Institutionalization of Quality Assurance Program in District Health Management

1. Institutionalization of Quality Assurance Program in District Health Management Anurag Mishra, M E Khan, and Vivek Sharma FRONTIERS Program, Population Council, New Delhi January 30, 2008

2. Contents • Overview of Quality Assurance • RCH QA Mechanism • QA Experience from Gujarat • On going QA Activities in Six States • Lessons Learned • Place of QA for ARSH

3. Need for Developing QA Program • Globally many tools are available to assess quality of RH services • Many have been adapted and tested in India • Most have been found too specific to a particular area of care, or too cumbersome and time consuming to institutionalize in Indian health care delivery system • They were used for periodic assessments and not institutionalized with health systems • A comprehensive operational manual covering RCH components in public health setting was considered critical to move forward

4. Development of Checklists and Manual • Checklists and manual were developed- • To demonstrate feasibility of institutionalization of QA systems at district level management • To improve RH Services provided at CHC/PHCs and Sub-centers • To provide a quality improvement model to states that could be replicated and scaled up

5. RH Quality Framework for Assessment

6. Quality of Care Elements • The manual identifies nine key elements to measure the quality of services - • Five generic elements • Four service specific elements

7. Generic Elements Generic elements include – • Service environment – infrastructure, basic amenities, clients comfort, privacy etc. • Client provider interaction - nature of provider – client relationship and information exchanged between them • Informed decision-making - availability of relevant information and service procedures that facilitate informed choice by client • Integration of services - linkage of services and health institutions • Women’s participation in management –Women participation in planning, implementation and monitoring of RH services

8. Service Specific Elements Service specific elements include – • Access to services – Location, distance, timing of facility, affordability in terms of travel cost, lost wages etc. • Equipment and supplies - Equipment of standard specifications are available? In working order? Sufficient supplies available? • Professional standards and technical competence – providers competent? Service guidelines/protocols available? Service standards established? • Continuity of care – clients follow up regular and effective? Side effects/complications managed? MIS designed and maintained?

9. QA Tools/Checklists Guiding Principle • Practical: Possible to complete within 2-3 hrs by 2-3 people • Specific: Critical to assess functionality of services • Independent: Stand alone assessment • Feedback: Could be provided it immediately to facility MOs • Transparent: Prior awareness of visit & criteria for assessment by QA team • Sensitive: Improvements and change quantified

10. Contents • Overview of Quality Assurance • RCH QA Mechanism • QA Experience from Gujarat • On going QA Activities in Six States • Lessons Learned • Place of QA for ARSH

11. Institutional Arrangements State Health Mission State QA Nodal Officer District Health Mission DHO/CMO (Chairperson) DQAG (12-15 members) Nodal Officer DCMO/ADHO/ RCHO DQAG Teams 2-3 members

12. Setting up QA Mechanism The QA Program recommends the following steps: • The State should assist districts to setup a QA unit within DPMU • The DQAG should consist of 12 to 15 members • CDHO will be the Chair of DQAG • A team of 2-3 members will make a QA visit • Each QA team will visit 3 to 4 facilities per month • Review gaps and actions in monthly DQAG meeting • District health management should provide all logistic support to DQAG including POL for visits, computer, office space, stationary etc. • District health Society/Mission should supervises the QA activities • Allocate resources in DPIP for actions identified by DQAG

13. QA visit to CHC/PHC/SC The QA manual recommends the following planning for QA visit: • Each participating facility should be visited bi-annually • Prepare bi-annual visit plan, share it with DQAG members and facility MOs. • Confirm availability of facility MO and QA team members at least one day before the visit • Predefine and divide the assessment work at facility • Debrief the facility MO about assessment and prepare action plan • Within a week after visit, enter visit data, prepare summary report and place it before CDHO/CMO During Second Visit to Same Facility • Review gaps and actions of previous visit with MO I/C

14. Contents • Overview of Quality Assurance • RCH QA Mechanism • QA Experience from Gujarat • On going QA Activities in Six States • Lessons Learned • Place of QA for ARSH

