Improving Quality Assurance Capacity at Health Centers in Ghana Kerry Bruce MPH MA (Quality Health Partners), Richard E. Killian MCHA (Quality Health Partners), Cynthia Bannerman MBChB, MPH (Ghana Health Service) Presented at the APHA Meeting 6 November 2007

About the Quality Health Partners (QHP) Project Overview About the Quality Health Partners (QHP) Project History of Quality Assurance in Ghana QHP’s Interventions Results Conclusions Way Forward This evening I would like to tell you a little bit about the Quality Health Partners Project in Ghana, some of the history of quality assurance work in Ghana, QHP’s interventions specific to QA, our results and other upcoming research, our conclusions and say a little bit about the way forward.

Quality Health Partners Five year, USAID bilateral project in Ghana Managed by EngenderHealth; JHPIEGO and Abt Associates as partners Improving reproductive and child health in 30 target districts in 7 southern regions Work on Focus ANC, Safe Delivery, IMCI, Family Planning, Clinical care of HIV and AIDS, Malaria and Disease Surveillance QHP is a five year, USAID funded, bi-lateral assistance program. It is one of four projects started in 2004. QHP focuses on improving quality at the facility level. The Ghana Sustainable Change Project focuses on behavior change, the CHPS-TA project focuses on health at the community level – especially in remote areas and the SHARP project focus on HIV and AIDS. QHP is managed by EngenderHealth in partnership with JHPIEGO and Abt Associates. QHP works in 30 target districts in the seven southern regions, and works in a wide range of areas including maternal and child health, family planning, clinical care of HIV and AIDS and infectious disease surveillance.

Quality Assurance in Ghana 2002 – first Quality Assurance Manual for Ghana printed – (revised in 2005) Aimed at hospital level care 2005 first “sub-district” QA Manual printed Aimed at the health center level and below. These Ghana Health Service (GHS) manuals define quality, quality assurance, review its principles, standards in health care and how to monitor and implement QA programs The Ghana Health Service defines health care quality as: “the degree to which health care services meet the expectations of an individual or group.” In 2002, the GHS developed the first quality assurance manual for Ghana, which was subsequently revised and improved in 2005. Focusing initially on hospitals the GHS with limited donor support from DANIDA began to introduce quality assurance concepts, especially in the hospital setting. When the Quality Health Partners project was funded in 2004, plans to scale-up the introduction of QA themes, especially at the health center level, were developed In their 2005 Quality Assurance Manual, they describe the attributes that contribute to health care quality as including: Access to services Clean environment Availability of requisite equipment and supplies Qualified and competent staff Good staff attitude Adherence to professional standards Prudent use of resources Safety privacy and confidentiality Adequate information Good health outcomes Affordable charges.

QHP’s Interventions related to QA Region Target Districts Districts Trained in QA Ashanti 3 1 Brong Ahafo 2 Central 13 Eastern Greater Accra 1** Volta 5 ** Western 4 Since 2005 – QHP supported the development and roll- out of both the hospital and health centre level QA manuals at the District level. 337 providers and managers were trained by QHP / GHS since 2005. **In Volta Region and Greater Accra Regional and District Management teams and providers from key hospitals were trained. The whole district approach was not used. QHP’s strategy has been to support the development of the QA Manuals and the training for providers that accompanies the manual. A total of 337 providers have been trained in QA using the 2005 manual largely using a District based approach. In some of the Regions where we support only a few Districts, such as Eastern Region and Brong Ahafo – we have completed training. In some Regions, such as Volta and Greater Accra – they adopted a different approach, choosing to train senior managers first. QHP implements most of its programming through a sub-award process with the Regions. This provides the Regions with the autonomy to decide what will work best for them.

QHP’s Interventions related to QA Supported application of COPE© for reproductive health and ART services. Trained 402 providers and supervisors in facilitative supervision. Now working with GHS to develop an in-depth supervision and on-the-job training tool to improve quality of clinical supervision. To compliment QA training, QHP also supports training in facilitative supervision and COPE. Facilitative supervision training supports managers to improve their method of communication with those they supervise and stresses the need to make expectations clear. COPE© is an ongoing quality improvement (QI) process and set of tools used by health care staff to assess and improve the quality of care that they provide. Two assumptions inform the COPE process: Recipients of health care services are not passive patients waiting to be seen by experts, but rather are autonomous health care consumers, or clients, who are responsible for making decisions about their own health care and who deserve—indeed, have a right to—high-quality health care. Health care staff desire to perform their duties well, but without administrative support and other critical resources, they cannot deliver the high-quality services to which clients are entitled.

