Fundamentals of Quality of Care A "Training Mannual -for NGOs
Item
- Title
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Fundamentals
of Quality of Care
A "Training Mannual -for NGOs - extracted text
-
Furda^ertals
o-f duality o-f Care...
Ar "Training Mannual -For NS Os
______________________________ ,
Regional Resource Centre
Population Foundation 0^ India
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Contributors
Dinesk Sin
Sudiptd Mukkopddkydy
Bkdirdri Buck
Mdtisk Kuwdr
Arssistdnce
A-run Kwwdr
A-writ Ksdvwt
Prewd Rxdwesk
SiAdkir Kuwdr
Foreword
The importance of assessing the quality of reproductive health services
and developing appropriate mechanisms to continuously monitor and
improve the quality of services need no emphasis. ICPD Cairo conference
also emphasised the need to address quality of care issues from both
clients and [providers perspectives.
Population Foundation of India has been supporting involvement of NGOs in reproductive
and child health programmes with the changing paradigm shift of making programmes more
relevant to the peoples needs. As a Regional Resource Centre (RRC) the Foundation has
been undertaking capacity building of MGOs/FNGOs under the MNGO scheme of
government of India to improve NGO effectiveness in RCH programmes. These efforts
include improving technical and managerial skills of the MNGOs/FMGOs under various
thematic issues including quality of care.
The manual covers all the generic and specific quality of care elements within a gender
sensitive and rights based framework. The manual describes, the process of ensuring quality
assurance in a simple user friendly and participatory manner. Wherever necessary, case
studies, stories, games, role play have been sued to make the sessions more interactive and
meaningful.
I
hope this manual will be a portent tool for district level managers from government and
civil society including RRC trainers, MNGO and FNGO staff to monitor the quality of
reproductive health services in a systematic manner. In addition the manual can be used as a
basic reference document for policy makers and civil society institutions.
I also take this opportunity to acknowledge the contribution of the PFI RRC team without
whose contribution this document would not have been possible. A special thanks to Dr
Dinesh Singh for his technical assistance in shaping this document. Finally I extend the
Foundations gratitude to MoHFW for providing the financial support for this document.
ARNanda
Executive Director
CONTENTS
Chapters
I Quality of Care:
•
•
•
•
•
•
•
•
II
Definitions of quality of care
Quality of care: framework
Why is it important to be concerned about quality of care?
Who does it benefit?
Who should be involved? Is it something new?
Quality assurance cycle
Elements of quality of care
Dimensions of the health system
Reproductive and Sexual Health Rights
•
•
•
•
Reproductive Rights
Clients Rights
Needs of service provider
Ensuring quality of care and rights based approach in service delivery.
Gender
Ill
Differentiate between sex and gender.
Discuss different attributes associated with male and female roles.
Explain the contribution of society in determining roles and the consequent
discrimination based on gender.
• Discuss the role of the service provider in mitigating gender discrimination
•
•
•
•
•
Communication Skill
Skills of good communicator
Barriers in communication
•
•
•
Counseling skills
What is counseling
Components of counseling
Skills in Counseling
IV
V
RATIONALE TO CONDUCT THE TRAINING
Quality is the central issue in the health care. Rising expectations of the people, advances in medical and
diagnostic technology, competition in health care industry, and increasing cost have made quality of
care an important issue today. There is a growing realization that quality improvement is essential for
enhancing efficiency and effectiveness of health services both in the public and private sectors.
Quality, a relatively new concept in health care, is a dynamic and complex phenomenon. There is an
extensive need for capacity building in planning, implementing, and managing quality assurance in
health care. Also, there is a great deal to be understood about the dimensions of the quality and the
standards and indicators, assessments and measurement, and management of the quality improvement
process.
AIM OFTHE TRAINING MANUAL
The purpose of this manual is to provide practical assistance to the trainers for imparting the training on
quality of care. The manual can be used in the context of training workshops, which could target
different groups such as healthcare providers, guideline developers, NGO workers and managers. The
manual can also be used as a template for developing training manuals in languages other than English.
OVERALL OBJECTIVES OFTHE QUALITY OF CARE TRAINING
The broad objective of the training programme is to develop knowledge and basic skills of different
stakeholders in quality assurance in health care. The specific objectives of the program are:
• To develop an understanding of the concepts of quality and its importance in health care
• To develop an understanding of standards and indicators of quality
• To equip the trainers with the required skills to integrate the provision of quality services in all
the Reproductive health program
• To develop the basic skills in assessment and measurement in quality
• To develop skills in monitoring quality of services and in planning and implementing quality
assurance program
Participants
The program will cater to the needs of health care planners, district level health officials, PRIs, NGO
service providers in developing basic competency in planning and managing quality of care in RCH
programs.
Batch Size:
The group size should be kept small. Not more than 20-25 participants at the time should be trained.
This increases the chances for a better outcome and more engaged participation.
Duration of the Training:
The manual provides thirty four hour curriculum and can be covered in full five days. If necessary
the trainers and participants can adopt as per their need and requirement.
Chapter 1
Session I Quality of Care
Objectives: At the end of this session the participants will be able to
• Understand meaning and concept of quality of care in general and specifically in health sector.
• List the elements of quality of care and its determinants.
• Ensure quality of care services in reproductive health programs.
• Relate and integrate essential elements of quality of care in their day to day to work.
Methodology:
• Group Discussion and Brain storming
Resources:
• Papers and Marker Pens
• Chart papers
• Flip chart Board and Pen
• Hand outs
Time:
Two hours
Process:
Activity 1: Brain storming on the word “quality of care”. Discussion on the definition, concept,
meaning, elements of quality of care.
