei__s reflects the
of sexuality. As
n< ncreasingly
trie ably linked,
-lo^v. Effective
h also of their
te OTdial in
”7
technical skills or that the medical nractices a
necessarily guarantee better
encourage and facilitate effort, to inlprove these XTota^ZteX'
QUALITY IMPROVEMENT APPROACHES
The QI experiences discussed in Chapter 6 demonstrate four
approaches to improve
n is to some quality:
tes in India are
■re :h activities 1.
>r and male
ormation.
'
^X^o« a“ r ““ for
(systenuc cause) or specml to one service uXtsZjXTdT Th° 311
rcu points. The
vded hospitals
as nee, as RH
?nmg, services
b-'^her levels.
*n should and
ctivities be as
required may differ accordinalv
, iu
Ministry of Health in Egyp illustrates th^an^
to assess the quality ofTare prodded at^P
e Provider- The remedial actions
aPProach used by the
checkIlste —e used
the checklists. The individual units were encouraSd ZcT We'e ,aSSIgned based on
score and thus improve quality on a continuing basl
to
2.
ity not only to
’ < care. How
1 . ill need to
follow-up on
I 'ee project
aXtch^T
r plays a
often appear
, Dre easily
jc
deVJped bp
could also cam- out a rapid assessment of the quality
provtding. Based on the assessment findings, various systems XS/mfT™ “
supervision and so on - are strengthened Thp Pnn A
c
g^ bcs'IEC' training,
ARCH (India) examples illustrate how NGOs ^PUlabOn Services (Zimbabwe) and
related to human resource mXXment^
tO
Practices
resource management ARCH uses a
7 H services.
making more
DI
nother in
?rally not
C°^
the Population Council are used to assess the’eternffl’^foTato of
’ ° lm^ro^e ^uatity. Besides effective human
—./and s^z7:rh.;nsxe~ms such “
Quality Improvement Approach.
■ —ZXoX^
“ deXd ™ Xto L°1Ve
m
P=
to
-
relatively simple low-cost localised
121
——’’r*1
-so*.’
problems may remain unsolved. The continuous quality7 improvement (CQI) example
in Mexico illustrates an approach where the results to be expected and the factors to be
controlled are established. Standards for operation and quality are set using a
participative approach. Local teams subsequently utilise the standards to institute a
continuous cycle of performance improvement.
4. Malaysia's Total Quality Management approach utilises all of the above approaches and,
in addition, aims to develop an organisational culture conducive to quality7 by paying
particular attention to issues related to the management of human resources. The
programme determines clients' needs and plans for quality.
Programmes may wish to gradually move towards a quality transformation
similar to TQM/CQ1. However, as the Malaysian example indicates, it may take more
than a decade of effort to reach that stage, and at that point, the process still needs to
continue.
A Blueprint for Action
Many actions are required to influence the organisational culture to make it conducive
to quality and QI. Various roadmaps have been developed for this purpose and include
a combination of quality planning, quality control and continuing quality improvement.
Below we describe the steps adapted from Juran's trilogy of quality management.
Quality Planning
1. Review or create a vision for the programme and raise the awareness of quality
throughout tire organisation
2. Determine who the clients are and determine their needs
3. Develop standards considering both the client, provider and programme
perspectives of quality
4. Select indicators for measuring quality of care
5. Design the service and develop the processes needed to produce or deliver the
service
6. Transfer the service to a site as a pilot project, implement and utilise evaluation
results
7. Plan for up-scaling
8. Review systems and structures
9. Upscale
Quality Control
1.
2.
3.
4.
5.
Eval iti
Compar
Act ( t
Revi y
Redo th
Continuous
1.
2.
3.
4.
5.
6.
7.
IG
Estal s
Review
ProviJe
Estal s’
Follow c
Do a il
Repe
Role of Lea !r
This sectio
organisatioiuJ
organisational
focus on pr :e
proactive app
experiments "’o
The que
managemei a
managemei p
quality. Leade
achievement ' t
sustains m^uv
resources avail,
excellent or; n
Qua! /
organisations, t
122
'SS-'"
(C »I) example
k ictors to be
e set using a
5
institute a
caches and,
iliiy by paying
recources. The
Quality Control
1.
2.
3.
4.
5.
Evaluate services actually provided
Compare with standards and goals
Act on the difference
Review standards and goals
Redo the above cycle
Continuous Quality Improvement
tr isformation
n take more
s still needs to
ce it conducive
•S' ind include
y improvement.
4g*“nent.
1.
2.
3.
4.
5.
6.
7.
Establish improvement teams, motivate and train them
Review training and development for staff
Provide training
Establish the infrastructure and provide resources
Follow a continuous improvement cycle to diagnose and solve problems
Do a pilot project, evaluate and upscale
Repeat steps 2 through 6.
Role of Leadership and Managers in Quality Transformation
This section will focus on the role of leadership in creating and sustaining
organisational commitment to quality RH care services. Various characteristics of
organisational culture conducive to quality are discussed such as client-orientation;
focus on processes and systems as well as overall performance; continuous QI and a
m s of quality proactive approach to QA; human development; and openness to learning,
experimentation and innovation.
id programme
The quality transformation puts the spotlight particularly on leadership and
management and the critical role they play in accepting and interpreting the new
management paradigm correctly and in creating an organisational culture conducive to
? or deliver the quality. Leadership has been defined as the process of influencing a group toward the
achievement of a goal or purpose (Reitz 1977). In other words, it creates a vision and
il ; evaluation sustains motivation. Management, on the other hand, is responsible for making
resources available and creating enabling conditions for employees. It is argued that, in
excellent organisations, managers are both effective leaders and managers.
Quality is not a separate issue or programme. In many client-oriented
organisations, the leaders/managers have made quality a way of life in the organisation
123
through its focus on meeting clients' needs and creating enabling conditions for staff to
perform at optimum levels (see the example of ARCH in Box 2).