Objective Measuring Quality - Methodology In December 2004 – Baseline Assessment - census of facilities in the 30 targeted districts (n=157). Midterm Assessment September 2007 (n=193). Census of same facilities (plus additional facilities in the target area). Compare mid-term with baseline to identify and understand changes. For our baseline assessment and our midterm assessments, we used a “facility audit” tool to assess facilities in all areas of management, service delivery and provider knowledge. We use the results from these tools to compare changes since the inception of the project.

Number of facilities surveyed by type and region At baseline we surveyed a total of 157 facilities in the 30 target districts and at midterm there were 193 facilities, including more health centers in almost every region. Because health centers are not as well resourced as hospitals, if anything adding more health centers to our dataset should weaken the results.

Quality Assurance Attributes at Baseline and Midterm The total number of facilities that had a Quality Assurance team at baseline was 54. By the time of the midterm analysis 99 facilities had a functioning QA team – a statistically significant increase (p=.0016). In health centers 42.9% have a QAT. But we noticed that the caliber of staff assigned to the facility also affects whether they have a QAT or not. Where there is a Medical Assistant (MA) present at a health centre 68.8% have a QAT and where there is a medical assistant and a midwife 72.4% have a QAT. There are 20 facilities that have no MA or midwife. If these 20 facilities are excluded from the requirement for a QAT, 58.2% of facilities have a QAT. However, disappointingly the action orientation of these teams has not changed much since baseline with a total of 64.9% of the QA teams actually having a current Action Plan. QHP also tracks the number and percentage of facilities that have regular management meetings (defined as at least once per month) as a proxy for quality. This indicator improved marginally between baseline and midterm (p=.0676) – but notably many more of the health centers are now having monthly meetings. COPE has been conducted in 70 facilities – and there is a plan to support the use of COPE in more health centers in 2007-2008.

% of Facilities with a QA Team by Region In Regions where most of the participants from the target districts have been trained (Brong Ahafo and Eastern) there have been good results in establishing QA teams.

Methods of Quality Assurance used-Overall (unprompted) There have been significant increases (p<.001 for all variables) in the range of QA methods that providers report using in their facilities. This may be a direct result of the QA training that focuses on equipping attendees with analytical tools to monitor the quality of care in facilities.

Activities done by Supervisors during Supervision (reported by facilities) Overall providers reported better quality supervision at the facility level when compared with baseline for most indicators. A main component of QHP’s strategy has been to get supervisors out into the field to follow up on training, observe service provision and mentor staff in the field. A full 94% of facilities reported that they had external supervision in the past 6 months (p <.001).

Types of Supervision Activities Reported by RHMTs and DHMTs (Midterm) QHP also surveyed the Regional Health Management Teams and District Health Management Teams (n=37) on their activities related to supervision at midterm. The only area that supervisors did not report high levels of activity was in observing clinical work. This is an area that QHP plans to address in during the next year.

Supportive Management 90% of RHMT/DHMTs had staff who have been trained in facilitative supervision 77% of RHMT/DHMTs reported they have written plans for supervisory visits 94% of RHMT/DHMTs have supervisory checklists Mirroring the results in the previous slide, the RHMTs and DHMTs report that they have a good basis in training and generally are using tools and are planning for supervision.

Conclusions Can increase % of facilities with QA team when Provide QA training for a broad population of providers / managers at the District Level Follow up and support for new QA teams is essential to their continuing activity. QHP trained a broad population of providers in Districts where QA training took place. This broad population and the close follow-up and support from supervisors were key to increasing the number of QA teams. It is also clear that merely distributing the QA manual to Districts –without training is not effective for getting facilities to establish QA teams. More work needs to be done on ensuring that QA teams are not in name alone – but are functioning well and have current Action Plans.

Way Forward Continue QA training in Districts that have not yet benefitted. Follow up with facilities on the status of their Action Plans until updating and working with them is routine. Improve quality of In-depth-Supervision/On the Job Training QHP plans to conclude the QA training for Districts that have not yet benefitted by June of 2008. Training a wide swath of providers and managers in the QA methodology developed by the GHS seems to be an effective way of starting QA teams at the district and sub-district level. QHP will also be working with the Regional and District Health Management Teams to follow up training and provide support for efforts to improve quality. We also plan to use a recently conducted study on Provider Adherence to Standards to help us to better understand provider’s needs when introducing new standards or trying to improve existing standards – to work towards better quality. We are currently in the process of working with the GHS to develop a standardized clinical supervision tool for use in Maternal and Child Health service delivery units and also for family planning providers. This tool would serve as both a supervision tool – but also a guide for the supervisor to provide on-the-job training and mentoring to providers who are lacking in a skill on the day of supervision – to trying and reduce the need for costly centralized training that does not always yield the expected results.

Thank you! – Any questions?