Facilitator encourage the participants to talk about quality in the general sense and relate it to why they
buy certain products or why they shop from certain stall holders. And then come up with a list of quality
factors such as:
•
•
•
•
•
Reputation
Prompt service
Customer friendly
Right price
Good standard
Activity 2: Group work on Quality of care in Health Care services especially in reproductive health
programs.
Facilitator divides the participants in to groups of two. Depending on the situation, the allocation of
groups can be systematic or random.
each group is asked to list based on the above discussion the elements or standards and determinants of
quality of care in reproductive health programs.
Group Presentation:
The group work exercise is followed by group presentation on the results of discussion
Facilitators Brief;
The presentation is then followed by facilitator's discussions and presentations on elements of quality
of care its determinants its importance and relevance in health sector especially the reproductive health
issues.
Session II Quality Assurance and Dimensions in Health system
Objectives:
At the end of this session the participants would be able to:
• Understand the importance and need for quality assurance
• Understand the dimensions in health system
• Relate and integrate the measures of quality assurance into the health sector program in
reproductive health issues from all the perspectives.
Methodology
• Group Discussion
Resources:
• Papers and Marker Pens
• Chart papers
• Flip chart Board and Pen
• Hand outs
Time:
Three hours
Process:
Activity 1: Group discussion on what is quality assurance and the steps in quality assurance
Facilitator would initiate and involve the participants in the discussion of quality assurance, its
importance and its need. The discussion can emerge around points as;
•
•
•
•
QA is a continuous process aimed at assessing, monitoring and improving the quality of health
services
It focuses on process, activities and style of working.
It has a team work approach towards problem solving and improvement.
It analyses through use of data any or all of the quality of health care dimensions.
Activity 2: Group work on dimensions in health care system
Facilitator divides the group into three
Each group will work separately on identifying important quality factors from their perspective.
Group 1 would represent client's perspective and list down various areas that a client/ patient expect
from clinic/hospital services.
Group would represent professional perspective and list down various areas that the professionals
need as a provider to ensure highest qual ity standards
Group 3 would represent management's perspective and list down various areas that are needed from
administration and management point of view in order to ensure better quality services.
Group Presentation:
The group work exercise would be followed by presentation by each group and discussion on it.
Discussion
The facilitator would the leave the session open for discussion and brief the participants about various
dimensions in health system. The facilitator would also orient the participants towards various aspects
of quality of care and its measurement. For example the structural quality measure, process quality
measure and outcome quality measure. The session can be made open for queries too.
Chapter 2
Session 1 Gender and Health
Objectives: At the end of session the participants would be able
• Differentiate between sex and gender
• Discuss various attributes associated with male and female roles
• Discuss the role of service provider in mitigating gender discrimination
• State how sex and gender impact on health of individual
Methodology:
• Quiz
• Group exercise
» Discussion
Resources:
• Papers/Marker Pens
• Handouts
Time:
Two hours
Process
Activity 1 Quiz'Sex and Gender'
Facilitator asks the participants to state what they understand by term gender and lists these responses
on one side of board. Facilitator asks the participants to state what they understand by term sex and lists
these responses on side of flip chart board. From the lists of the responses then facilitator highlights the
difference in two concepts. Facilitator then presents and explains characteristics of gender.
Facilitator conducts quiz on Sex/Gender statement by reading out each statement and
asking participants to say whether its sex or gender
Statements For Quiz
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
>
Women are gentle by nature
Men are better at playing cricket than women are
Women menstruate
Men are violent in nature
Women are better cooks then men.
Women have long hair
Men have moustaches and beard
Women are better housekeepers then men
Men cannot do housework
Men cannot contro; their sexual desires
Men get bald as they grow older.
Women are protected from heart diseses.
Women have ovaries
Women eat after men have eaten their food
Men are not able to look after children
Voice changes in boys as they grow up
Women leave their parents house after marriage.
Activity 2 Group exercise on gender discrimination
Facilitator will provide for zopp cards prepared in advance containing various statements. Each
statement would be repeated three to four times, and each pair would have one statement each.
Facilitator would ask the participants to divide into pairs. And distribute the cards to each pair.
Facilitator asks them to discuss the statement with their partner, and write down their main points:
• Do you agree with the statement?
• If yes, then why is the situation/statement true?
• If not, then why do you disagree?
• What impact does the statement have on the health of women and the development of
communities and the nation?
• What can be done to improve situation
The group exercise would be followed by group presentations.
This would be followed by group discussion and the facilitator would discuss how gender affects
various spheres of life cycle of an individual. How the differences in biological sex and gender interact
to produce different categories of health conditions. Brainstorm with the participants how they can
contribute towards minimizing the gender discrimination.
Chapter 3
Session 1 Reproductive Rights
Objectives: At the end of the session the participants will be able to
• Know the reproductive and sexual health rights of the individual
• Know what are clients rights
• Would be able to integrate a rights based approach in daily service delivery.
Methodology
• Exercise
• Brainstorming
• Documentary/Video showing or Role Play
Resources:
• Chart Papers/Pen
• HandOuts
• Television, Video Player
■
Time:
Two hours
Process:
Activity 1 Exercise on Rights in general and reproductive rights
Facilitator divides the participants in to four groups. Generate the discussion on general rights that we
enjoy in day to day life. Ask them to brain storm about reproductive rights and discuss among
themselves and record it on the flip chart
The exercise is followed by group presentation and discussion
The facilitator then presents the background regarding the origin of reproductive rights, about the 1CPD
conference and lists the reproductive rights of individual. It states that
" - ------------ r’
Reproductive Rights
The right of individuals and couples
•
To freely and responsibly decide
Whether to have or not to have children
The number and spacing of children
And have the information and services to do
so
To have a safe and satisfying sex life free from violence, pregnancy and disease
To have the information and services to ensure a safe outcome for pregnancy
Acth ii\ 2. Clients rights and Needs of Service Provider
The facilitator involves the group in brain storming about the clients rights and needs of the service
provider while ensuring quality of care. The activity is for 30 minutes and the responses are listed down
on a chart paper and after the brain storming is completed discussion takes place.
