Following are POPLINE records corresponding to selected citations in the bibliography of Family Planning Programs: Improving Quality (Population Reports J-47). Only the items that were particularly useful in the preparation of this issue of Population Reports are presented here.

25.
DOCUMENT NUMBER: PIP/116530
AUTHOR: Ben Salem B ; Beattie KJ
TITLE: Facilitative supervision: a vital link in quality reproductive health service delivery.
ABSTRACT:
A transition to a facilitative style of supervision is being implemented at AVSC sites in Bangladesh, Kenya, Tanzania, Zimbabwe, and Uganda, with consequent improvements in service quality. This approach emphasizes mentoring, joint problem solving, and two-way communication between the supervisor and the supervised. Supervisors are viewed as essential intermediaries who can facilitate the implementation of institutional goals and local-level problem solving. The conventional approach of scrutinizing individual performance and assessing end results is replaced by an emphasis on anticipating and preventing problems. Four key concepts underlie this strategy: 1) the supervisor is a catalyst for quality improvement; 2) joint problem solving, with full staff participation, and the use of simple, practical tools will foster the quality improvement process; 3) facilitative styles of communication and support (e.g., mentoring and group discussion) are preferable; and 4) supervisors must have technical knowledge for the duties they are to perform and know how and where to gain additional support. Family planning program supervisors must address needs in the areas of management, supplies, site infrastructure, information, and training. In Africa, AVSC used a three-stage process (introduction of the concept, description of the quality assurance improvement process, and training in specific skills) to introduce facilitative supervision to selected family planning programs.
SOURCE: New York, New York, AVSC International, 1996 Aug. 19 p. (AVSC Working Paper No. 10)

33.
DOCUMENT NUMBER: PIP/098791
AUTHOR: Bertrand JT ; Magnani RJ ; Knowles JC
TITLE: Handbook of indicators for family planning program evaluation.
ABSTRACT:
This handbook of indicators for family planning (FP) program evaluation was compiled with the following objectives: 1) to differential between the need for programmatic and the population-level indicators, 2) to compile the most useful indicators in a single volume, 3) to provide definitions which will enhance the consistent use of the terms, and 4) to promote the evaluation of programs by increasing familiarity with the indicators and making them easier to use. The handbook was specifically designed to benefit FP administrators and managers, the staff of international FP agencies, in-country evaluation specialists, and applied FP researchers and demographers. In addition to the above, the overview presents a list of contributors to the handbook and information on the use, organization, and conceptual framework of the handbook; the types of indicators (input, process, output, and outcome); sources of data; scoring of indicators; and anticipated update of the handbook. Chapters 2-9 present the indicators which measure the policy environment, service delivery operation, FP service outputs, demand for children, demand for FP, service utilization, contraceptive practice, and fertility impact. Chapter 10 is a discussion of future steps in the development of indicators for FP evaluation. The handbook also provides a summary list containing all of the indicators, a list of acronyms, references, and the following appendices: a listing of all indicators by primary source of data; indicators for evaluating the management functional area; indicators of quality of care in FP programs; indicators for evaluating program use of operations research; and an illustration of the calculation of unmet need.
SOURCE: Chapel Hill, North Carolina, University of North Carolina at Chapel Hill, Carolina Population Center, Evaluation Project, [1994]. 218 p. (USAID Contract No. DPE-3060-C-00-1054-00)

53.
DOCUMENT NUMBER: PIP/118655
AUTHOR: Bruce J
TITLE: Fundamental elements of the quality of care: a simple framework.
GENERAL NOTES: A slightly expanded version of this paper was published originally as a Population Council Programs Division Working Paper, No. 1 (May 1989).
ABSTRACT:
A framework for analyzing quality of family planning services is offered. Quality is a property that all programs have. The framework is made up of 6 parts: 1) choice of methods; 2) information given to clients; 3) technical competence; 4) interpersonal relations; 5) follow- up and continuity mechanisms; and 6) the appropriate "constellation" of services. Switching contraceptive methods is common. The ability of people to switch satisfies them. First use with temporary contraception methods is usually under 2 years. Having different contraceptive methods helps the program respond to the individual's need. Choice is not possible without an adequately developed delivery system. A positive relationship exists between a wide range of methods being available and contraceptive prevalence rates. Of Indonesian client who had reported not receiving the contraceptive method that they wanted, 85% discontinued within the year. Of those who got the method that they wanted, the discontinuation rate was 25%. Clients who wanted to practice contraception will be discouraged if not given information that can be used, or if the method is not available. How much contraception information should be given to the client? Enough so that they know that these are choices and that methods can be changed. There appears to be poor knowledge among clients of use, risks, and benefits of contraceptives. Many different monitoring technics are needed to analyze technical competence. The disparity between standards of competence in the West and what is found in the field should be addressed. Interpersonal relations is the affective content of the provider/client transaction. The characteristics of programs and clients have changed since the idea of follow-up was first brought about. The appropriate constellation of services should respond to clients rather than some artificial demarcation. Ways in which the framework may be used as an analytical and practical tool are discussed. Quality can be seen from the structure of the program, the service- giving process, and the outcome of care. The outcome of care consists of knowledge, behavior, and service satisfaction. (author's modified)
SOURCE: STUDIES IN FAMILY PLANNING.. 1990 Mar-Apr;21(2):61-91.