Box 3 - A.
| Unless h
challei _e<
have no
' "quali 7
Box 2 - Making Quality a Way of Life: Leaders as Role Models and Facilitators
Action Research and Development in Community Health (ARCH)
i-'-h-
' ft
i |l"
'Mill
r ■ I*
Creating an
ARCH (discussed in Chapter 6) invested considerable time in the development
are en.pt
of staff, CHWs, with relatively low educational levels. They were rooted in the
beliefs an
community and received intensive on-the-job training working side-by-side with the
also
cl
founders who were their role models and mentors. The leadership greatly facilitated
crisis sirue
the tasks that staff were to perform by creating enabling work conditions. Adequate
is failin'' •
infrastructure, equipment and supphes were available. There was timely feedback and
RH pi ti
effective supervision. The CHWs had a sense of control over their work situation; and,
HIV pandt
above all, a sense of purpose and meaning. The organisation has always had high
expectations of staff, but accepts mistakes as part of learning.
\ u
(Information taken from a paper written by Dohlie et al, 1995)
philosopny,
Underly’^g
granted
t
are generail
The issue of leadership style has received much attention. The terms used to
describe the styles generally reflect the relative level of direction and support provided I
T •t
to employees.1 Gradually, the concept of situational leadership has emerged, i.e., the levels. Duri.
leader must use different styles adapting to the particular situation. This situation depends activity
(
on the employee(s), the task(s) to be accomplished, and so on. Variables include, among change il.. i
others, the employees' experience, background, age, gender, education, skills level, j
maturity, etc., and their response to the leader; the task to be accomplished such as level
D e
of complexity and the degree to which it is structured; the personality of the leader; and below, lue’
the context including the leader s own superiors and peers, the organisational culture, people, p’-oc
policies and so on (Reitz 1977).
j
Quality implies focusing on people, process and product/service. The emphasis on
people is not limited to (external) clients and leadership, but also includes employees.
Waterman (1994), for example, suggests that excellent companies have organised to meet
the needs of their people. They have created a culture that nurtures quality. The
Malaysian example provides an example of how a programme may go about doing
that
2 Organisation^
and act.
Examples of such terms include authoritarian, democratic and laissez-faire.
124
w
—
.
V.
.x..
liliuns for staff to
Creating an organisational culture conducive to quality
K*”itators
h development
2 rooted in the
tide with the
re^dy facilitated
ti^ns. Adequate
1] eedback and
k situation; and,
lv ys had high
Box 3 - Artifacts
Organisations that prioritise quality
tend
to develop similar organisational
Unless the inward view of culture is
challenged to change, new artifacts cultures? Culture is usually defined at three
have no meaning. For example, different levels: 1) artifacts, 2) values and
3) underIying assumptions
"quality" symbols and celebrations Stefs'
Artifacts can be easily
are empty gestures unless values, (Schem, 1985).
observed
they
are
the "outward view" of
beliefs and underlying assumptions
also change. This often happens in a culture - but their meanings depend on the
crisis situation, e.g., when a company other two levels (or the 'inward view' of
is falling on hard times, or, in some culture). Artifacts comprise, among others
programmes, when facing the management practices, behaviour, norms,'
-IIV pandemic.
symbols, communications, etc. (Box 3).
Values and beliefs guide decision
philosophy, purpose,
T”'7 "d,‘de ViS'On'
£ 2,
■re geueraUy no, comdous of
as
? rms used to
pr art provided
lerged, i.e., the
u ion depends .cavity to challenge
include, among
3r skills level,
uch as level telow. “ey'rete Zs^™e^T“C?' “ ^"^onal culture are discussed
the leader; and
unProvement implies a focus on
a" mal culture, people, process, and product.
te mphasis on
employees.
rganised to meet
s uality. The
o about doing
Organisational culture is defined
as the ways members of a particular organrsatron tend to think
ar>d act.
125
assun ig
programi
they s’ )i
Box 3 - Vision and Underlying Philosophies and Beliefs
Re
requir e
their
;ic
compellin
client/ rc
Women's Health Care Foundation (WHCF)
n. a 2VHCF TS f°Unded m 1116 Philippines in 1980 by men and women who felt that
the definition of women's health must be expanded to include all aspects of their life
cycle from birth to death. From its inception, many beliefs, among others, that quality
health care should be available, affordable, safe, acceptable, comprehensive
appropriate and gender-sensitive, guided the organisation.
by proved
Focus c it
i w P16
d,eveloPed obiectives reflecting underlying beliefs, namely to
establish and effectively operate quality and affordable clinical and laboratory facilities
I
needs
Good —si
genera ■’
for organii
they ar ?c
procesj
processes;
educati i.
dis’d—^d—
i ip
hl
I
Ife Hi ■
I ■p
I
if
*1
The organisation currently runs three clinics in Metropolitan Manila in addition
to outreach clinics offering a wide variety of health services such as physical exams- FP
services; RTI/STD screening and treatment, prenatal and postnatal care; birthing
facilities at one site; services related to menstrual and post-menopausal problems; and
basic laboratory services mcluding blood count, gram stain. Pap smears, pregnancy
testing, urinalysis. Hepatitis B testing, stool exam, and semen analysis.
It w
thereto
organisatic
targets ’^h
among n
systems and
Finally the WHCF focuses on various
target groups
groups for
for reproductive
reproductive health
various target
health
education in addition to its advocacy efforts; in
the
area
of
women's
health
and
rights,
in the area of women's health and rights.
(information taken from a paper written by Tadiar et. al. 1996)
b
Overall;
Some tir s
counter o<
the health
creating le
service ^Ji
personnel,
there is j f
Clients' values, perceptions and needs must be understood and prioritised ahead of
organisational goals
Quality is customer-driven and implies that clients' needs, perceptions and values are
put ahead of internal organisational goals. For example, demographic targets have
eef1 G
orce behind many traditional FP programmes, often with the result
that quality has suffered and chents have become alienated from the programme.
re
Programmes must know and understand their clients' needs. Research and
surveys are major activities in industry to anticipate customers' needs. Rather than just
taken th b
functions.