The facilitator orients the group regarding rights based approach in reproductive health issues, its need
and importance. Facilitator also presents the clients rights in a situation, what are they and how they are
to be protected in order to provide better and effective service delivery and receive better health
outcome. The discussion should highlight following points.
• Freedom of choice
• Accurate information
• Confidentiality and Privacy
• Compassion, respect and understanding
« Freedom to express opinions
• Access, Continuity and follow up.
The facilitator then generates the discussion regarding needs of the service provider while providing
quality services. The following points should be stressed upon
» Facilitative supervision and management
• Information, training and development
o Adequate and timely supplies, of equipments and drugs
° Adequate and well maintained infrastructure
Activity 3. Video film viewing/ Role play on Client provider interaction.
A video film on reproductive rights and clients rights to be shown to the participants. Before viewing of
the film the facilitator should orient the participants regarding the issues in the film and also ask them to
take notes regarding how reproductive rights are violated, what is lacking and how one can improve
upon the shown situation.
After the film the participants would be given time to list down the responses to questions and then they
can present the views and a discussion is held on the same.
In lieu of video viewing, The facilitator can conduct the session with a role play.
Facilitator asks the participants to volunteer themselves for a role play and then the situation is
explained to the volunteers. The situation would be the following:
A married couple comes to the Primary Health centre with issue an concern of unwanted pregnancy
and abortion related services. The couple in the first visit talks to the doctor about heir concerns and
the medical officer is not able to pay attention, getting disturbed by phone calls etc. The couple on
their exit approaches the ANM regarding it and the ANM pays a home visit. The home visit shows the
involvement of the family the in-laws on the issue.
The facilitator asks the participants to observe and list responses to following questions
1. What kind of reproductive rights are involved in the situation?
7 How the rights violation is done at the family as well as at the service provision level?
3. What can be done to improve the situation?
This is followed by discussion regarding the responses and also how the participants can integrate the
knowledge of the same in their own routine of providing care and service.
Chapter 4
Communication skills
Objectives: at the end of this session the participants will be able to:
• Understand the process of communication
• Make an effective use of two way communication process
• Understand the barriers in communication
Methodology
• Discussion
• Role Plays
• Exercises
• Group Discussion
Resources
. Chart Papers/Pens
. HandOuts
Time:
Two hours
Process
Activity 1. Group discussion on qualities of good communicator
Facilitator asks the participants to recall an individual who is a good communicator. Ask them to recall
on qualities of such a person. Facilitator writes the responses on Board. The discussion should reflect at
least following responses
• Clarity in speech
• Easy simple language
• Positive attitude
• Ability to express ideas and feelings clearly
• Good listener
• Friendly
Facilitator summarizes the qualities of effective and good communicator. One quality common to all is
the ability of empathy Also quality to convey message effectively to receiver. And sincerity are always
associated with effective communication.
Activity 2. Exercise on communication
Facilitator instructs participants to close eyes and recollect five people they had met and write down
what they said to them. After five minutes the facilitator asks the participants asks participants to read
out what they have written. Generally it happens that they write and remember what they themselves.
said than what they heard. It is explained that most of the time one does not remember what others said
because many times messages are transmitted but not listened to.
Activity 3. Role Play on Patient doctor communication
Facilitator asks two volunteers from the group. They are asked to do a role play in which following
situation is described.
' A patient comes to health clinic to ask about] F^'Htator discusses about barriers in communication
missed periods. There is lot of noise around
while staff is going in and out of room. The
doctor is talking to two or three people
Chapter 5 Counseling Skills
Session 1 Counseling skills
Obj ectives: At the end of this session, the participant will be able to:
• Describe what counseling is.
• Identify qualities and skills of a counselor.
• State the client's rights in a counseling situation.
• Begin to practice some specific skills of counseling
Methodology:
Brainstorming
• Group exercises
• Role Plays
Resources:
, Chart papers/Pens
. Hand outs
Time:
Three hours
Process:
Activity 1. Brainstorming on concept of counseling.
Facilitator brainstorms with the group about the concept of counseling. The possible responses are
• Advising
•
Telling them what to do
•
Giving Information
• Exchange of ideas
•
Motivation.
The facilitator then presents definition of counseling and steps in counseling. Errors in counseling are
also presented.
Activity 2. Discussion clients Rights
Facilitator presents what are clients rights. A discussion is generated on what actually happens at the
health clinics and dispensaries. Feasibility of operationalisation of these rights at the level and possible
difficulties are discussed.
Facilitator then lists down concrete steps with the help of participants on operationalisation of clients
rights at the health clinics. Fol lowing could be the possible responses:
•
•
•
Ensuring responses
Ensuring confidentiality
Alternatives to make informed decision
•
•
Separate place for counseling
Provide complete information
Activity 3. Role Plays on Counseling Skills
The facilitator divides the participants into three groups. Role play situations are given to the
participants to practice the skills of counseling. The role play situations are:
•
•
.
A woman comes to the clinic with missed period
An adolescent girl comes with heavy bleeding complain.