65.
DOCUMENT NUMBER: PIP/118500
AUTHOR: Campbell B ; Adjei S ; Heywood A
TITLE: From data to decision making in health: the evolution of a health management information system.
ABSTRACT:
This book focuses on self-assessment and action related to monitoring and supervision of a health management information system (MIS). MIS is intended to address the problem of overburdened health workers collecting quantities of useless or unused information as well as the scarcity of vital data available for analysis or managerial planning. The case study is detailed of the transition from a traditional reporting system to MIS in three regions of Ghana. The first chapter addresses reasons for implementing MIS. Chapter 2 describes the project design, including process and objectives. Chapter 3 explores the tools used for planning and data collection as well as those for self-assessment and reporting. Perhaps the most important step of the MIS process is addressed in Chapter 4: the development and introduction of self-assessment tools, including 45 essential indicators that can be graphed easily at any level of the system. The graphs serve to stimulate discussion during regular management team meetings at that level. Chapter 5 looks at the achievements to date and major project outputs. The last chapter examines obstacles and answers to a series of critical questions for designing, developing, and implementing an MIS. The annexes cover self-assessment tools: instructions for using the tools and examples of completed self-assessment tools (primary health care coverage assessment and primary health care: continuity/quality of care assessment).
SOURCE: Amsterdam, Netherlands, Royal Tropical Institute, 1996. 96 p.

70.
DOCUMENT NUMBER: PIP/112408
AUTHOR: Conn CP ; Jenkins P ; Touray SO
TITLE: Strengthening health management: experience of district teams in The Gambia.
ABSTRACT:
In recognition of the importance of developing strong district health teams in order to implement primary health care in developing countries, a district-level health management strengthening project took place during an 18-month period starting in 1991 in the Gambia. The objectives of the project were to teach regional health teams (RHTs) how to function as decentralized management units, improve team management skills, achieve improved resource management, and increase awareness of district health management problems at the national level. RHT training involved the introduction of a six-month planning cycle which identified priorities and problems and defined ways to address them. This analysis formed the basis for the RHTs to make realistic workplans and to begin to exhibit initiative in planning. New teamwork skills led to the delivery of more coordinated supervision and training support to health staff. The new planning process also involved initiating local analysis and use of local service delivery data and the improvement of problem analysis skills. Regional health administrators were hired to improve resources management, including repair and construction of health facilities and developing better transportation mechanisms. Project effectiveness was enhanced by a the motivation of the team members, the support of new team leaders, the problem-solving, hands-on approach, and better access to information. Restraints included national procedures that resisted decentralization, a lack of skilled national-level managers, the resistance of national-level health managers, and donor policy that created vertical and parallel programs and supported top-down decision-making. While the project resulted in some gains, it also demonstrated that the initiatives of district level health teams are not sufficient to achieve reform. Further improvements will rely on actions taken at the national level and by donors.
SOURCE: HEALTH POLICY AND PLANNING.. 1996 Mar;11(1):64-71.

