TCI University Toolkit: Services & Supply
Health Facility Strengthening
What Is It?
Improving the overall ability of a public or private health facility to provide high-quality family planning services. Health facility strengthening includes:
- Facility assessment
- Management of human, physical and material resources
- Quality assurance and quality improvement
- Performance monitoring
- Compliance with national policies and protocols
- Management information systems (MIS)
Other related approaches, such as skilled providers, whole-facility orientation and commodity security, are covered in more detail elsewhere on this site. Health facility strengthening can focus on several of these aspects or just a few.
How Did Kenya Strengthen Health Facilities?
In Kenya, Tupange strengthened facilities through many approaches including:
Nigeria’s Systematic Process for Strengthening Health Facilities
When the Nigerian Urban Reproductive Health Initiative (NURHI) began in 2009, the project found a family planning service delivery system in collapse. Government health facilities were poorly staffed and equipped, and they were riddled with contraceptive stockouts. Many couples were getting family planning services from patent medicine vendors (PMVs) or pharmacists.
NURHI followed a systematic process for strengthening facilities. First, the project defined and selected high-volume health facilities, including pharmacies and PMVs. Then, they conducted participatory assessments of all the selected facilities. Following the assessments, the project and the facility jointly developed a customized performance improvement plan for each facility. These plans defined targets, actions to be taken, and investments required. NURHI supported the implementation of these plans, which often reflected the need for improvement in multiple areas. The project monitored progress toward the performance improvement plan each quarter.
What Are the Benefits?
- Increases client satisfaction with services
- Provides a conducive working environment for health care workers
- Ensures high-quality services are being delivered in a friendly, welcoming, professional environment
- Improves the ability to identify areas in need of improvement and ways to better serve clients
How to Implement?
Define the criteria of facilities to target for strengthening
- Criteria could include sites that serve a large number of clients, underperforming sites that serve a large catchment area, or sites that serve a particular function. NURHI targeted public or private sites that had the highest volumes of antenatal, delivery and immunization clients. Most were tertiary or teaching hospitals, secondary-level facilities or general hospitals, military hospitals and hospitals that provide free maternity services.
- Decide if you will include only public-sector sites or some combination of public and private sites. India’s URHI project of engaging the private sector saw evidence of increased uptake of FP services associated with an increase in the number of empanelled providers and accredited facilities under the Hausala Sajhedari initiative of the Government of Uttar Pradesh.
- Depending on available resources, you may need to prioritize the criteria. This will enable you to target certain key facilities if you are not able to work with all of the facilities.
Select the facilities
- Prepare an inventory and a simple map of all the sites in a particular geographic area.
- Using data, identify the sites that you wish to strengthen.
Conduct participatory assessments of the selected sites
- See a sample facility assessment tooI.
- Use the assessment as a baseline against which to measure progress.
- Discuss the results of the participatory assessments in meetings with the appropriate government officials and representatives from the health facilities.
- Discuss ways to address gaps identified in the assessments.
In addition to performance improvement plan activities, facilities should be adhering to all relevant national guidelines and protocols. Examples of protocols from Nigeria include: National Service Protocols for Family Planning Family Planning Performance Standards
Create a performance improvement plan
- Together with the facilities and appropriate government officials, develop a performance improvement plan which includes standards, targets, and status for each facility. This may require a series of planning sessions, but can result in a framework for organized monitoring of all facilities.
- The performance improvement plan should define targets, actions to be taken and necessary budget.
- Establish clear timelines, roles and responsibilities, including how you will monitor and update the performance improvement plan.
- Share the final performance improvement plans with appropriate government authorities so that actions and costs can be included in work plans and budgets.
Support implementation of the performance improvement plan
- Each plan will be different. However, most performance improvement plans will include common TCI approaches and activities such as:
- Training of skilled providers and perhaps including on-the-job training
- Procurement and distribution of equipment
- Contraceptive commodity security
- Provision of guidelines, communication materials and reference materials
- Continuous supervision and mentoring
- Integration of family planning with other services
- Family planning outreach services or mobile service delivery
- In addition to performance improvement plan activities, ensure each facility is maintaining routine record-keeping and reporting, so you have good-quality data on which to base your decisions.
Monitor and replan
- Conduct regular (quarterly) service utilization reviews.
- Collect monthly family planning service statistics.
- Use other monitoring tools to track progress against the targets set in the performance improvement plan. Examples of monitoring tools from Nigeria and Kenya include:
- Update the performance improvement plan as necessary, at least annually.
What Is the Evidence?
In Kenya, health facility strengthening in the Tupange program contributed to:
- Increased client satisfaction with services offered by the health facilities as evidenced in the client exit interviews report.
- Improved contraceptive method mix, with long-acting and permanent method use on the increase (Kenya Endline Service Delivery Point Survey 2014: Table 3.17, Provision of Modern Methods at Baseline and Endline; Kenya Endline Household Survey 2014: Figure 6.1, Current contraceptive use among all women ages 15-49 at baseline and endline, by city)
- Active involvement of work improvement teams in monitoring quality of services in the facilities.
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What are some possible approaches to strengthening health facilities?CorrectIncorrect
It is important to define the criteria of facilities to target for strengthening. This may include whether you will target sites that serve a large number of clients or underperforming sites that serve a large catchment area. It may also include specifying if your focus will be on only public-sector sites or some combination of private and public-sector.CorrectIncorrect
In Kenya, health facility strengthening in the Tupange program contributed to:CorrectIncorrect
Health facility strengthening is an ongoing process that is never fully finished; there are always ways to improve quality. At the beginning, set targets for minimum standards of quality. Later in the process, raise the standards to a higher level.CorrectIncorrect
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- Ensure good record-keeping and data, which are essential for measuring the performance of a health facility.
- Conduct advocacy with government health officials to ensure health facility strengthening is included in appropriate government work plans and budgets.
- Organize quality improvement committees in each facility and convene monthly meetings to discuss quality and take steps to maintain high standards of management, facility upkeep and service delivery.
- Health facility strengthening is an ongoing process that is never fully finished; there are always ways to improve quality. At the beginning, set targets for minimum standards of quality. Later in the process, raise the standards to a higher level.
Tools Related to This Approach
- East Africa: Supportive Supervision Checklist for Community Health Units
- Facility Assessment Tools
- Monitoring for Health Systems Strengthening Template
- Nigeria: Health Systems Strengthening Template
- Nigeria: National Service Protocols
- Supervision Checklist for Level One Service
- Supportive Supervision Tool for Reproductive Health Services
- TCI Performance Improvement Assessment