Acouple comes with doubts on use of contraceptive.
Role plays are followed by presentation and discussion on it.
Notes And Guidelines:
Chapter 1 Quality of care:
Introduction:
Quality means different things to different people. It might mean reputation, durability of a product,
right price, prompt service, high standard, friendly reception, availability of services.
"Quality of care does not mean sophisticated or exclusive care, but is concerned with fully meeting the
needs of those who need the service most, at the lowest cost to the organization, within the limits set by
higher authorities
The health care provider is supposed to provide technically appropriate health care to the patient. To
ensure that the patient receives appropriate care the system of health care delivery is divided into
specialities and there is supposed to be an arrangement of referrals that ensures that the person with a
particular kind of problem reach a particular practitioner. Each provider in terms provides what she or
he knows as the most appropriate course of therapy. The provider is supposed to be the expert and
his/her advice and treatment reflects this expertise. The more qualified the provider, the more up-todate the investigations and drugs the more high quality it is supposed to be. However most patients
know, that at times the treatment from two doctors with the same professional degree, is slightly
different. The doctors use their own judgment to make what they feel is the most appropriate treatment.
How can the patient then case be sure which of these treatments is of better? Is the doctor who has a
better bedside manner better? Is the doctor who has a more well equipped clinic better? Or is the doctor
who prescribes more tests and gives more drugs better? The basic question is how do we judge between
different kinds of healthcare services? Understanding quality of care is one way in which we can make
such ajudgment, and as managers, providers or clients we can make choices about what kind of service
to provide oruse.
There are a number of definitions of quality of care and some of these are given below.
> Quality of care is the degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional knowledge.
(Institute of Medicine 1990)
>
Quality of care can be defined by the way the clients are treated by the system, or the actual process
of care-giving, and by the focus on the client's or user's perspectives of services (Hull, 1994),
>
The degree of match between the client's view of the performance of the services and the service
providers view determines clients satisfaction (Ishikawa, 1985)
>
Quality of care is
Doing the right thing
Doing things right
Doing things at the right time
Doing things with the right attitude (Abou-Zahr, 1994)
From the different definitions given about it is clear that providers attitude towards the client the clients
satisfaction and perspective, as well as technical appropriateness and the desired health outcomes are
important components of quality. Another important issue of quality especially in a communitv health
care setting are management issues like access, training, infrastructure.
7
©
Ensuring Quality of Care
In order to improve quality of care of service or to measure it different authors have suggested looking at
different aspect of services. Among the different frameworks that have been proposed to define quality
of care the most notable in the context of Family Planning programmes has been the one proposed by
Judith Bruce (1990) which incorporates six elements. These include
(1)
Choice of methods
(2)
Information given to users
(3)
Technical competence
(4)
Interpersonal relations
(5)
Mechanisms to encourage continuity
(6)
Appropriate constellations of services
The Judith Bruce formulation is a very robust definition and has been applied to measure quality of
sendees for a long time. However in recent years the increasing focus of client's perspectives has led to
the addition of other components to this framework. UNFPA developed a reproductive health quality
framework which includes nine elements. Of these nine elements five are applicable in all situations
while four are specific to the different reproductive health conditions. An important feature of this
framework in the inclusion of client's participation in management decisions which goes well beyond
the concept of client provider interaction. This framework is given below
GENERIC ELEMENTS (common to all RH services)
4
4
4
4
4
Service environment
Client provider interaction
Informed decision making
Integration of services
Women's participation in management
SERVICE SPECIFIC ELEMENTS (specific to each RH service)
4
4
4
4
Access to services
Equipment and supplies
Professional standards and technical competence
Continuity of care
What this framework implies is that the generic elements have to be improved and ensured in all service
environments while equipment, supplies, technical competence will depend upon the level of service as
well as the reproductive health condition for which services are being provided. Thus at the Sub Centre
the ANM will provide a different level of service while at the District Flospital the specialist will
provide another. Similarly for the same RFI condition (for example obstructed labour) will be dealt
differently at the PHC ( with referral) compared to the Emergency Obstetric Care Centre ( with
Caesarian section).
What is Quality Assurance?
Quality Assurance is a systematic and planned approach to assessing, monitoring and improving the
quality of health services on a continuous basis. It promotes confidence, improves communications and
allows clearer understanding of community needs and expectations.
1.
Quality Assurance is oriented towards meeting the needs and expectations of the patient
and the community
2.
Quality Assurance focuses on the way we work, our activities, and processes of health care
delivery
3.
Quality assurance uses data to analyse how we are working and delivering health services
4.
Quality assurance encourages a multi-disciplinary team approach to problem solving and
quality improvement
In practice Quality Assurance is a continuous process and the quality assurance cycle can be used to
guide your activities. There are various different stages in the cycle which are explained
Quality'Assurance Cycle:
Quality Assurance is systematic way of ensuring and maintaining “quality” of services and has proved
useful globally. The process of quality assurance has three major steps
1. Realizing and acknowledging the problem
2. planning an intervention and its implementation
3. Reviewing the outcomes of the intervention
If the desired outcome is not achieved, the process is repeated thus making it cyclical and continuous
one.
A composite and comprehensive way of looking at Quality of Care is to consider factors at three points
in time - upstream at systems (structures and capacities); at the time of client- provider interactions
(procedures and performance); and beyond at outcomes. The different factors which contribute to
quality of care are indicated in the table below.