126
■
■
•
assuming they know what their needs «are, the health sector, including FP/RH
programmes, is beginning to ask clients what services should be provided and how
they should be provided to be acceptable.
ei vho felt that
?cts of their life
ai that quality
cc iprehensive,
opportunity to review
their vision, values, and beliefs. Quality - meeting clients' needs
- may be a more
compelling vision than meeting targets which often works
against a good
chent/provider interaction. Hence a new vision could act as a highly motivating factor
by providing employees with meaning and pride in their work.
Focus on improving processes and systems rather than the results themselves
namely to
ira^ory facilities
n jed women,
ni in addition
sical exams; FP
< re; birthing
f )blems; and
ars, pregnancy
ductive health
1 id rights.
they are conducive to quality services. Tins includes not only service providers and the
process of care giving, but all processes and systems supporting them. Planning
processes; systems and processes related to human resources; logistics; MIS; health
education, etc. must also be considered.
It was mentioned above that quantitative goals might compromise quality It is
therefore important to consider what to measure and reward. For example if an
rSaTahun
t0 Prioritise
but continues to reward staff for reaching
targets whi e offering no rewards for providing client-sensitive services, cynicism
among employees is frequently the result. New visions and goals are easily defeated if old
systems and processes counteract them.
J
lJ ola
Overall performance is more important than maximising various functional results
ti^d ahead of
ir'4 values are
c rgets have
vith the result
re ime.
Research and
at ?r than just
Sometimes different functional objectives may work against each other and be
thTh kb
t0 016 °PtlmaI Performance of th6 entlre Programme. For example,
the health education programme may be very successful in raising awareness and
g demand for a newly introduced reproductive health care service while the
service dehvey system cannot cope with the demand for lack of adequately trained
personnel, lack of equipment, supplies, etc. Client dissatisfaction mav result because
mere is no holistic view of programme performance.
functional mmdset" is hard to overcome also in organisations that have
functions. Majchrzak an^ng(1996) emphaTs
hv
127
a collaborative culture, which cultivates shared responsibility for quality. This causes
functional sub-cultures to blend while meeting customers' or clients' needs becomes the
overriding goal for 1allnoand
longer the responsibility of a quality department,
inspector or programme.
to use the er
morbidity anc
lead to nor is
As dis
proactive i p
Quality improvement is a continuous and never-ending process
ti
ill
itr 1'
CQI does not stop with conformance to existing standards. Standards, or the status quo,
are not considered the limits of performance, but something that may be improved
upon. CQI is contrary to the saying "if it ain't broke, don't fix it" because it goes beyond
fixing defects and problems to find the root causes of problems. And these are generally
found in processes and systems rather than in people.
Programmes can never consider the process of improvement as <complete
because surpassing clients' expectations has become the goal of excellent companies.
Clients perceptions and needs are dynamic and change over time with rising incomes
and new knowledge. For example, rising expectations were one of the reasons stated for
adopting the Z/Q" programme in Malaysia. In addition, scientific knowledge and
technology change rapidly indicating a new for continuous review of standards and
medical practices.
It must be remembered that clients' knowledge about reproductive health issues
and their expectations of the programme are often low. The onus of initiating QI is
therefore on programme managers, planners and service providers.
Proactive as opposed to reactive approaches to quality
One of the major reasons for prioritising quality in industry is the issue of efficiency
and sayings. Preventing problems and defects is more cost-effective than fixing them
afterwards. Defects are costly because defective goods are discarded and may lead to
loss of customers and market share. Besides, when systems and processes do not
function smoothly, there is inefficient use of resources leading to waste. Although there
are initial costs involved in adopting; a proactive approach to quality assurance,
industry has discovered that there are considerable long-term, sometimes even
immediate, savings.
Mistakes and inadequate systems and processes in the health care sector are
equally costly. Incorrectly performed medical procedures and treatments may lead to
more advanced and expensive treatment. Lawsuits may follow. Clients may choose not
128
People mus
e
Because tb~ q
the organi ti
thinking chan
QI can tai p
knowledge s
organisation t
quality (Be 5
Box 5 - Devel
Integrating I
When Tha;1ar
and testinj tl
The programi
have estal ’ s’
regular co e
common prot
importance )f
Superv
that quali
technical con
including ™iv
When
programir h
recognisec h.
supervisors. I
in a dialog e
setting up
(Information take
.....
r. 'his causes
s becomes the
r epartment.
“7™^ Se7iC6S
l3Ck °f tniSt LaSt' but not least' medical malpractice adds to
morbidity
and mortality
nrnrnrino the wrong equipment or suppliesUS
ro
io
utuiy. Moreover
moreover, procuring
may
lead to non-use and waste as well as inadequate treatment of clients.
PP
Y
As discussed above, total mobilisation of
staff at all levels is required for
proactive approaches to quality assurance to work.
h status quo,
be improved
t ^oes beyond
i ! generally
People must be improved along with systems and processes
Because the quality transformation relies on mobilisation of employees at all levels of
JXnTT3
I Pe°P 6 r6 °f CritiCaI “P01^6- Un]ess behaviours and ways of
QI can takeXe OW1!OIP tT’ TTT*
d°Wn'iC * faCt' difficuIt t0 see how
Ql can take place. While strong leadership and commitment are essential to OI nPw
knowledge, skills, behaviours and ways „f thinking must spteaXLX't
< complete
it companies,
is g incomes
o stated for
owledge and ii
5 ~ DeveIoPing human resources and creating enabling conditions
ta lards and | Integrating HIV testing in Thailand's FP/MCH programme
arc
“ d° Under“e ‘he
-X
When Thailand's FP/MCH programme integrated HIV services, i.e. HIV counselling
h ilth issues and testing, the mteivention relied on the use of existing staff who received traZing
ibating QI is tvePXTshed
d that a.°ne'time training is not enoug^ and most hospitafs
e established in-service training. Some provincial health offices also organise
regular conferences for counsellors so that they may share experiences and dfscuss
I impoTnc^Sj addltl0n' was ^alised that staff had to be made aware of the
I importance of QOC. Therefore, the training developed emphasises this component.