76.
DOCUMENT NUMBER: PIP/104677
AUTHOR: De Geyndt W
TITLE: Managing the quality of health care in developing countries.
ABSTRACT:
A public health specialist at the World Bank has reviewed World Bank-funded projects, various approaches and models of assessing quality of health care, and quality of health care studies in developing countries to present state-of-the-art in measuring, assuring, and improving quality of health care, to set up a common knowledge base, and to propose a framework to direct current and future attempts to improve the quality of health care services in developing countries. The proposed framework attempts to ensure that limited resources have an optimal impact on the health of the population. It consists of three elements (structure, process, and outcome) to help World Bank staff help developing countries as they work towards selecting and organizing indicators. The structural inputs (buildings, equipment, drugs, medical supplies, and vehicles; personnel; funds; organizational arrangements) are tangible and can be quantified. They are needed for good quality of health care but are not a sufficient condition of it. Assuming a sufficient minimal supply of inputs, the principal element to assure quality of health care is process. Persons should stress process measures and embody the philosophy and methods of Quality Improvement when designing a project. This will allow project managers to assess and improve the service delivery processes consciously and continuously. Process indicators include functions (e.g., prevention and diagnosis), patient and provider compliance, programs, and support tasks (e.g., supervising). Outcomes are the end results of the process of patient care and of the timely availability of the necessary inputs. Their indicators are mortality, morbidity, pain and suffering, functional impairment, patient satisfaction, and behavioral changes. Factors that the health worker cannot control (e.g., environment and genetics) can also affect favorable outcomes.
SOURCE: Washington, D.C., World Bank, 1995. ix, 80 p. (World Bank Technical Paper No. 258)

87.
DOCUMENT NUMBER: PIP/140651
AUTHOR: Brown LD
TITLE: Lessons learned in institutionalization of quality assurance programs: an international perspective.
ABSTRACT:
This article reviews the lessons learned by the Quality Assurance (QA) Project (which has institutionalized QA programs in more than 15 countries) and offers recommendations based on work in Chile, Jordan, Costa Rica, Niger, and Egypt. Institutionalization involves carrying out appropriate QA activities effectively on a routine basis, and this depends on creation of a QA structure, standard setting, monitoring, quality improvement, and a culture of quality that recognizes QA as feasible, as a central objective, as the responsibility of every individual, and as depending on teamwork. Lessons learned include: 1) it is essential to assess organizational strengths and weaknesses to plan a QA program, 2) conducting a quality of care assessment at the start of the program has advantages and disadvantages, 3) the program methodology must be flexible yet standardized, 4) training must be part of an integrated strategy, 5) the QA structure should be developed gradually, 6) close alliance with the existing Ministry of Health structure is essential, 7) top-down and bottom-up strategies must be pursued simultaneously, 8) political support should be gained and sustained from various health sector actors, 9) frequent personnel turnover must be dealt with, 10) mechanisms for QA documentation must be developed at the outset, and 11) provision of extra initial funding provides an incentive to try QA but may have a negative impact on ultimate sustainability. The report concludes that the idea of quality is powerful, especially if those at all levels can participate in its definition.
SOURCE: INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE : ISQUA.. 1995 Dec;7(4):419-25.

113.
DOCUMENT NUMBER: PIP/109363
AUTHOR: Franco LM ; Newman J ; Murphy G ; Mariani E
TITLE: Achieving quality through problem solving and process improvement.
ABSTRACT:
USAID's Quality Assurance Project has published this monograph with the aim to improve processes and to solve problems related to health care quality and delivery, especially in developing countries, regardless of the level of the health system. It presents guidelines on how to achieve these goals. The four leading principles defining this approach to quality assurance are focus on client needs, focus on systems and process, focus on data-based decisions, and focus on participation and teamwork in quality improvement. The quality assurance process involves designing for quality assurance (planning, setting and communicating standards), monitoring quality, and problem solving. The monograph presents two examples of health service areas to illustrate the problem-solving process and tools: efforts of a supervisor and subordinate to improve client compliance with acute respiratory infection treatment regimens and efforts of a team of district supervisors to reduce waiting times for prenatal services. The monograph is divided into two parts. The first part lays out and provides details on the six steps to solving quality problems and improving processes, which include identify problems and select opportunities for improvement, define the problem operationally, identify who needs to work on the problem, analyze and study the problem to identify major causes, develop solutions and actions for quality improvement, and implement and evaluate quality improvement efforts. The second part explains how to apply each of the quality improvement tools and when to apply them (i.e., during what step). These tools are brainstorming, affinity analysis, prioritization tools, systems modelling, flow charts, cause and effect analysis, force field analysis, statistical tools (bar and pie charts, run charts, histograms, scatter diagrams, and pareto charts), client windows, benchmarking, Gantt charts, and quality assurance storytelling). The monograph concludes with a glossary of key terms and selected references.
SOURCE: Bethesda, Maryland, Quality Assurance Project, [1995]. xii, 50, 46, [13] p. (Quality Assurance Methodology Refinement Series)