Quality of Care - determinants
Structures/capacity
Processes/Performance
Outcomes
Policy intention Program
design Laws, regulation
' and licensing
Training of providers and
competence
All the above include
gender and rights
perspective
Protocols and standards
Service infrastructure and
access
MIS
Supplies and logistics
Client (especially
women's) participation in
management decision
making
Diagnostic and
therapeutic
appropriateness
Timeliness of care
Integration
Continuity of care
Interpersonal aspects
Involving clients in
decision making
Attending to client
comforts - cleanliness,
privacy, confidentiality
etc.
Special provisions for
women and their needs
Therapeutic outcome
Unintended outcomes
Client awareness and
knowledge
Fulfillment of client
expectations
Client satisfaction
Client behaviour
Opportunity for
feedback
(especially for
women's opinion)
Structural Quality Measures
This is the availability and quality of resources, management systems and policy guidelines. These
things are quite easy to measure, but are not always very informative unless they can be related to
processes and outcomes.
Structural aspects refer to the inputs absorbed in the production of health services. They include the
conditions of the workplace, service providers qualifications, available equipment and drugs. The
structural aspects of health care delivery are the easiest to be studied. Even in the most troubled
environments, some indicators related to structural aspects may be found, from routine data or in
evaluation and supervision reports. Checklists designed to collect indicators of this class abound.
The value of these indicators is mainly negative, in the sense that the absence of basic inputs suggests
. inadequate quality, whereas their presence does not ensure it. In many cases, expressing the availability
of basic inputs as proportions of health care delivery points endowed with them is preferable than as
averages. For example, the finding of 60% of PHC facilities lacking a functioning sphygmomanometer
is more telling than stating that the average PHC facility is equipped with 0.8 sphygmomanometers.
Thus, structural measures include number of qualified staff, functioning X Ray equipment, number of
road worthy vehicles, amenities, etc.
Process Quality Measures
This is the actual process of health care delivery. The measurement of services provided is more
difficult to make, but this information is more useful because it tells us what happened to the patient.
Process aspects refer to the way available inputs are transformed into health activities. They depend on
a host of factors, including service providers' competence, work organization, incentives at play,
information to the public. Whether a certain condition is correctly identified, the right treatment is
prescribed, the patient complies with instructions, drugs and vaccines are properly stored, all fall within
this group. Additionally, patient perceptions of care belong to this category. The majority of process
indicators are collected through direct observation and interviews. Routine information systems
produce some process indicators, like case fatality rates, or the success rate of a treatment schedule.
Given the shakiness of routine figures, considerable caution is needed before related process indicators
are retained as reliable.
Collection of the data depends on having monitoring systems. Process measures include things such as
waiting time, being given a clear diagnosis, examining the patient properly, etc.
Outcome Quality Measures
This is the end result of health care; the outputs and health status. Outcome measures include things
such as mortality, patient satisfaction, coverage, attendance levels etc.
The outcomes of health care are obviously the ultimate quality criterion. Unfortunately, their study is
technically demanding and usually expensive. Moreover, their interpretation is fraught with
difficulties. Long-term outcomes are particularly difficult to assess in unstable environments, where
few or no variables can be controlled. Measures of outcomes of health care are therefore scarce in
distressed health sectors. Reliance on the assessment of structural and process aspects is commonplace,
on the assumption that if all needed inputs are available and working practices are sound, the outcome
of health care is likely to be satisfactory. Before embracing wholeheartedly this assumption in a
troubled health environment, multiple checks are recommended. Caution is needed with single
disease-control programmes, which by nature leave untouched a vast array of environmental and
violence-related risk factors. The health gains expected from reducing the burden of morbidity and
mortality of the targeted disease may be offset by concomitant losses in other area, induced or
magnified by the crisis.
The important thing to remember is that we should focus our attention on all 3 dimensions and not just
concentrate on one aspect. For example, if we want to improve health outcomes, we must understand
the processes and structures that contributed to achieving the outcome.
Therefore when we start seriously looking at quality we have to remember that:
•
quality has many dimensions
•
quality can be viewed from different perspectives
*
we can measure quality at different points in the health system.
Chapter 2
Gender and Health
Quality of Care from the Gender Perspective
Gender refers to the socially and culturally defined differences between men and women (sex being the
biological difference). It includes the different roles that are ascribed to the two sexes, the expected
behaviors and also includes the differential power and control vested in each sex. Nominally gender
does not indicate a hierarchy but in actual practice men and women do not have equal access and control
over various kinds of resources and a strict hierarchy exists between the two. This hierarchy is clearly
evident in Indian society. Women are expected to eat only after the men of the house have eaten, girls are
provided fewer years of formal education, women are expected to stay at home and there are strict rules
e.ven about visiting the natal home. It would be a mistake to surmise that these differences will
automatically reduce over time. While gender roles, expectations and behaviors do change over time
the assumption that the difference in hierarchy reduces is somewhat naive, witness the increase in sex
selective abortions especially among developed states like Punjab, Haryana and Gujarat.
Gender equality is formally defined as a situation or state where there is an absence of discrimination on
the basis of a person's sex, in opportunities and the allocation of resources or benefits or in access to
services. However this is far from what exists in reality where an individual's biological sex often
becomes the basis of enjoying social/economic/cultural advantages or disadvantages. Men and women
live their lives in society accepting and reproducing socially prescribed roles and behaviors. These roles
and behaviors are often strictly enforced and also incorporate a hierarchy between women and men,
giving men a distinct advantage. These differences not only manifest themselves in roles and behaviors
but most importantly in the access to and control over the various kinds of resources that women and
men enjoy. Thus it is assumed that the son will inherit the property of the father, husbands own and
deploy the family resources while women have to remain content with comparatively lesser education
and wives cannot decide whether or not to use contraceptives.
