QI implementation in Hyderabad – Group photo of TCI Team with Government Health Staff

In close coordination with district governments, The Challenge Initiative (TCI) has been supporting 15 active districts in Pakistan in the implementation of high-impact interventions. To support this effort, TCI introduced quality implementation (QI) checklists grounded in global core components and adapted to the Pakistan context.

Beginning in early 2024, QI checklists were rolled out in 328 facilities within the Health and Population Welfare Departments in Karachi and Hyderabad in Sindh province. The checklists assess family planning service delivery against agreed-upon quality parameters, identify gaps, strengthen documentation, and inform facility action plans that improve services and strengthen the wider health system.

Early Findings and Priority Gaps

During the initial stages of QI implementation, several gaps emerged:

• Refresher trainings for community health workers (CHWs) had not been conducted for an extended period.
• Clinical guidelines and checklists for family planning counseling and services, including implants and IUCDs, were not consistently available.
• Lady Health Workers (LHWs) were not regularly receiving quarterly supportive supervision visits from Lady Health Supervisors (LHSs).
• Manual registers and digital ECR entries often lacked key information, including CNICs, contact numbers, referral details, time since last outcome or pregnancy, and client category.
• Service providers had not received refresher training in years, particularly on long-acting family planning methods.
• Many facilities were not holding monthly meetings, and minutes were not recorded in the DHIS meeting register.
• The Lot Quality Assurance Sampling (LQAS) tool was not being used by the Medical Superintendent.
• Bin cards were not consistently updated, and medicines were not arranged by expiry date.

These gaps were documented and incorporated into facility-level action plans.

Progress Through Quarterly QI

With ongoing TCI technical assistance and the engagement of district-led master coaches in the quarterly QI process, gradual improvements became evident in facility performance and QI scores. One key area of focus was strengthening monitoring reports that track the performance of LHWs and LHSs. The QI team, comprising relevant government officials and TCI staff, observed measurable progress over time.

The rollout of QI checklists has played an important role in ensuring that high-impact interventions, along with broader health system strengthening efforts, align with established quality standards. TCI Pakistan has also built the capacity of city managers to understand QI objectives and indicators, enabling them to coach local government teams and service providers and sustain quality improvements.

Using Data for Decision-Making

Regular data for decision-making (D4D) meetings at the district level have been critical to sustaining momentum. During these meetings, QI performance of facilities, LHWs, and LHSs is reviewed. This routine review has contributed to increased uptake of family planning services. Clinical records are now maintained more accurately, DHIS tools are used more effectively, follow-up action plans are discussed consistently, and meeting minutes are documented and tracked to strengthen accountability.

Dr Abdul Kabeer Kolachi, DHIS Coordinator from the Sindh Government in Hyderabad, explained the importance of QI in his own words:

QI Implementation in Karachi, Sindh.

Due to TCI’s support and implementation of QI, the checklist is wisely developed to never leave any corner unattended. There is an attention to detail so it has minimized the errors to zero, services have been improved – specifically, data recording and staff performance – and the results are visible in our monitoring reports.

Dr Aneela Noor, Deputy District Health Officer RMNCH East, added:

Over the past two years, we’ve seen a real change because of the QI process. Our teams are more confident, better organized, and truly understand the importance of doing things the right way. From record-keeping to family planning services, everything has become more structured and accountable. The best part is seeing how staff have started to take ownership; they don’t wait for someone to remind them anymore. This approach has really helped us build a stronger, more reliable health system in our district.

Strengthening Data Quality and Service Performance

Use of LQAS, a DHIS data validation tool, has improved data accuracy, completeness, and accountability among facilities and district health staff. This has enabled the health system to better track service delivery outcomes and client uptake trends.

Percent of facilities achieving a QI benchmark score of 75%.

Although the Health and Population Welfare Departments in Sindh already had functional Monitoring and Evaluation (M&E) systems with digital tools and structured field monitoring mechanisms, the introduction of QI checklists for interventions has been well received. These checklists are now being integrated to complement and reinforce existing systems. Their use has contributed to sustained improvements in both service delivery and system-level performance.

The capacity and performance of community health workers have improved through ongoing training, coaching, and supportive supervision. Uptake of postpartum family planning (PPFP) has increased due to stronger counseling, improved data recording, and better integration of family planning services across maternal and child health contact points. In addition, the completeness and accuracy of facility-level data have improved through structured follow-up and stronger accountability.

District-Level Gains

QI processes at the facility level have also strengthened monitoring and supervision at the district level. The structured quarterly QI approach has generated clear benefits for district offices: more reliable reporting, renewed use of LQAS, improved service delivery coverage, and reinforced supportive supervision practices. Together, these improvements are enabling district teams to use more accurate and timely information for effective decision-making and planning.