125.
DOCUMENT NUMBER: PIP/138492
AUTHOR: Haberland N ; Miller K ; Bruce J ; Fassihian G
TITLE: Unrealized quality and missed opportunities in family planning services.
ABSTRACT:
This document is the sixth chapter in a Population Council publication describing findings from 12 situation analysis studies conducted in 1995 to determine the quality of clinic-based family planning (FP) and reproductive health services in 11 countries of sub-Sahara Africa since 1989. This chapter uses data from situation analysis studies in Botswana, Burkina Faso, Kenya, Senegal, and Zambia to explore the hypothesis that the underutilization of existing resources diminishes service quality and client choice. The examination covered the degree to which 1) contraceptive method choice, 2) use of staff time (client load), 3) use of clinic equipment and water, and 4) consideration of social context and clients' sexual relationships were employed by the FP programs. The discussion of findings describes the particular indicators used to explore the extent of unused quality in each case. The analysis revealed that 1) clients wishing to space births were offered fewer than the methods available in the clinic, 2) providers failed to take advantage of available IEC (information, education, communication) materials, 3) most providers saw three or fewer clients per day, 4) providers used equipment when available but failed to use materials available for asepsis pelvic exams, 5) providers failed to inquire about client's sex behavior to aid counseling, and 6) providers rarely discussed the ability of condoms to protect against sexually transmitted diseases. These findings reveal unused resources that could be tapped to increase quality of care.
SOURCE: In: Clinic-based family planning and reproductive health services in Africa: findings from situation analysis studies, edited by Kate Miller, Robert Miller, Ian Askew, Marjorie C. Horn and Lewis Ndhlovu. New York, New York, Population Council, 1998. :125-39.

131.
DOCUMENT NUMBER: PIP/133618
AUTHOR: Hardee K ; Janowitz B ; Stanback J ; Villinski MT
TITLE: What have we learned from studying changes in service guidelines and practices?
ABSTRACT:
A group of researchers in 1992 observed that, while family planning methods have been made safer over the past several decades, many contraceptive prescribing practices remain based upon outdated scientific data or were produced for contraceptives which have since been reformulated. Noting that providing quality care to clients may be hindered when providers base service delivery practices upon guidelines developed from outmoded data, they argued that rather than preserving women's health, some practices impede quality contraceptive access. Others, however, argued that focusing narrowly upon medical procedures as barriers would reduce the quality of care for clients. This debate over medical barriers broadened the focus upon service delivery practices. Improving service practices is part of the US Agency for International Development's Maximizing Access and Quality (MAQ), an initiative of which separating necessary service practices from medical barriers is a fundamental element. To evaluate how research can help program decision makers, the authors examined the methodologies used in service practice research and recommend directions for future research upon the subject. Advances in practice research, decision-makers' concerns, service guidelines and practices, and service safety, access, and quality are discussed.
SOURCE: INTERNATIONAL FAMILY PLANNING PERSPECTIVES. 1998 Jun;24(2):84-90.

154.
DOCUMENT NUMBER: PIP/141089
AUTHOR: Hull VJ
TITLE: Improving quality of care in family planning: how far have we come?
ABSTRACT:
This paper aims to provide access to quality of care (QC) principles and practices based on experiences during 1993-95 with the QC in Family Planning project in Indonesia. Information was initially presented at a 1994 Indonesian epidemiology conference. The report offers advice for policymakers, researchers, and social activists. Chapters focus on concepts, justification, frameworks for defining and improving QC in family planning programs, lessons learned from QC improvement strategies, research questions, and future directions. QC refers to the way clients are treated by a service delivery system. Policy support and commitment at the highest levels for a client-oriented approach is constrained by lack of frontline exposure. At the service delivery level, workers lack commitment and focus and have very low client knowledge and expectations. Little attention is paid to nonusers. There is a need for research to determine the cost of quality and its impact and the practical indicators of QC. A review of 1990s obstacles indicates weakness in training and management and lack of program standards and guidelines; all of which are surmountable. Current improvements are constrained by sociopolitical contexts, which require changing bureaucratic attitudes that involve a slower process.
SOURCE: Jakarta, Indonesia, Population Council, 1996. 103 p. (South and East Asia Regional Working Papers No. 5)