•
iLiS“P®rvision and monitoring at different levels also take place. In order to ensure
of efficiency
r
11 mg them [ that quality services are provided, the programme measures, among others ffie
lx y lead to
technical privacy;
competence
of providers;
Including
and client
comfort/co^SeS ale^nl'Pr°V‘der i‘’teraCli0"S
?ssps do not IJ
tl igh there
y assurance,
Xff LaJbutnoUelst
ed—ies even
*e ector are XntaL n8Ue rn1Se rlr awareness and Sain
n y lead to setting up counselling clinics.
y choose not ^(Information taken from paper written by Auamkul et. al, 1996)
cooperation in supporting staff in
6
129
However, training and development are not a panacea and cannot substitute for
required actions to create an enabling environment, for example, adequate supervision
and support; adequate resource allocation; hiring practices and reward systems
supportive of qualitative goals, etc.
Although all staff must be mobilised to improve quality, top management
cannot delegate the responsibility for quality. Many of the actions that must be taken to
enable staff to provide quality services are beyond their authority. However, they must
have sufficient autonomy to make day-to-day decisions related to their work.
Openness to learning, experimentation and innovation
I ■
•‘•■I j
I
Prog n
particular c
but they >r
better y , :
mistakes, tb
to findir t
from theixi v
In ad ti
people mus
themseh
Organisations that prioritise quality must ensure openness to learning and create a safe
environment for experimentation and innovation. Factors ensuring this include, among
others, open communication throughout the organisation and considering mistakes as
part of the learning process as opposed to an occasion for assigning personal blame
(Box 6). These issues have universal relevance, but are maybe particularly important as
reproductive health programmes undergo thorough transformation and search for
viable courses of action.
Ji
Box 6 - The overall importance of open communication to quality
’t.
•
•
•
•
Poor communication is at the base of many quality problems and may take many
forms.
Poor communication between health care worker and patient a) inadequate
information gathering during consultation leading to incorrect diagnosis b)
inadequate explanation to patient and c) inadequate instruction to patient
Poor communication within the health system: a) health worker unaware of health
system's goals and directions b) health worker does not receive feed-back on service
information forwarded to headquarters and c) management unaware what is really
happening in own health system.
Poor communications - health system to users: a) important health messages not
communicated b) messages poorly communicated - unintended messages received,
and c) existing services underutilised increasing inefficiency of health system d)
health system fails to monitor health concerns of the population and address these
through effective communication.
(Kaijuka, 1996)
130
Leadership ar
managemont:
behaviou;
Systems
substitute for
? Lpervision
ard systems
management
st e taken to
ei hey must
'k.
Programmes must experiment to find innovative and appropriate solutions for their
particular context. Some experiments will be less successful, or they may outright fail
but they provide an opportunity for learning - either to prevent similar mistakes, or'
better yet how to improve. Unless people feel safe to discuss and learn from their
mistakes, they will cover Cthem up instead. Moreover, a safe environment is conducive
to finding the root causes of problems rather than focusing on the problems resulting
from them which leads to ineffective solutions and quick fixes.
In addition to increased awareness and systematic building of knowledge and skills
people must be encouraged to use analytical skills and tools to continuously improve
themselves, systems and processes as well as the services they provide.
create a safe
zlr-de, among
j istakes as
-rsonal blame
ii ?ortant as
d earch for
Figure 1 - Quality transformation
Leadership and
management:
behaviour
y take many
i (adequate
diagnosis b)
n
a_ of health
ck on service
vl t is really
nr^sages not
g< received,
li system d)
td ’ 'ess these
Vision
Values
Beliefs
Goals
Processes:
Service delivery
Planning
I
Quality transformation:
Customer need
Proactive QA approach
Systems
Institutional structure:
Team-based
People:
Empowerment
131
WHAT WOULD MANAGERS NEED TO DO?
Both the action research and programme experiences reviewed in earlier chapters show
managers made a variety of interventions to improve the quality of care Table 1
earT?
the" discussion of the role 0
" interVentions-
eadership/management in this chapter indicates the broad areas requiring particula
attention. Figure 1 illustrates the quality transformation and categorises tire differed
areas of concern where interventions are required. On this backgromd, several possible
required. On tills background, several possible
QI interventions are proposed below (see also Box 7).
possible
id
■p
i i1
IS,H
F
Interventions to Imp.rove Quality
c
Establishing organisational arrangements to
catalyse QI efforts. First, top managers
must be sensitised to quality issues and to
the importance of their commitment to
sustained quality improvement. Then
organisational arrangements would need
to be established to provide and/or
mobilise technical and financial assistance
for QI. This may comprise of a cell and an
advisory committee. Some financial
allocations are needed.
Orienting programmes' management
systems of training, logistics, MIS,
supervision, monitoring and evaluation
towaids QI. Various management systems
would need to be reoriented towards QI.
For example, training must include
sensitisation of staff to QOC and meeting
clients needs, up-date on technical skills
for comprehensive RH care services,
special training for counselling, and onthe job training.
Often supplies are available in the
system but not where and when they are
needed. Therefore, the logistics system
needs to be strengthened.
C
Box 7: Actions Needed to Improve
QOC
•
•
•
•
•
Establish
arrangements
I u
Iu
I '40->
i
t
4
(
(
organisational
15
I
Orient p
---------programme
management
systems: Training, logistics, MIS,
supervision and monitoring/
evaluation
s
c
>
o
r
E
o
Set QA standards
w
C
O
•JM
lac
Develop supervisory checklists
5
£;
OJ
k
C
>
c
CC
,6
Provide necessary infrastructure
H
0)
•
Institutionalise CQI (a) at middle
management and (b) through
local teams
•
Institute community actions
•
Continue advocacy for QOC
•
Celebrate QI
Xi
£
I2
-<
I s>
s
I
132
-- •
n
o
2 £ 5
sw
rf
n
i j
c g;
§
p
til
H)
w
nr.
o
2
I
fD
(
5
‘TJ
O
fP
H
"
5’
...
