Strengthening Systems to Ensure Quality Family Planning Services

An IUCD training demonstration.

Purpose: To help systematically assess existing mechanisms / systems to ensure continuous quality family planning (FP) services to the clients.

Audience:

  • Chief Medical and Health Officers (CMHO/CDMO/CMO)
  • District Quality Assurance Committee (DQAC) / District Quality Assurance Unit (DQAU) members, Chief Medical Superintendents (CMS)
  • Urban Health and FP Nodal Officers
  • Facility-in-Charges and Medical Officers in Charge (MOIC)
  • District Program Managers (DPM)
  • Urban Health Coordinator/Assistant Program Manager, NUHM
  • Technical organizations (The Federation of Obstetric and Gynecological Societies of India (FOGSI), District Obstetrics and Gynecological Societies, India Medical Association (IMA) members, etc.
  • Representatives of relevant NGOs

Background: Quality Assurance (QA) is a dynamic mechanism of objectively assessing and facilitating the conversion of inputs and processes into the expected outputs and outcomes with quality ultimately borne out by the client’s satisfaction. It includes all activities involved in “defining, designing, assessing, monitoring and improving the quality of healthcare”. QA is about preventing errors in healthcare service delivery by deploying a Quality Management System and prevention and safeguarding activities. The National Urban Health Mission (NUHM) launched in 2013, specifies dedicated attention and focus on bringing quality assurance in services including family planning services across all service delivery points including urban primary health center (UPHC).

The National Quality Assurance (NQA) program provides guidelines towards ensuring quality in family planning services. To ensure adherence to NQA standards, Quality Assurance Committees/Units are formed to monitor all types of facilities including district hospitals, urban community health centers (UCHC), and urban primary health centers (UPHC). They are mandated to objectively and systematically monitor and evaluate FP services as per GoI guidelines; resolve identified problems; and improve overall quality of services and client care.

The capacity of most of these QA Committees/Units needs regular strengthening and ongoing follow-up.

Structure of QA System in India’s Public Health Sector

  • National (Central Quality Supervisory Committee)
  • State (State Quality Assurance Unit & State Quality Assurance Committee (SQAC))
  • District (District Quality Assurance Unit & District Quality Assurance Committee)
  • Facility (Quality team)

 

Evidence of Effectiveness

Supported by the Government of India, Population Services International’s (PSI’s) Expand Access to Quality to Broaden Method Choice (EAQ) seeks to increase the use of long acting reversible contraception (LARC) and long acting permanent methods (LAPMs) by expanding choice and access among men and women residing in urban slums of 32 districts of Uttar Pradesh through private sector engagement. EAQ identified that an important criterion for private sector engagement is to ensure that the private sector facilities meet minimum standards as defined by national guidelines and have an accreditation certificate from an authorizing body, such as District Quality Assurance Unit (DQAU) & District Quality Assurance Committee (DQAC). However, it was found that the authorizing bodies at the district level were inactive in some places or functioning sub-optimally. Thus, under the EAQ project, DQACs/DQAUs were activated and formed wherever they did not exist.

The EAQ project implemented activities with 27 DQACs, which were activated in Uttar Pradesh from January 2016 to December 2017. Several meetings were organized, where quality-related issues and quality assurance plans for the districts were discussed. The remaining 48 districts received technical support in the form of guidance only to activate DQACs. These efforts resulted in 1,040 private facilities receiving accreditation by the government after DQAC visits and certification.

Guidance on Implementation of Quality Assurance (QA)

Continuous assessment of quality services provided by healthcare providers is fundamental to ensuring client satisfaction. The sub-committee of DQACU responsible for ensuring quality standards of family planning services is the Family Planning (FP) sub-committee. The following steps need to be carried out to ensure QA for family planning services in both public and private sectors.

The FP sub-committee would comprise of:

  • District Magistrate (Chairperson)
  • Chief Medical Officer/District Health Officer (Convener)
  • District Family Welfare Officer/RCHO/ACMO/equivalent (Member Secretary)
  • Empaneled gynecologist from public institutions
  • Empaneled surgeon from public institutions
Identify if District Quality Assurance Committee Exists

If it does not exist, then form one by nominating members per the GOI guidelines (refer to the above box). Orient the members on their roles and also on the national family planning standards.

Develop a Plan of Action

Develop a plan of action per terms of reference (TOR) of the District Quality Assurance Committee, which can be found on page 17 of the MoHFW’s Quality Standards for the Urban Primary Health Center (2015). The plan should include the frequency of visits, quarterly meetings of the District Quality Assurance Committee, facility visit, client exit interview and observation of service procedures as per the TOR.

Ensure Implementation of the Plan & Follow-Up

Involve development partners working in the district in the QA process.

Conduct Sensitization Sessions

All facility service providers, including public and private doctors, should be engaged in QA sensitization sessions, with a focus on FP services.

Plan & Coordinate Interface Meetings

Meetings with private providers and key stakeholders in the government, including DQAC members, should be planned and carried out.

Conduct a Baseline Assessment

Involve different departments of a facility in a baseline assessment based upon the standard tool/checklist developed by the government (refer to the revised Kayakalp checklist, NQAS checklist for PHC).

Organize DQAC Meetings

Make sure DQAC meetings include a defined agenda. Make an action plan for structured visits of DQAC to the facilities, and develop plans for other QA activities. During the facility visits, ensure a regular facility audit is conducted by DAQC members related to the infrastructure and supplies, record review, procedure observation and client exit interview. If a facility meets the quality standards, then it is scored or certified/accredited (for private sector).

