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 1.Overview of Quality Assurance 2.RCH QA Mechanism 3.QA Experience from Gujarat 4.On going QA Activities in Six States 5.Lessons Learned 6.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 RH facility based Services to be assessed INPUTSPROCESSOUTPUTS Family Planning Building Infra- structure Equipment Personnel- training Supplies Clinic-wide procedures e.g.- Schedules, Hygiene, Asepsis Technical competence Client Provider interaction FP method mix Complications Follow-up Maternity Care ANC/PNC attendance Normal Deliveries Complications managed RTI/STI & HIV -VCT Lab tests Case treatment Follow-up

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 1.Overview of Quality Assurance 2.RCH QA Mechanism 3.QA Experience from Gujarat 4.On going QA Activities in Six States 5.Lessons Learned 6.Place of QA for ARSH

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

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 1.Overview of Quality Assurance 2.RCH QA Mechanism 3.QA Experience from Gujarat 4.On going QA Activities in Six States 5.Lessons Learned 6.Place of QA for ARSH

15. Four Quarter QA visits in Dahod Grade = Score A = 76+% B = 51-75% C = 26-50% D = 1-25% III - Quarter Visit IV - Quarter Visit N=13 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 1.Overview of Quality Assurance 2.RCH QA Mechanism 3.QA Experience from Gujarat 4.On going QA Activities in Six States 5.Lessons Learned 6.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 Input Indicators Percentage A’nagar n=40 Tumkur n=34 A doctor trained in EmOC6321 A separate labor/delivery room7256 Complete delivery kit with scissor/blades, cord ties/clamps and forceps available 9285 Oxygen cylinder with tubing and wrench and disposable masks available in working order 7321 Proper waste disposal arrangements7059 All essential drugs for active mgmt of infections/ complications in pregnancy 130 RTI/STI – management protocols available2518 Normal delivery guidelines available5853

26. Examples of Process Indicators Observed- CHC/PHC Process Indicators Percentage A’nagarTumkur OCP usage and new acceptance records are maintained in last 3 months 45 (40)79 (34) Client Counseled on how method works56 (34)69 (13) Women screened for signs of anemia61 (36)61 (23) ANC women counseled on danger signs29 (35)40 (23) Measels vaccine being administered at 9-12 months of age 63 (33)63 (32) Records show children are managed for RTI35 (40)40 (34) Temperature record card maintained and updated 89 (37)88 (33) Providers wore gloves when required68 (23)79 (21) Figures in bracket show the denominator

27. Preliminary assessment of QA Impact – Ahmadnagar

28. Contents 1.Overview of Quality Assurance 2.RCH QA Mechanism 3.QA Experience from Gujarat 4.On going QA Activities in Six States 5.Lessons Learned 6.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 1.Overview of Quality Assurance 2.RCH QA Mechanism 3.QA Experience from Gujarat 4.On going QA Activities in Six States 5.Lessons Learned 6.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