5CD rr
"O
Cl
on
d>
o
(Z
<
cn
5
c? 2
H
Hi
*
- o H cn
n o £>
E nr
-
£
rrT O
Table 1. Interventions to Improve Quality of Care
Interventions
Kenya
COPE,
Banglades
h
Esta bl ish orga nisa tiona 1
arrangements
Orient programme management
systems: Training, IEC, logistics,
MIS, supervision and
monitoring/evaluation
CQI,
Mexico
X
X
MOH,
Egypt
X
Supervisory check lists
Celebrate QI
133
ARCH,
India
TQM,
Malaysia
X
X
X
X
X
X
X
X
X
Institute community actions
Continuing advocacy for QOC
Population
Services,
Zimbabwe
X
QA standards
institutionalise CQI
Middle management
Local teams
Taichang
County,
China
X
X
X
X
X
X
X
I
i
Effective supervisory systems are a key intervention to facilitating quality
improvement. They generally need to be reoriented for this purpose. Prioritising
quality requires reliance on qualitative indicators. However, MIS systems frequently do
not measure QOC. Programmes would have to rely on supervisory checklists, client
feedback surveys, and observation of facilities and service provision, and perhaps
specially commissioned studies. More work is required to explore how MIS and
monitoring systems should be modified.
••. -’pi
i gl
I
iWa.
!S!<i th ■
m
K Hi
J-
!■ .H
Introducing quality assurance through the establishment of standards and use of
supervisory systems to enable implementation of the standards. Clear standards should
be established for service provision and counselling, technical competence of staff, and
so on. Adherence to the standards requires an effective supervisory system and
increased accountability through the establishment of QA teams.
Provide necessary infrastructure. Inputs required for quality improvement are
often inexpensive, but not available, for example, water containers, curtains, brooms,
benches for waiting clients, and so on. Therefore programmes need to ensure that these
are available at the SDPs. This may involve review of procurement processes.
Cle
facilita c
accomplis
commi^mf
many ti
necessary
level
ai
commi it
Conclude)
Institutionalising continuous QI through the development of capability at middle
management levels. Key middle level managers in the system must be identified,
sensitised to QOC, and trained in QI approaches and techniques.
The vi it
effectively
in achi^ii
involvi r
Clients - p
Mobilising initiatives at the local level through team efforts. Middle level managers
would need to initiate and sustain QI/problem solving teams at the local level. These
teams could use the COPE approach.
[
«K
Instituting community actions. The accountability of the health care system/
programme to the community would need to enhanced through the formation of
women s health or village committees and similar groups. They must receive education
and support to sustain their commitment
Continuing advocacy and support for QI through mechanisms such as Quality Day
and rewards for successful QI teams. These efforts would need to be supported by
continuing advocacy as well as demonstrated commitment by top management. Such
actions include celebration of a quality day, rewards for effective QI teams, and awards
for excellent facilities.
134
5
h
arrangem
implei ?r
in con il
actions a
transfc ti
about chai1
process it
Hi ting quality
ds
Prioritising
is frequently do
:h klists, client
i, und perhaps
how MIS and
SJ:oXTd'XaS;
aU0XXelS°L“d
ir^s and use of
ai ards should
ice of staff, and
-rj system and
level managers can use supervisory checklists form local OT 7
community actions and seek client feedhack
'
Q
p vement are
rL^ns, brooms,
-isure that these
' mstltute
Conclusion
S5
1
at middle
identified,
e 1 managers
al level. These
QI takes place in a context that may be more or less resistant tn rb.™ n
about challenging and breaking down barriers, and, as suggested it is l/6 _i
process rather than a separate programme or short-term project.
'
care system/
rmation of
=eive education
s Quality Day
s >ported by
g lent. Such
s, and awards
135
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w
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Bruce J. 1990. "Fundamental Elements of the Quality of Care: A Simple Framework"
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Huezo C >
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Crosby PB. 1982. "Quality is Free". New York:McGraw HiU.
ICOMF
Crosby PB. 1996. "Quality is Still Free". New York: McGraw-Hill.
ill
p
! <1
!
* i
IF ■' •
ir
I
Fisher z
"Guide te.
York.The 1
Deming WE. 1986. "Out of the Crisis". Cambridge, MA: MIT (Center for Advanced
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Faisel AJ, M Ahmed, KJ Beattie, BP Pati. 1994. "Introducing COPE in Asia: A Quality
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-‘'ft ■
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Mw' A' B Mensch, R Miner, 1 Askew, A Jain, C Ndet L Ndhlovu, P Tansoba 1992
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3ive Reproductive
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to
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md
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Advanced
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Juran JK. 1989."Juran on Leadership for Quality". New York:The Free Press.
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— -gaursatoaf
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of I T
■ PapSr Presented at 1116 International Seminar
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C°"“P'S' Syste"s- Sto‘'«'K'
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si
Catpma^ J"4’ ''A^ontinuous Quality Improvement Programme: Experience of the
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Murthi N. 199a. "Quality of Family Welfare Services in Rural Maharashtra: Insights from a
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ictive health
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P ulation and
IL ' Studies in
139
Si
ri
annex
USEFUL QUALITY IMPROVEMENT TOOLS AND AIDS
The following tools may be used when programmes aim to improve the quality of
care they provide:
1. List of methodologies and tools to assess and/or improve quality
2. Checklist for mobilising community groups
3. Training checklist for QI
4. Supervisory checklists
•
Checklist for FP/well woman clinic (female HCW)
•
Checklist for RH care services (male HCW)
I-
5. The referral system
•
Example of referral protocol
•
Example of referral card
i
■q
4
141
.I
■
-
TOOLS FOR ASSESSING QUALITY
Assesj le
Clion
Assessing Quality
Cl ic
A large number of methodologies and instruments may be utilised to assess
quality. Among others, the following three methodologies may be mentioned:
•
•
•
Aga Khan Foundation: The Primary Health Care Management Advancement
Programme, Modules 1-9
AVSC International: COPE
The Population Council: Guidelines and Instruments for a Family Planning
Situation Analysis Study.
