Improving the Quality of Family Planning Services Throughout Bhopal and Beyond
Contributors: Shafique Khan, Parul Saxena, Prabhat Kumar Jha
In August 2018, India’s Challenge Initiative for Healthy Cities (TCIHC) learned that quality assurance visits were not happening at the urban primary health centers (UPHCs) in Bhopal, Madhya Pradesh. To address this and support the improvement of quality services at UPHCs, TCIHC worked with the health department to introduce a quality assessment (QA) checklist for family planning services (adapted from various national-level quality checklists).
TCIHC recommended placing two Field Program Service Assistants (FPSAs) in each facility. FPSAs are qualified nurses who can provide coaching to facility staff on contraceptive technology, infection prevention practices and quality assurance protocols. TCIHC explained the role of FPSAs and the concept of a quality improvement (QI) team to the Chief Medical Health Officer (CMHO) of Bhopal to gain his support for them providing coaching and overseeing quality parameters for family planning services. In September 2018, the CMHO issued a letter to the 20 TCIHC-supported urban primary health facilities (including UPHCs and civil dispensaries) allowing FPSAs to support QA.
Following this order, TCIHC facilitated the formation of QI teams in the 20 TCIHC-supported facilities. These QI teams organize facility-level internal meetings to review quality issues and gaps documented by the FPSA in the QA checklist. In each QI team meeting, a time-bound action plan is developed based on identified gaps that notes who is responsible for each action step. Some gaps identified include the scarcity of equipment, dustbins, gloves, storage cabinets, partition curtains, water supply issues, etc. Addressing these gaps requires approval from the health department to purchase these items, which can be a time-consuming procurement process.
To accelerate the process, TCIHC and the FPSAs shared all the QA checklist findings across the 20 facilities with the CMHO, Urban Nodal Officer, District Program Manager and Assistant Program Manager of Bhopal in January 2019. This compilation of gaps across 20 facilities intrigued the CMHO who decided to form a team that included National Urban Health Mission (NUHM) officials, the TCIHC team manager and FPSAs that would use the TCIHC QA checklist to assess gaps and needs in other UPHCs as well. As a result, the team submitted a compiled list to the CMHO for items to be procured for 31 urban facilities (20 TCIHC-supported facilities and 11 other facilities). TCIHC followed up with the CMHO’s office to ensure the items totaling $85,000 would be procured.
Apart from procurement, the QA checklist also strengthened quality aspects of the facilities such as:
- Training of service providers on IUCD insertion and injectable contraceptive
- Displaying the charter of client rights
- Ensuring supply of family planning products
- Establishing separate counseling corners
- Ensuring running water supply
- Ensuring hand washing facilities and functional toilets
- Ensuring follow-up cards for IUCD/Antara, etc.
These quality improvement measures have contributed to a 53% increased uptake of family planning services comparing health management information system (HMIS) data for the quarter before the assessment, January to March 2019, to April to June 2019, when the QA gap assessment and procurement was completed.
The FPSA intervention has clearly demonstrated that near to real-time data on facility-based input-output indicators is possible through such an intervention. The data from the analysis of these checklists helped TCIHC and the District Program Manager bring these issues to the attention of the CMHO and DQAC and ultimately get them resolved.
“I am still amazed how a simple QA checklist became the reason for how we improved the quality indicators of urban facilities,” said the Assistant Program Manager of Bhopal. “Quality improvement is not a static concept; hence, we intend to continue these processes to improve quality of health care as it is essential for increasing the client’s trust and satisfaction.”
As of June 2019, TCIHC’s demonstration and scale-up of its proven QA approach has resulted in the formation of 496 of 508 QI committees at TCIHC-supported facilities. Over the last 10 months, 64% of these were certified by the DQAC to provide family planning services across 31 TCIHC-supported cities.