1. Abt Associates Inc. in partnership with: Data Management Services Inc. Dillon Allman and Partners. LLC Family Health International Forum One Communications Global Microenterprise Initiatives IntraHealth International London School of Hygiene and Tropical Medicine O’Hanlon Consulting Population Services International Tulane University School of Public Health and Tropical Medicine Improving Quality in the Private Sector Approaches and Tools Jeffrey Barnes, MBA, Abt Associates Leah Levin, MPH, Abt Associates Mary Segall, PhD, RN IntraHealth International 31 May 2006

2. Presentation Objectives Why work in the private sector? Quality in the private sector: unique challenges, unique interventions Private Sector Quality Improvement (QI) package: steps and implementation Results from a recent pilot test in Uganda Next steps

3. Why The Private Sector? Donor resources unable to keep up with growing demand for RH/FP services Changing roles due to health sector reform Private health expenditures already substantial Often a preferred source of health care

4. Concerns about the private sector Profit motivation Equity of access, affordability Quality of care, lack of oversight

5. Perspectives Private sector experience may enrich public sector approaches QI work may build important links between public and private sectors and create synergy which has been missing

6. Private and commercial sectors: Integral to total health system

7. Private Health Services Utilization Overall: 60-80% of health care services in many developing countries are delivered in the private sector Viet Nam: In the lowest income quintile alone, 48% of ill respondents chose a private provider in 1997/1998.* India In 1998/1999 private services accounted for 56.5% of health services utilization in the most deprived households.** Uganda In rural populations, the private sector accounted for 44% of of medical services used.*** *Ha, Berman, & Larsen, 2002 **Srinivasan and Mohanty *** Uganda National Household Survey 1999/2000

8. Challenges in improving quality in the private sector Knowledge base comes from public sector experience Minimal supervisory structures in the private sector Preferred providers are often beyond the reach of accreditation/regulatory structures Improving quality may increase costs without increasing revenues Provider motivation

9. Need for a private sector QI tool QI tool should be: Adaptable to different providers Effective with minimal or no supervisory structure Proven effective in different contexts Easy to implement, acceptable to providers

10. How to approach quality in the private sector? Quality Panel Review: March 2005 Review of public sector approaches Adapting public sector approaches to the private sector: PSP-One ’ s approach

11. Private Sector Quality Improvement (QI) package: Contents Implementation Guide Steps 1 and 2 Review of Statistics Form Quality Improvement Self-Assessment Tool Step 3a: Action Plan for Provider Step 3b: Action Plan for Supervisors

12. Review of Statistics Form Collect data on key indicators to ascertain if the midwives ’ quality improvements are resulting in changes in health outcomes and service use Can use existing statistical forms if they exist

14. QI Self Assessment Tool Key quality dimensions o Physical Environment o Technical Competence o Continuity of Care o Management o Marketing o Business Practices Problem identification Using answers to create an action plan Quarterly use

15. Dimension #1 Physical Environment: This dimension refers to the facility ’ s ability to provide a safe environment for health care and examines equipment, supplies, and medicines in facilities and the condition of the clinic ’ s infrastructure.

16. Action Plans Action Plan for provider 70% of problems can be solved “ in house ” at low cost Action Plan review and scoring for supervisor Use in review meetings Prioritizing interventions Possible uses of scores Public private partnerships Contracting out Licensure and accreditation

18. Implementation Step 1: Set goals using Review of Statistics Form Time: 2 times per year Step 2: Assess Quality using QI Self Assessment Tool Time: Quarterly Step 3: Develop Improvement Plan using Action Plan Instrument Time: Quarterly Step 4: Enlist more help using Supervisor’s Tool Time: Monthly/Quarterly Purpose: help measure quality, determine gaps, and track improvements Purpose: collect data to determine if improvements result changes in health outcomes Purpose: help facilitate problem solving process

19. Pilot test Methodology in Uganda Discussion groups; content review and finalization Orientation meetings; training in use of tool Clinic visits; implementation testing

20. Pilot Test Results Rater reliability (Midwives appeared to be accurate in their self-assessments) Job aide Ease in problem identification and prioritization Public Private Partnerships positive response Use by other projects and quality directorate and PPPH office at MoH

21. Next steps Complete Training guide Conduct evaluation study in Uganda to determine usability and effectiveness to improve quality of services Adapt package for use by other cadres (physicians, pharmacists) Share experience with other projects and organizations