The action research project to improve the quality of care at sites in three
different countries described in Chapters 2, 3, 4 and 5 used the following tools.
They were borrowed and adapted from several sources:
i!
•
•
Interviews with: current or ever user, non-user, male with spouse of
reproductive age, antenatal care client, immunisation (observation, client
and provider interviews all in one instrument), service providers,
manager and supervisor, private medical doctor (PMD), community
based distributor (CBD)
Group discussions with: users, non-users, men, service providers,
managers
•
Observation of: counselling session, medical examination, antenatal
care, CBD
•
Facility checklist
Cc~si
Cc n.
De—ic
Fo__is
Mr a
Mi—d:
M< i:
Monit
Ol
T
I Pa: 1
Pa ben
Pre re
Qualit
Sin k
Situati
Co: ir
Contir
Katz et al. (1993) provide a list and description of tools which have been used
by programmes to assess quality. However, it should be remembered that more
than one perspective on quality should be considered when programmes assess
CO i
Service
(Tak
142
MM
•
■
-
’
......
•
..
ij
IgaSSj'
3 JUALITY
Assessment anchor Improvement Tools:
s
Client Satisfaction Studies
Lf I Clinic Manag<
;ement System (CMS)
ss ;s
ti led:
rr
merit
la
0 Consumer/Client Intercept Studies
□
□
Counselor Training Evaluation
Demographic and Health Survey (DHS) Oversample
Focus Group Discussions
Management Information Systems (MIS)
0 Matrix (CEDPA)
Matrix (Enterprise)
i three
ng tools.
oouse of
)! client
•oviders,
n*" unity
oviders,
ntenatal
□
?s ssess
Observation
Operations Research
0 Panel Studies
Patient/Client Flow Analysis
s Program Quality Assessment
Tool (PQAT)
0 Quality Definition and Assessment
0 Simulated/Mystery Client Studies
0 Situation Analysis
□
e used
lat more
Momtoring Voluntary Surgical Contraception Procedures (VSC)
Continuous Assessment (SEATS)
Continuous Quality Improvement (CQI)
COPE
0 Service Quahty Improvement (SQI)
(Taken from Katz et al, 1993)
143
CHECKLIST FOR MOBILISING COMMUNITY GROUPS
Al'wdJ
Mobilising Community Groups
Mobilising community groups is a key intervention to assure and sustain
improved quality of care in the area <of reproductive health. A checklist is
provided to systematise the efforts or steps in such mobilisation
C(
Checklist:
Bi
■■I?
/
Select a group, team or organisation that can undertake the mobilisation effort
I ihw
2c
I
I Establish trust in the community while providing RH education to raise
its
awareness of needs in this area
F
Do a needs assessment in consultation with the community and ensure that all
perspectives are taken into consideration (programme context and goals,
technology available, community and service providers' needs, and so on)
■I
!•
Develop a plan of action with the community and other stakeholders based on
the results of the needs assessment
11
Procure needed physical inputs after taking all stakeholders' perspectives into
consideration
i€
J;'; ■.;
t-:
K.
/
Provide health education in the community
p
I•
Provide appropriate training to staff
PH Continue to sensitise staff and community to the need for quality RH services
Establish institutional linkages and structures to ensure that the effort becomes
self-sustainable
Monitor and review the efforts and make corrections as needed
144
.j
---- .
•>
i
TTY GROUPS
Always consider:
ai
sustain
checklist is
Community participation:
•
Is the community an equal participant?
Community responsibility:
• Do the efforts inculcate this value to the community?
• Do the programme's actions reinforce this value?
ation effort
rkxje its
nsure that all
t nd goals,
■1: on)
s ased on
2(
p/~| Community ownership:
•
Does the community feel that it "owns" the plan of action and the activities
to improve quality?
Gender sensitivity - Different groups have different needs:
•
Does the programme aim to meet the needs of all groups?
•
Does the programme aim to meet the different needs of women and men?
•
Does the programme address the needs of youth - female and male?
ves into
d services
becomes
145
EXAMPLES OF SUPERVISORY CHECKLISTS
SUP' ’A
Supervisory checklists
Name:
Training must be accompanied by appropriate support on-the-job after the trainee
returns to work, and supervisors can do a better job if they have tools to assist them.
Supervisory checklists may be used for this purpose. The QOC project developed
several generic checklists which were subsequently adapted to each country context.
Attached as examples are the checklists developed for the female and male HCWs.
In Vietnam, checklists were also developed for managers to assess themselves.
Il II
fiH
The supervisor and supervisee should use 1the checklist together. The checklists mav
be used for sensitisation, training and problem-solving. Ultimately, it would be
desirable to have service providers (as well1 as supervisors and managers) assess
themselves continuously against the checklists.
The checklists must be up-dated on a regular basis to allow for rising expectations of
clients, new medical knowledge and improved technology.
I'®
M
Iu
Did the
a. try to ( si
knows abou
methods
b. encourage
a method ..
FP/well woman visit (female HCW)
Antenatal care (female HCW)
Did the p v
methods vv O
PNC (female HCW)
/
Commu c£
c. try toa__e.
client (sexua
frequenc n
wanted a^d
The following checklists were developed during the QOC project:
K
FAMILY PL
WOMA V
PRACTUE
(If the me'1 io
tubectom N
provider stre
is irreven le
RH care sendees (male HCW)
Did the prov
effects?
IUD (service provider. manager, and collaborator (screening only))
Did the p v
necessary fol
MR (service provider and manager)
3id the p id
possible gyne
such as sy—p
146
•vwr
ZH^CKLISTS
SUPERVISORY/TRAINING CHECKLIST
(female health care worker)
Name:
r e trainee
assist them.
’t eveloped
n j context,
nale HCWs.
e es.
Area:
YES
FAMILY PLANNING/WELL
WOMAN VISIT: SKILLS AND
PRACTICES OBSERVED
NO
COMMENTS
Correct
eoklists may
t rould be
gers) assess
)ectations of
AREA OF
IMPROVEMENT/
Incorrect
Communication
Did the provider
a. tryr to ensure that the client
knows about all available
methods
b. encourage the client to select
a method
c. try to assess the needs of the
client (sexual practices, coital
frequency, number of children
wanted and domestic violence)
Specify:
Did the provider explain how the
methods work?