Regularly Monitor the Action Plan

Regularly monitor to see whether meetings, DQAC visits, and client exit interviews are occurring. Analyze the checklist completed by DQAC members to assess accuracy of steps being followed (see Quality Standards for the Urban Primary Health Center, MoHFW, 2015, page 53-55).

Regularly Share Observations

Share observations of the visit and audit findings in DHS or DQAC meetings.

Roles and Responsibilities 

Role
Responsibility
CMHO/CDMO/CMO/CS
  • Ensure the formation of FP sub-committee
  • Conduct regular meetings of the sub-committee with the support of DPM/Nodal Officer – Urban
  • Ensure that private facilities, UPHCs providers or MOI/Cs are included in the meetings respectively
  • Address all the issues identified by providers including private provider
  • Monitor the progress according to the planning and expenditure benchmarks
  • Ensure regular updates of DQAC information on FP portal
  • Keep SQAC posted on the development and support required
  • Conduct periodic visit to facilities (both public and private) as per government guidelines
  • Build the capacity of the program officers and DQAC members to enable them to provide direction and support for improving quality of services
Nodal Officer
  • Ensure supply chain
  • Coordinate between DQAC members and facilities for implementation of activities
Facility/Medical Officer-In-Charge
  • Formation of quality team at the facility (refer to list in Standards & Quality Assurance in Sterilization Services Nov 2014, page 49).
  • Ensure regular quality meetings at the facility to improve quality of services
  • Assess the HR requirements and send the request to the CMO as per need
  • Sensitize facility team to quality assurance
  • Ensure infection prevention guidelines
  • Report and manage complication cases as per guidelines

Monitoring Benchmarks Management

The CMHO/CDMO/CMO/CS with assistance from the Nodal Officer Urban Health and FP / DPM or other team members should regularly monitor the following indicators:

  • Frequency of quality team meetings and other activities at facility level
  • Number of urban health facilities including UPHC and urban private accredited facility visited at least once by DQAC members annually
  • Number of facilities meeting quality standards
  • Monthly and quarterly review of physical and financial progress of all approved FP activities
  • In case of adverse event/death/complication, immediate reporting – maximum up to 24 hours to DQAC.
  • Ensure reporting to SQAC in case of adverse event

Facility Level

Facility level monitoring and evaluation through a three to four-member Quality Circle comprising of MOI/C, Storekeeper, Public Health Nurse and Community Mobilization Officer.  MOI/C shall lead the group, taking specific responsibility for the technical & managerial capacity of the group, clinical and related para-clinical protocols and guidelines.  Storekeeper shall represent facility management issues.  Public Health Nurse shall be responsible for ANMs/ASHAs/ IEC/BCC .  Social (Community) Mobilization Officer shall be responsible for the community-based activities, ASHAs, RKS, HSCs and inter-sectoral convergence.

Cost Elements

financial support for these activities under Quality Assurance (FMR Code 13), which comprises of Quality Assurance (FMR Code- 13.1), Kayakalp (FMR Code-13.2) and other activities (13.3). The table below illustrates the manner in which cost elements are provisioned in the government PIP, thus providing guidance on where to look for elements related to particular task for quality assurance.

Cost Elements FMR Code
Quality Assurance 13.1
Quality Assurance Implementation (for traversing gaps) 13.1.1
Quality Assurance Assessment (State & district Level assessment cum Mentoring Visit) certification & recertification (State & National Level) 13.1.2
Miscellaneous Activities (incentives only) 13.1.3
Any other (please specify) 13.1.4
Kayakalp 13.2
Assessments 13.2.1
Kayakalp Awards 13.2.2
Support for Implementation of Kayakalp 13.2.3
Contingencies 13.2.4
Swachh Swasthya Sarvatra 13.2.5
Any other (please specify) 13.2.6
Any other activity (please specify) 13.3
IEC activities under Mission Parivar Campaign 11.6.5
Dissemination of family planning manuals and guidelines 12.3.1
Printing for Mission Parivar Campaign 12.3.2
Processing accreditation/ empanelment for private facilities/providers to provide sterilization services 15.1.1
Family planning QAC meetings 16.2.3

Source NHM PIP Guideline, 2018-19

Sustainability

Linking costs of quality assurance activities to PIP and PIP resource mobilization tool is the key to making these activities sustainable. After action plan is developed (step 3), subsequent assessments by various stakeholders – facility in charges, district health administration, state and external certification body – would need to be undertaken using the same tools, so that there is clarity on expectations and objectivity in the assessment is maintained. This ensures in-house ownership, which is important for sustainability of any quality assurance Initiative.

Discussion of the planning and regular monitoring of these activities in the monthly CMO/CMHO/CDMO meetings is another important step toward institutionalization and sustainability of these quality assurance activities. Regular and strict monitoring of QA of accredited private sector facility is importance for long-term sustainability.

Broadly focus on facility-based interventions and involve technical organizations and development partners to further ensure sustainability.

Disclaimer: This document is based on the learnings collated from Urban Health Initiative (supported by BMGF), Health of the Urban Poor (supported by USAID) and Expanded Access and Quality (EAQ) to broaden method choice in Uttar Pradesh (supported by BMGF). This document is not prescriptive in nature but provides overall guidance of how this particular aspect was dealt with in these projects for possible adoption and adaptation.