187.
DOCUMENT NUMBER: PIP/116736
AUTHOR: Keller S
TITLE: Summary report of: Updating Service Delivery Guidelines and Practices: a Workshop on Recent Recommendations and Experiences, Guatemala City, Guatemala, March 6, 1995.
GENERAL NOTES: RH Training Materials
ABSTRACT:
In March 1995, Family Health International (FHI), JHPIEGO Corporation, and seven collaborating agencies hosted an international workshop in Guatemala City so 60 family planning specialists from 23 countries could discuss how national guidelines for the use of contraceptives can be developed and implemented that are universally agreed upon and accepted. This workshop was held because a key obstacle of achieving high-quality family planning services is the lack of such guidelines. The participants reviewed the international recommendations developed by USAID and the World Health Organization (WHO). They also discussed the merits of the guidelines principle and learned from the pioneering countries in this initiative. The pioneering countries were presented in Session II as country case studies and included Mexico, Tanzania, and Turkey. The first session addressed the international initiative to update service delivery guidelines and practices, specifically how medical barriers stand in the way, and the WHO and USAID guidance documents. Session III involved working groups on contraception for young adults, contraception in postpartum care, contraception in postabortion care, progestin-only methods, and client perspectives. Participants suggested that the workshop be adapted into an easily replicated format to introduce the guidelines worldwide. The next step would be to translate the documents into national guidelines and convert them into changes in practice. One way would be to publish training materials for all levels of family planning providers. JHPIEGO has already published a user-friendly pocket guide in five languages to simplify the USAID and WHO documents. FHI has developed Contraceptive Technology Modules to educate policymakers and providers on the latest scientific information. JHPIEGO and FHI have created expert slides to accompany the modules.
SOURCE: Research Triangle Park, North Carolina, Family Health International [FHI], 1995 Aug. [2], 26 p. (MAQ: Maximizing Access and Quality)

195.
DOCUMENT NUMBER: PIP/130293
AUTHOR: Koenig MA ; Hossain MB ; Whittaker M
TITLE: The influence of quality of care upon contraceptive use in rural Bangladesh.
ABSTRACT:
This report opens with an overview of the development of the concept of "quality of health care" and attempts to identify appropriate research methodologies to define and measure quality of care indicators. The present study uses longitudinal data collected after May 1989 via interviews with 7829 women in rural Bangladesh to describe the influence of quality of care on contraceptive behavior. After describing the study setting and data, results are presented in terms of 1) evidence gleaned about the standards of care offered by the government field workers from the perspective of the clients served and 2) the relationship between selected quality of care indicators and contraceptive adoption and method continuation. The analysis provided compelling evidence of the important effect of quality of care on contraceptive behavior. Clients were more likely to continue contraceptive usage if they perceived a high quality of care from field workers. Higher standards of care were also associated with a 27% increase in subsequent adoption of contraception by nonusers. It was also found that the absolute number of contraceptive methods offered to a client may not be as important as the degree of trust developed between the field worker and the client. The findings also indicate that significant improvements are needed in the quality of care provided by field workers. Only half of the ever-visited respondents received acceptable standards of care, only 25% welcomed a return visit, and only a minority had positive views of services provided through government clinics. Further research is needed to collaborate these findings in other settings, and efforts should be made to identify the ways that policies and programs realistically can be changed to improve quality of care in order to meet the needs of individuals and broad demographic goals.
SOURCE: STUDIES IN FAMILY PLANNING.. 1997 Dec;28(4):278-89.