(If the method selected is
tubectomy/vasectomy, did the
provider stress that this method
is irreversible?)
Did the provider discuss side
effects?
Did the provider explain
necessary follow-up?
Did the provider enquire about
possible gynecological problems
such as symptoms of RTI?
147
YES
NO
FAMILY PLANNING/WELL
WOMAN VISIT: SKILLS AND
PRACTICES OBSERVED
AREA OF
IMPROVEMENT/
COMMENTS
Correct
FAMIL' ’I
WOMAN V
PRACTj E
Incorrect
Did the provider explain:
a. menstrual and other hygiene....
b. self breast exam
1
Did the provider explain the
importance of doing a Pap smear
(if applicable)?
is
If
Exam and universal precautions
Did the provider wash his/her
hands with soap?
Wi
1
Did the provider:
a. take the medical and
reproductive history.....
b. refer according to protocol
-
1I
.r- r
11 hi
i’ 'i
Did the provider change gloves
after seeing the previous client?
Was the speculum and other
instruments sterilized according
to WHO standards
Was the exam table wiped with
disinfectant/bleach between
clients?
Did the provider perform a pelvic
exam?
Did the provider:
a. check for signs of RTI/STD?...
b. treat RTI/STD
c. discuss need for partner
treatment
Was blood pressure taken?
Did the provider do a breast
exam?
Did the provider do a Pap smear?
148
FAMILY PL
WOMANT V
PRACTI E
Overall: p
The provide
a. durii
t
b. during t
prov o
The provide
a. wasf eisupp ti
b. encoura^
ques: n
to eru^n
understc
c. used £
models/
d. encoi
comi r
about FF
e. couni e
The client's i
and com ’ 2t
4
OF
D'-iMENT/
4_<TS
YES
NO
FAMILY PLANNING/WELL
WOMAN VISIT: SKILLS AND
PRACTICES OBSERVED
AREA OF
IMPROVEMENT/
COMMENTS
Correct
YES
Incorrect
~
NO
FAMILY PLANNING/WELL
WOMAN VISIT: SKILLS AND
PRACTICES OBSERVED
AREA OF
IMPROVEMENT/
COMMENTS
Correct
Incorrect
Overall impression:
The provider ensured privacy:
a. during the counseling
b. during the exam and
provision of a method
The provider:
a. was friendly and
supportive
b. encouraged client to ask
questions and made an effort
to ensure that client
understood information
c. used IEC materials/
models/samples
d. encouraged client to
communicate with husband
about FP
e. counseled the couple.....
Tie client's record was accurate
and complete
149
SUPERVISORY/TRAINING CHECKLIST
'REPRODUCE 7)
. CARE SERVICES
AND PRACTTCE
(male health care worker)
Name:
Area:
Other RH issues
REPRODUCTIVE HEALTH
CARE SERVICES: SKILLS
AND PRACTICES
YES
Correct
NO
AREA OF
IMPROVEMENT/
COMMENTS
Incorrect
Family planning
Provider explained all methods
available:
a. condoms
b. OCs
c. Depo- Provera
d. IUD
e. Norplant
f. tubectomy
g. vasectomy
h NFP
i. other.......................
Overall impre~ic
RH services.
Provider:
a. was friendly c
supportive .
b. encourage q
tried to ensure
understooi h
c. used IEC mate
d. ensured pi' a
counseling f
Provider explained how the
methods work.and stressed the
lack of reversibility for
vasectomy and tubectomy)
Provider explained side effects
Provider explained necessary
follow-up and resupply
Provider:
a. encouraged husband to
communicate with wife
regarding FP
b. discussed FP with the
couple
c. discussed FP with a group
Provider distributed a
contraceptive method
I Provider:
' a. enquired i o
symptoms of
b. gave an S" )/
prevention n
(monogam v,
condom u ).
c. Demonstratec
d. answered h
related to
e. gave treatmer
for possibl T
f. discussed dor
violence...
Immunization
Number of im u
sessions done wit
to date: (T r
supervisory/ 1 ii
Minor ailments
Which method:
Malaria
Sanitation
tiier_______
dumber of RH outi
150
. .......................... .......................... -.. .. —
REPRODUCTIVE HEALTH
CARE SERVICES: SKILLS
AND PRACTICES
YES
NO
COMMENTS
Other RH issues
Or
)XZT7MENT/
fl ITS
AREA OF
IMPROVEMENT/
Provider:
a. enquired about possible
symptoms of STD....
b.
gave an STD/HIV
prevention message
(monogamy, abstinence,
condom use)....
c. Demonstrated condom use.
d. answered other questions
related to sexual health
e. gave treatment or referred
for possible STD
f. discussed domestic
violence....
Specify:
Overall impression related to
RH services.
Provider:
a. was friendly and
supportive...
b. encouraged questions and
tried to ensure that clients)
understood the information,
c. used IEC materials /models.
d. ensured privacy during
counseling of individuals..
Immunization
Number of immunization
sessions done with female HCW
to date: (For skills use
^supervisory/ training checklist)
J Minor ailments
e'1 jd:
"
[Malaria
Sanitation
Other
umber of RH outreach sessions done year-to-date?
151
LIBRARY
08655
[ DOCUMENTATION
*nd
J r-B
I
EXAMPLES OF REFERRAL PROTOCOL AND CARDS
The Referral System
Beneficial
An effective referral system is essential for FP programmes and becomes even more
important and more complicated when they begin to offer comprehensive RH care
services. For a programme focusing on mainly preventive services such as FP
referral may take place mainly within the programme. Comprehensive RH care
services require extensive referral also outside the programme which may involve
more contact with the part of the health care system providing curative services.
otentially life-threatening diseases such as reproductive cancers will require
referral to hospitals.