Despite the socially prescribed, acknowledged and encouraged differences in the status of women and
men, the principles of universal human rights, as well as the Indian constitution upholds the equality of
women and men. Gender equality is thus an ideal which is not only universal but also constitutionally
and legally binding in India.
In order to achieve gender equality one must first acknowledge that there is gender discrimination today
and that women are disadvantaged. To reverse and balance this discrimination it is necessary to apply
the principle of equity. Gender equity can be defined as fairness and justice in the distribution of
benefits and responsibilities between women and men. The concept recognizes that women and men
have different needs and power and that these differences should be identified and addressed in a
manner that rectifies the imbalance between the sexes. Thus while equality is an ideal, equity is the
operational principle which realizes the need to make special provisions for the disadvantaged and the
powerless. Without practicing gender equity it may not be possible to achieve gender equality because
of the unevenly shared power and resources between women and men that exists today.
The Linkages between gender and health
The subordinate status of women in society deeply influences their health status. The principal
responsibility of women in many societies including our own is usually restricted to childbearing. This
over emphasis on one biological aspect has led to such situations as early marriage and repeated child
bearing and its attendant complications. Son preference, another strong trait of Indian society has led to
the heinous practice of sex-selective abortion and repeated abortions and its attendant complications.
Women's workload in many places is considered minimal, but a careful daily analysis reveals that
women hardly have a moment to spare in the course of the entire day while men are entitled to their
share of relaxation after a days hard work. Women's subordinate status has also led her to be an easy
target of family planning programs in our country with the bulk of sterilizations being tubal ligation
operations. To add to the situation described above women have very little autonomy to decide what
they should do for keeping healthy. Many women's reproductive health issues, which are related to her
genitals are considered dirty and shameful and hence women not only feel uncomfortable in openly
discussing their problems, but they refuse treatment from male medical providers. Medical providers,
themselves are products of the society in which they live and thus carry with them the usual social and
cultural biases regarding women and their abilities. In short the gender differences between men and
women are reflected
•
•
•
•
•
at the level ofcause of ill health
at the level of the individuals own response to the ill health condition
at the level of family response to the situation
at the level of the treatment accessibility and availability of treatment as well as the attitude and
behaviour of the health care provider
at the level of ultimate health outcomes
If we examine any reproductive health condition it will emerge that all reproductive health conditions
either arise from or are complicated by unequal gender relations.
Some important RH concerns in India include
•
•
•
•
.
•
•
Unwanted pregnancies
Maternal Mortality and morbidity
Contraception as well as infertility
Unsafe abortion, Sex-selective abortion
RTI/STI/HIV/AIDS
Cancers
Concern for adolescent health and so on
Origin of Differences in Health / Profiles
Biological Differences
• Anatomical/ Physiological
• Anatomical, Physiological
And Genetical
Susceptibilities
• Anatomical, Physiological
and Genetic
Social Differences
•
Roles and Responsibilities
• Access and control
• Cultural Influences
and Expectations
• Subjective identity
Health situations, conditions or problems
•
•
•
•
Sex Specific
Higher prevalence in one or other sex
Different characteristics for men and women
Generates different response by
indivijjulas/family/institutions depending on
? Whther the person is male and female
Chapter 3
Reproductive and Sexual health Rights
Introduction
Equal human rights for all human beings are not only a principle of international human rights but a core
principle of the Indian Constitution. In 1993 the Vienna human rights conference was organized and
right to development was also included in the list of human rights. Out of the 1994 Cairo conference on
population and development evolved a clearer and more precise definition of reproductive rights. The
Fourth World Conference on Women organized at Beijing in 1995 tabled the agenda for women's
empowerment. All these changes were possible because of struggles of many national and international
movements spearheaded by women's rights and human rights activists on the one hand and the
willingness of governments to sit together and negotiate a common agenda.
A consensus definition of the rights approach may be found with the UN Commission on Human Rights
which defines it as “an integration of the norms and standards contained in the wealth of international
treaties and declarations into the plans, policies and processes of development”. To this one may add the
component of legislation, because without appropriate legislation, the rights approach looses teeth in
ensuring justice in the case of rights violations and mandating the state to ensure enabling conditions to
enjoy the rights.
India has one of the most progressive constitutions in the world incorporating many of the features of
the rights approach within its framework. There are many appropriate laws in the penal code. The
changes in international understanding that took place in the 1990's were also readily endorsed by the
Indian Government by the formulation of National Policies and programmes meant to translate these
principles into action. The Target Free and Community Needs Assessment Approach, the Reproductive
and Child Health Programme, the National Population Policy (2000), the National Policy on the
Empowerment of Women (2001) and the National Health Policy (2002) are testimony to the states
commitment. At the same time redressal mechanisms like the National Human Rights Commission and
the National Commission on Women were also set up to safe guard human rights. The Indian legislative
and courts too have adopted a pro-humanAvomen's rights approach. The Pre Natal Diagnostic
Techniques Act (1996), the Vishakha judgement ( 1997) are some examples of this change in approach.
Rights Approach in Reproductive Health:
Reproductive health, especially that of women is area shrouded with ignorance, shame, silence and
mystery. At the same time it is one area where there are large number of societal expectations and
prescriptions, at least in traditional societies like India With societal expectations and norms on the one
side and woman's own needs and desires on the other, reproductive health becomes one of the most
contested area of 'rights'. Who will decide whether or not to marry? Who will decide the age at
marriage? Who will decide whether to have children or not? Who will decide the number and spacing of
children? Who will decide whether to wait for a son or not? Who will decide whether to use
contraceptive? Who will decide whether to carry a pregnancy or abort it? These and many similar
questions form the crux of reproductive rights.