219.
DOCUMENT NUMBER: PIP/084677 ; IND/8025552
AUTHOR: Lynam P ; Rabinovitz LM ; Shobowale M
TITLE: Using self-assessment to improve the quality of family planning clinic services.
ABSTRACT:
The association for Voluntary Surgical Contraception (AVSC) had developed a family planning (FP) clinic operations assessment approach called COPE: client oriented and provider efficient. The COPE method were employed in 11 sites in Ghana, Kenya, Nigeria, and Uganda and evaluated 5-15 months after implementation. COPE aims to improve client services through change in the organization, by continually revising plans and services, and by evaluating outcomes. The focus is not on outcome or distributional statistics, but on qualitative and quantitative data on the process of service delivery. Cope meets the criteria of using multiple methods, being flexible in research design, and being simple. The 4 main components of COPE are as follows: 1) self-assessment; 2) client interviews (10); 3) client-flow analysis (CFA); and 4) plan of action. COPE is currently integrating into its methodology the routine for follow-up evaluation visits by COPE facilitators. Evaluation of COPE implementation took into consideration the number of problems solved or addressed since the introduction of COPE, the results of the client-flow analysis, and the results of interviews of providers. The lack of baseline information on client satisfaction prevented analysis of changes. The instruments of evaluation included a table of lists of problems and proposed staff solutions, several CFA summary sheets, and a structured interview questionnaire for service providers involved with COPE. AVSC staff found that the proportion of solvable problems that were solved varied by site and ranged from 33-75%. It appeared that the level of dedication of service providers and the interest, cooperation, and involvement of administration determined the disparity in problems solved. There were 109 problems identified at all sites and 59% solved. 73% of the problems did not call for outside help. 88% of these solvable problems were solved or partly solved or had attempts at solutions. The cases involved a need for more training of staff in FP the lack of a forum to discuss FP, the lack of directional signs to the FP unit, the long client waiting times, the inadequacy of FP supplies, and the incompleteness of records. Positive results of COPE centered on decreased waiting times, improved morale and staffing, and increased satisfaction. Lessons learned and future directions are given.
SOURCE: STUDIES IN FAMILY PLANNING.. 1993 Jul-Aug;24(4):252-60.

248.
DOCUMENT NUMBER: PIP/121447
AUTHOR: Mensch BS ; Arends-Kuenning M ; Jain A ; Garate MR
TITLE: Avoiding unintended pregnancy in Peru: does the quality of family planning services matter?
ABSTRACT:
An analysis linking data on pregnancy intentions from the 1991-92 Peru Demographic and Health Survey with information from a 1994 follow-up survey found that among 1093 women from Nor-Oriental del Maranon and Lima who participated in both surveys, 20% had a mistimed or unwanted pregnancy in the 29 intervening months. In all, 15% had an unintended pregnancy ending in a live birth and 5% had an unintended pregnancy with another outcome. The proportion having an unintended pregnancy was 32% in rural Nor-Oriental, 24 in urban Nor-Oriental, and 13% in Lima. Unintended pregnancies were predominantly attributable to failure of a traditional contraceptive method (35% of such pregnancies) or nonuse of any method (26%). The proportion of women who failed to meet their reproductive goals between surveys declined as their education and the quality of available family planning services, as measured by a 1992 situation analysis, improved. The effect of quality of care on women's ability to avoid unwanted fertility was significant in logistic regression models including only service factors and women's demographic characteristics. In models including rural-urban residence and region, neither these variables nor quality of care had a significant effect. (author's)
SOURCE: INTERNATIONAL FAMILY PLANNING PERSPECTIVES. 1997 Mar;23(1):21-7.

272.
DOCUMENT NUMBER: PIP/140743
AUTHOR: Nicholas DD ; Winter L ; Crespin X ; Boukar AM
TITLE: Results of CQI in Africa: the Niger experience.
ABSTRACT:
This chapter features the results of Continuous Quality Improvement (CQI) in Niger for the past 10 years. Improvement in the quality of care can be attributed to the democratization movements, efficient and effective use of resources, service improvements to increase fees, application of the same method to assure quality and the expansion of Managed Care and other health reform initiatives. In addition, 4 tenets have been incorporated to provide an ideal quality assurance program: 1) must be client-focused; 2) focus on processes and systems; 3) reliance on measurement and data to determine if quality is being achieved and to identify problems and causes of problems; and 4) reliance on a team approach to solve problems and improve the systems of care. Among the lessons learned during the implementation of CQI is that it is a systematic approach to managing health services at both the regional and district levels. Also, health workers became much more interested in their work and expressed feelings for the first time. Having to impress upon the staff the importance of measurement and data, as well as documentation of cost savings, is one of the difficult aspects of implementing CQI in developing countries. This chapter underscores the need to improve both clinical and support services, and the significance of devising solutions to problems within the existing resources and measurement of improvement in performance among health worker teams.
SOURCE: In: The effectiveness of CQI in health care: stories from a global perspective, edited by Vahe A. Kazandjian. Milwaukee, Wisconsin, ASQC Quality Press, 1997. :239-66.