I1
Pregnant
women
Effective follow-up also becomes a major concern with comprehensive RH services.
STD treatment and abnormal Pap smears are good examples.
The three country QI teams described in earlier chapters (Chapters 2-5) began to
take actions to improve their referral system and follow-up of referred and other
chents. Attached is the referral protocol and cards developed by the Indian QI team.
Training was provided to staff in using the new protocol and cards. It also proved
imperative to stay in contact with the different referral institutions.
I
I
•i
I
152
.
-
—
’ ’ '' ■*
L
J
•p
■- I
__ _________________ ___ ___ _ ___ ,..............
)T XND CARDS
Referral Protocol
even more
ve RH care
2S such as FP
-n; re RH care
=h ~iay involve
rative services.
$ dll require
n
?r
e
H services.
>) began to
red and other
ic m QI team.
It also proved
Beneficiary
Period
High Risk
Pregnant
women
AntejL
Bad Obstetric
History:
Abortions, Still Birth
Previous Caesarean
Previous third stage
Complications: Post
partum
haemorrhage
Pregnant with low
birth
natal
PHC
Abnormal position
(before 32 weeks)
Abnormal position
(after 32 weeks)
Multiple
pregnancies
Severe anemia
Rh incompatibility
Hydroaminos
Pregnancy Induced
Eclampsia
Antepartum
haemorrhage
Cardiac disease
Diabetes
; complications
Grand multipara
Previous uterine
surgeries
Sub
District
Teaching
district
hospital
hospital
#
#
#
i
#
#
#
#
#
#
#
#
_#
#
#
#
£
#
B’
1
153
■
-
---------
Referral Protocol
Beneficiary
Period
High Risk
Beneficial
PHC I
Sub
District
I district hospital
During
Labour
I-11
h
Post
natal
Infants &
children
New
born
Prolonged labour
(>24 hrs in primi
and 18)
Obstructed labour
Cephalo pelvic
disproportion/
Contracted
Mal-presentations
Hydrocephalus
Retained placenta
Post partum
haemorrhage
Ruptured Uterus
Puerperal pyrixa
Secondary PPH
Low birth weight:
2000-2500_______
Low birth weight:
1500- 2000_______
Low birth weight:
1500____________
Birth Asphyxia
Neonatal Jaundice
within 24 hrs
Neonatal Jaundice
after 24 hrs
Neonatal sepsis
Neonatal tetanus
Respiratory
Infections________
Diarrhoea_______
154
hospital
#
£
#
£
£
£
#
#
#
#
#
#
#
£
#
#
#
£
#
#
Other infections of
new-born Oral
Bleeding disorders
Teaching
#
#
Referral Protocol
Beneficiary
?t~r Teaching
al
n
hospital
#
£
#
#
’I
Period
High Risk
Congenital
anomalies involving
the vital__________
Other congenital
anomalies_________
Convulsions_______
Precious babies
Cyanosis__________
AU
Severe
infants
ARI/ Pneumonia
&
Severe diarrhoea
children Convulsions_______
up to 5
Measles__________
years
Polio_____________
Childhood
TuberculosisPulmonary________
Childhood
TuberculosisMeningitis______
Whooping Cough
Diphtheria_________
Tetanus___________
Fevers lasting more
than one week______
Fractures__________
Head injuries_______
Bums: ________
Nephritis_________
Rheumatic Heart
Disease____________
Growth retardation
Marasmus/
Kwashiorkar_______
Childhood
malignancies
PHC
Sub
District
Teaching
district
hospital
hospital
#
#
#
£
#
£
#
#
#
#
#
#
#
£
#
#
#
£
£
#
#
#
#
155
I
4
-
4
Referral Card*
Oiiqnosis:
! ’ estigations (if any):
Name (with surname):
Age:
Sex:
Treatment given:
Husband/Father’s Name:
Surgical procedures (if any):
Address:
House No.:
Village:
Mandal:
District:
Follow-up services:
Referred from:
Date of review if necessary:
Referred to: PMC |
| Sub-Dist.Hosp. [
|
Dist.Hosp. |
| Teaching '
Signature of the Medical Officer:
Reasons for referral:
Name of the Institution:
Place.
Complicated pregnancy
Fever for more than one v
Complicated delivery
Injuries
Low Birth Weight/Pregnancy
Hypertension
Convulsions
Chest Pain
ARI
Unconsciousness
Diarrhoea
Others (specify)
I
-
F
2
3
Descriptive Note:
Discharge Summary from Place of Referral*
Investigations (IF any):
OP/IPNo.:
Date of receiving the
patlent/admlsslon:
Date of discharge:
Treatment given:
Name (with surname):
Age:
Signature of the Health Worker:
Sex:
Husband/Father's Name:
Date:
Address:
I
■
Village:
Mandat:
District:
I
■
&■'
■.
ICOMP - the International Council on Management of Population
Programmes - was established in 1973 by a number of top third world
population/family planning programme managers and heads of man
agement institutes as well as representatives of donor agencies.
i
The initiative, twenty-four years ago, was taken in response to ex
pressed concerns that management of population programmes was be
coming increasingly demanding as more and more programmes were
taken up on a national scale. There was a felt need to have a forum for
exchange of experiences among population programme managers and
between them and the academic community in the field of populationrelated management. ICOMP was to serve this function, within a SouthSouth context.
For the past twenty-four years, ICOMP has assisted in sensitizing
the top managers to professional management, trained middle-level man
agers, created a network of management-related institutes in this field,
promoted women's programmes and disseminated state-of-art knowl
edge and experiences in the field of population programme manager
ment.
Much remains to be done. Current programmes and those of the
early next century would need to provide comprehensive reproductive
health services, respond to people's needs, focus on quality of care with
a balanced emphasis on women and men, promote govemment-NGO
partnership and be financially more self-reliant. Reaffirming its mission
of improving population programme management, ICOMP has refocused
its activities to meet the emerging challenges of the 1990s and beyond.
ICOMP gratefully acknowledges the financial support from UNFPA
towards the publication of this series of Population Manager.
J
- Media
6655.pdf
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