15. Four Quarter QA visits in Dahod N=20 N=13 • Grade = Score • A = 76+% • B = 51-75% • C = 26-50% • D = 1-25% III - Quarter Visit IV - Quarter Visit N=20 N=22

16. Change in Input Scores

17. Selected MCH Process Indicators

18. Selected FP Process indicators

19. QA Scale-up in Gujarat • Commissioner and Secretary of Health appreciated the program and decided to scale-up in entire state • Scale-up in all 25 districts was planned in phased manner • A State Nodal Officer appointed to coordinate QA activities • QA budget allocated separately in state PIP • Decentralized approach suggested. Block level QA teams constituted and trained to conduct QA visits • FRONTIERS Program provided TA in scale-up

20. Scale-up Coverage • 1072 PHCs and 272 CHCs covered in entire state • 128 state and regional level officials oriented • 2261 providers of different level trained, including– • 38 District Program Coordinators and M&E Assistants • 263 DHOs, ADHOs and BHOs • 593 Block Health Visitors and Block IEC officers • 1234 CHC/PHC Medical Officer In-charges • 5 District statistical Assistants

21. Contents • Overview of Quality Assurance • RCH QA Mechanism • QA Experience from Gujarat • On going QA Activities in Six States • Lessons Learned • Place of QA for ARSH

22. QA Pilot in Six States • As part of NRHM, slightly modified version of QA checklists is being piloted by MoHFW in 7 districts of six states of India • Population Council is providing TA in one district each of Maharashtra and Karnataka. • UNFPA is providing financial and technical inputs for piloting in these states

23. Current Status • 80 and 100 QA visits have been completed during first round in A’nagar, Maharashtra & Tumkur, Karnataka. • Both input and process elements have shown significant service delivery gaps • On an average 28 and 43 actions have been identified at CHC/PHCs of A’nagar and Tumkur districts • A mechanism to review gaps and initiate actions has been established in both the districts • 61 percent and 43 percent of actions have been executed so far in A’nagar and Tumkur districts

24. Typical Examples of Gaps Observed At CHC/PHC • Training of providers in EmOC, RTI/STI, partograph use • Non-adherence of maternal and immunization service standards • Shortage of important equipments At Sub-centers • No display of citizen’s charter and other information • Poor waste management practices • Poor knowledge of IUD, OCP and ECP among ANMs Common to all • Short supply of medicines and contraceptives • Poor infection prevention practices • Poor maintenance of facilities • No proper updating of records • Non-availability of protocols and jobs-aids

25. Examples of Input Indicators - CHC/PHC

26. Examples of Process Indicators Observed- CHC/PHC Figures in bracket show the denominator

27. Preliminary assessment of QA Impact – Ahmadnagar

28. Contents • Overview of Quality Assurance • RCH QA Mechanism • QA Experience from Gujarat • On going QA Activities in Six States • Lessons Learned • Place of QA for ARSH

29. Lessons Learned • QA checklists considered useful in monitoring and improving quality of services • QA could be institutionalized within district health management • Greater state’s stake is required to resolve problems such as frequent rescheduling of QA visits, delayed initiation of district/state level actions etc. • Mechanism for monitoring actions need to be strengthened • Beside inputs focus should be put to address process gaps • TA for capacity building of districts/state required until it migrates from project to program mode

30. Contents • Overview of Quality Assurance • RCH QA Mechanism • QA Experience from Gujarat • On going QA Activities in Six States • Lessons Learned • Place of QA for ARSH

31. Possibilities for Including ARSH Services in QA • QA checklists already include many indicators which have been considered crucial under seven standards of ARSH strategy • AFCs will be an activity by same facility and human resources. However, infrastructure and services such as ARSH training, IEC material, outreach programs for community awareness need to be ensured. • Extending role of DQAG by including more people seems more feasible and cost-effective than making AFC QA a stand alone program. • However, AFC QA project should be first piloted separately to finalize QA tools and assess their usefulness.

32. Thanks FRONTIERS Program Population Council 53 Lodi Estate, New Delhi – 110 003 Tel: 24610913/E-mail: frontiers@popcouncil.org