However reproductive rights are not limited to these decisions alone. The ability of an individual to
make these decisions depends upon the amount of information that is available to make these decisions.
Informed choice, a key element of reproductive rights, is the outcome of the possession of adequate
knowledge and information, the ability to make abiding decisions, and having access to the appropriate
services that are needed. The role of the state or the government in providing the
knowledge/information as well as ensuring the services is key to the enjoyment of reproductive rights.
At the same time the state also has a responsibility to ensure that women are able to make decisions in
the context of their reproductive lives, which in actual practice are curtailed by family members and
societal norms. Thus education of family members, making legislation to prevent discriminatory
practices is also a role of the state.
Clients Rights
Just like any other services the health sector also is one of kind of service sector only dealing with the
technical parts of human lives. Thus just like other sectors have consumer protection and all the health
care sectors also has to view its patient as customer and the clients has its rights and these rights should
be protected. Thus all the clients whether they are taking services in the private sector ot at the
government set up they have following right for better quality of care.
1.
Right to Information
Clients should be given complete, correct and latest information. The Information should be
understandable to the client. Merits and demerits of different alternatives, where they are
available; How to get access to; at center in community should be provided. Clear cut
information should be given regarding the available services, timings, how the clients can
access over the services, place of available sendees etc. Information should be given that who
can provide the services at which level. .All the relevant information should be displayed at the
common place of the center
2.
Right to access over the services:
The services should be available to all the people irrespective of any Socio- economic status
including adolescents, youth of marrying age, pregnant women and post natal women,
physically challenged people, refugees, migrants, displaced people, victims of physical and
sexual violence, sex workers, homosexuals, marginalized people(who don't get service in
time) people relegated from society
3.
Right to Confidentiality
Safe, comfortable, feeling of confidentiality, environment should be comfortable should be
provided.. There is a great deal of medical and personal information sharing by the client
during seeking service. Thus utmost attention should be paid regarding the information being
kept confidential.
4.
Right to Trust
Every client has the right to get trust into the provider that the service provided would be as per
expectation and of good quality.
5.
Right to Dignity
All clients should be treated with respect, regardless of their social status or way of thinking. If
compassion and understanding are difficult because of cultural or religious differences
between the client and provider then it may diminish the providers ability to be objective.
6.
Right to Safe services
Clients must see that all safety standards are followed properely.. and if not then he/ she has
the right to reject unacceptable procedures.
7.
Right to freedom of Choice
Freedom of choice implies, “informed choice”. Therefore the clients are entitled to
information that will help them in making decisions. According to their choice alternatives
should be explained with their contraindications and merits
8.
Right to Expression
Clients hold the right to express good or bad feelings, right to suggest as per convenience and
also express their opinions.
9.
Right to Continuity
The clients should be provided uninterrupted continuity of service as per the need, right to take
service from others, right to be referred and follow up
10.
Right to redressal of grievances
The health seeker has a right to redressal of his/her losses regarding deficiency in service,
deficiency in due care and caution, negligent services and damages caused so far.
Implementing And Integrating a rights based approach in Reproductive health service
delivery.
Implementing a rights approach in reproductive health is a multidisciplinary initiative requiring a
knowledge and appreciation of technical health issues, policy and programme provisions and legal
positions around different reproductive health areas.
A simple framework that can be used for implementing a rights approach is to see each reproductive
health condition in terms of entitlements of the individual and the responsibilities of
individual/community. The entitlements and responsibilities emerge out of the technical health
interventions, government laws, policies and programs. Two examples are given below.
Antenatal Care
•
•
•
•
•
•
•
Entitlements (Right)
Responsibilities
Registration
2 TT injections at the
appropriate time
100 iron and folic
acid tablets
Three antenatal
examinations for high
risk screening
Advice for minor
problems
Referral for major
problems/high risk
Etc
• Rest
• Contact ANM for
Antenatal check up and
injections
• Diet and IFA as per advice
• Contact the ANM for
problems
• Follow other ANM
advice
• Follow referral advice
• Husbands support and
sharing of responsibility
• Etc..
Legal Policy and
Program (Framework
•
•
•
•
•
CNA Approach
RCH Programme
National Population
Policy
National Health
Policy
Articles 38, 39 and
42 of the Indian
constitution
Etc.
Contraception
Entitlements (Right)
Information about
variet of contraceptive
options to both men and
women
Advantages and
disadvantages ( side
effects) of different
contraceptives
Access to contraceptive
of choice with clear
instructions about how to
use it
Good quality service and
compliance with the
standards of care
Services for
complications and
failures
Responsibilities
•
•
•
•
To use the
contraceptives as
directed
To inform the
provider when new
supplies are
required
To inform the
provider in case of
side effects,
complications and
failure.
Male partners
sharing
responsibility
and so on
Legal Policy and
Program (Framework
RCH Programme
National Population
Policy
National Health
Policy
National Policy on
Empowerment of
Women
MTP Act
PNDT Act
Article 14 and 15of
the Indian
Constitution and so
on
Article 14 and 15of
the Indian
Constitution and so
on
In order to implement a rights approach it is necessary to inform both health providers and the
clients/community of their rights and responsibilities and the legal or policy/programme framework
which applies
Chapter 4
Communication Skills
Introduction
Effective interpersonal communication between health care providers and clients/patients is one of the
most important factors for improving patient satisfaction, treatment compliance and outcomes. There
is evidence of better treatment outcomes with effective communication skills.
