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
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
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
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
RH Quality Framework for Assessment
RH facility
based Services
to be assessed
Family Planning
Maternity Care
RTI/STI &
HIV -VCT
INPUTS
PROCESS
 Building
 Clinic-wide
 Infra-
procedures
e.g.Schedules,
Hygiene,
Asepsis
 Technical
competence
 Client Provider
interaction
structure
 Equipment
 Personneltraining
 Supplies
OUTPUTS
 FP
method mix
 Complications
 Follow-up
 ANC/PNC
attendance
 Normal Deliveries
 Complications
managed
 Lab tests
 Case treatment
 Follow-up
Quality of Care Elements
 The manual identifies nine key elements to
measure the quality of services 
Five generic elements
 Four service specific elements
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
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?
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
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
Institutional Arrangements
State Health Mission
State QA Nodal
Officer
District Health Mission
DQAG (12-15
members)
Nodal Officer
DQAG
Teams
DHO/CMO
(Chairperson)
DCMO/ADHO/
RCHO
2-3 members
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
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
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
Four Quarter QA visits in Dahod
Baseline Survey
Grade D
8%
Grade A
0%
II - Quarter Visit
Grade B
8%
Grade C
0%
Grade B
50%
N=20
N=13
Grade C
84%
III - Quarter Visit
Grade C
0%
Grade = Score
A = 76+%
B = 51-75%
C = 26-50%
D = 1-25%
Grade A
50%
IV - Quarter Visit
Grade D
0%
Grade B
25%
Grade D
0%
Grade C
0%
Grade D
0%
Grade B
23%
N=20
N=22
Grade A
75%
Grade A
77%
Change in Input Scores
100
BL
QAV-2
QAV-3
Percent
75
50
25
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Selected MCH Process Indicators
100
90
85
80
percent
75
75
55
65
60
60
55
50
45
25
0
QA-1
QA-2
QA-3
ANC cards available and filled
Delivery record shows any normal delivery and complications
Any delivery performed between 8pm and 8am at the facility
Any low birth weight baby kept for 24 hours observation
Selected FP Process indicators
100
85
90
85
95
90
percent
75
50
35
25
23
15
20
0
QAG-1
QAG-2
FW records show OCP usage and new acceptance
Any IUD inserted at the facility in last 3 months
Any IUD acceptors screaned for STI with a lab test
QAG-3
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
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
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
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
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
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
Examples of Input Indicators - CHC/PHC
Percentage
A’nagar
n=40
Tumkur
n=34
A doctor trained in EmOC
63
21
A separate labor/delivery room
72
56
Complete delivery kit with scissor/blades, cord
ties/clamps and forceps available
92
85
Oxygen cylinder with tubing and wrench and
disposable masks available in working order
73
21
Proper waste disposal arrangements
70
59
All essential drugs for active mgmt of
infections/ complications in pregnancy
13
0
RTI/STI – management protocols available
25
18
Normal delivery guidelines available
58
53
Input Indicators
Examples of Process Indicators ObservedCHC/PHC
Process Indicators
Percentage
A’nagar Tumkur
OCP usage and new acceptance records are
maintained in last 3 months
45 (40)
79 (34)
Client Counseled on how method works
56 (34)
69 (13)
Women screened for signs of anemia
61 (36)
61 (23)
ANC women counseled on danger signs
29 (35)
40 (23)
Measels vaccine being administered at 9-12
months of age
63 (33)
63 (32)
Records show children are managed for RTI
35 (40)
40 (34)
Temperature record card maintained and
updated
89 (37)
88 (33)
Providers wore gloves when required
68 (23)
79 (21)
Figures in bracket show the denominator
Preliminary assessment of QA Impact –
Ahmadnagar
100
86
Percent
75
89
92
76
71
61
79
71
84
80
69
57
50
25
First QA visit
Second QA visit
0
Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6
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
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
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
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.
Thanks
FRONTIERS Program
Population Council
53 Lodi Estate, New Delhi – 110 003
Tel: 24610913/E-mail: [email protected]