However effective communication may not come naturally or easily. It is seen that though the health
care provider and client belong to same geographical area, there may be differences in social status and
education and cultural background. Due to this the message may not be interpreted correctly. Factors
such as lack ofprivacy, and time constraints also affect effective interpersonal communication.
Health care providers by virtue of their training tend to use jargons while talking to the patients, which
increases the feeling of inequality between the health care provider and patient/client. Health care
providers have to be constantly aware that they wield considerable power in their relationship with
patients. Effective communication will help in bridging the gap between provider and patient by
listening, empathizing with them, sharing information and helping them to come to decisions related to
theirhealth.
Communication Process:
It is a two way process. There is a sender and receiver in it. The sender is the originator of the message.
To be effective the sender must be clear about
• The objective ofcommunication
• Needs, interests and abilities of receiver
• The content and usefulness of message
• The channel to be used
It is important that the message is sent in language understood by receiver. The message should be clear
and free from ambiguity.
And the receiver has to be good listener. To be a good listener
• Be attentive, look at speaker.
• Absorb clearly
• Listen to the underlying feelings in message is important.
Barriers in Communication
• Socio cultural gaps
• Language differences, terminology and mannerisms
• Lack ofprivacy, sensitivity
Skills in effective interpersonal communication.
• Effective listening leaning forward, eye contact, head nod
• Encourage dialogue ask open ended questions
• Avoid interruption
• Avoid being judgmental
• Probe for information
Chapter 5
Counseling skills
Introduction
Counseling is a process of communication, involving two or more persons who meet to solve a
problem, resolve a crisis or make decisions regarding personal intimate matter.
What Counseling Is?
There are many interpretations of what counseling is. The best represents for reproductive health issues
is, “a mutual exchange of ideas, opinions etc, discussion and deliberations.”
What Counseling is not?
Counseling is not telling a client what to do. A counseling session is not a question and answer period.
Components of Counseling
Counseling has both process and content components, all directed towards achieving th purpose of the
counseling session which is defined by clients.
Process Components
• Establishing Rapport
• Listening and
Questioning
• Discussion
• Decsion making
Content Component
• Obtaining
information
• Giving information
The process and content components of a counseling session are dependent on each other. The process
components are more numerous but they are dependent on content to give them substance. In a like
manner the content components depend on process for transmission.
Skills In Counseling
Macro Skills in Counseling
• Clarification: This is is to ensure that you have understood the client's message correctly. It is
important to ask for such feedback from the client frequently during the communication.
• Asking open ended questions: Begin Questions. As far as possible avoid questions beginning
with why, where, etc. Ask questions which will encourage the client to speak and not to give
monosyllabic answers. Do not ask directive or leading questions
• Conveying Empathy: Empathic understanding involves accurately sensing the clients world
and being able to see the way he or she does and verbally sharing your understanding with
client.
• Reassurance: The client could be agitated, depressed or anxious and the counselor needs to
reassure the client in verbal and non verbal way such as keep faith or things should be fine.
• Summarizing: Clients who are agitated or are in state of shock may talk fast and about many
topics. The counselor should summarize points.
• Recapitalizing: Asking the client to recapitulate the information given is usually done in
concluding session, after information about an investigation or treatment procedures has been
given to client.
Micro Skills in counseling
•
•
•
•
Paraphrasing of Content: A paraphrase is saying the clients primary words and thoughts in
another way. It involves selective attention and response to the clients message content by
rephrasing it.
Reflection of feeling: A counselor reflects the client's feelings in her own words. By this it can
assured that you have understood the client accurately. And help the client to recognize her
feelings.
Appropriate use of silence: Silence in counseling session gives the client opportunity to reflect,
integrate the feelings, think through an idea and absorb new information.
Focusing: A counselor should help the client to focus on his/her thoughts on most important
issue on hand. The aim of focusing is to prioritize what needs immediate attention.
What makes Good Counselor
Good counseling consists of two elements. One establishing a trusting and caring relationship with
clients and another of giving and receiving relevant, accurate information to help client to make
decisions.
References
Berwick, Donald M., et al. 1990. Curing Health care. San Francisco: Jossey-Bass
Publishers.
Bruce, Judith. 1990. Fundamental elements of the quality of care: A simple framework.
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EngenderHealth. 1995. COPE: Client- Oriented, Provider- Efficient Services-A
Process and Tools for Quality Improvement and Other Reproductive Health Services.
New York: EngenderHealth
EngenderHealth
EngenderHealth
1999. Facilitative Supervision Handbook. New York:
EngenderHealth. 1996. Medical Monitoring Handbook: working Draft. New York:
EngenderHealth.
Harper, A., and Harper, B. 1996. Team Barriers: Action for Overcoming the Blocks to
Empowerment, Involvement and High Performance. New York: MW Corporation.
Huezo, Carlos, and Diaz, Soledad. 1993. Quality of care in family planning; Clients'
rights and providers' needs advances in Contraception 9:129-139.
Imundo, L.V. 1993. The Effective Supervisor's Handbook New York: AMACOM
International Covenant on Economic, Social and Cultural Rights (Article 12).
Me Caffery, J., et al. 2000. Performance Improvement: Stages, Steps and Tools. North
Carolina; INTRAH.
Mager, R.F. 1992. What Every Manager Should Know About Training Atlanta: The
Centre for Effective Performance.
Senge, Peter M. 1990. The Fifth Discipline: The Art and Practice of the Learning
Organization New york: Currency Doubleday.
Thaddeus, S., and Maine, D. 1994. Too far to walk: maternal mortality in context. Social
Science Medicine 38 (8): 1091-110.
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