278.
DOCUMENT NUMBER: PIP/125892
AUTHOR: Omaswa F ; Burnham G ; Baingana G ; Mwebesa H ; Morrow R
TITLE: Introducing quality management into primary health care services in Uganda.
ABSTRACT:
To strengthen district-level management of primary health care services in Uganda, a national quality assurance program was introduced in 1994. This approach includes the development and dissemination of standards and guidelines, determining the needs of patients and their families, strengthened communication between health care providers and users, and the use of data to identify gaps in service quality. Among the gains documented in the first 18 months of implementation of this strategy were a reduction in maternal mortality among pregnant women referred to Jinja District Hospital from 13.5% to 2.9%, elimination of lengthy waiting times and increased patient satisfaction at Masaka District Hospital, and a marked decrease in reported measles cases in Arua District. More subjective improvements have included increased morale among district health team members, improved patient satisfaction, and greater local government involvement in district health committee decision making. District quality management workshops, followed up with regular support visits from the Ministry of Health headquarters, have enhanced central staff understanding of district-level needs and issues. Implementation of this program has been achieved largely with existing resources. Difficulties encountered at the district level have included a tendency for some teams to select overly complex problems and a lack of management capacity for problem solving. Overall, however, the principles of quality management are highly applicable to the Ugandan context and can be easily mastered by health workers.
SOURCE: BULLETIN OF THE WORLD HEALTH ORGANIZATION.. 1997;75(2):155-61.

318.
DOCUMENT NUMBER: PIP/142338
AUTHOR: Schuler SR ; Hossain Z
TITLE: Family planning clinics through women's eyes and voices: a case study from rural Bangladesh.
ABSTRACT:
At present, Bangladesh's rural family planning program relies heavily on domiciliary services provided by the family welfare assistant. However, as part of a strategy to deliver a more comprehensive package of essential health services, the domiciliary system will gradually be de-emphasized and family planning will be provided through static clinics, periodic satellite clinics, and supply depots. To help program leaders develop strategies for this transition, interviews were conducted in 1996 with 34 women from six rural villages who already rely on government and nongovernmental clinics for reproductive health services and client-staff interactions at these sites were observed. The issues that emerged from the interviews and site observations related more to power relations between clients and providers, accountability, and broad institutional policies than to technical skills, standards, and protocols. In five of the eight clinics, at least some clients (especially the poorest women) were treated harshly and in a hierarchical manner by staff. In two clinics, women were observed pleading for services. Although only one of the 13 women who requested IUD insertion had difficulty obtaining the device, six of 10 women seeking IUD removal experienced problems. Medication was another source of conflict. Clients believed that staff were withholding and illegally selling drugs, while staff viewed clients as pestering them for medications to which the women were not entitled. In general, rural women tended to be less critical of the quality of the care they received than the researchers. Most clients were willing to overlook rude treatment, long waits, and unhygienic conditions, maintaining that because they were poor, they could not expect better care. Measures must be taken to ensure that poor rural women understand basic reproductive health, know their rights and what to expect, and can make informed decisions in utilizing health services.
SOURCE: INTERNATIONAL FAMILY PLANNING PERSPECTIVES. 1998 Dec;24(4):170-5, 205.

328.
DOCUMENT NUMBER: PIP/077774
AUTHOR: Shelton JD ; Angle MA ; Jacobstein RA
TITLE: Medical barriers to access to family planning.
ABSTRACT:
Medical barriers to family planning (FP) are identified as contraindications, eligibility, process hurdles, the provider of contraception, provider bias, and regulation. These obstacles to FP are considered practices which may have a medical rationale in some manner but are scientifically unjustified. The denial or interference in obtaining contraception is unacceptable. Examples are given of barriers, i.e., eligibility criteria such as lack of headaches or history of diabetes. Obstacles that deter oral contraception (OC) are a by-product of testing requirements, repeat visits, and long waits. OC provision does not require a physician's prescription; a trained technician can perform similar functions. When a provider such as community-based distributor is limited in provision of methods, women are not given the right to choose from a full menu. Medical barriers occur due to the ignorance about the safety of contraceptives, the benefits of FP, and the role of health professionals in service delivery. Clinics tend to be curative rather than preventive. In place of careful thinking, there are rules in a hierarchical medical system suitable for treatment of complicated life-threatening illness. Barriers are complicated, interrelated, and situational. The solutions suggested are 1) informing the health community and mobilizing medical leadership, 2) defining and treating the FP seeker as a client and not a medical patient, and 3) engaging in more epidemiological research to assess the risk/benefits of contraceptive use and operations research to evaluate ways to reduce medical restrictions. The position that obstacles are an example of quality of care does not support the Bruce-Jain FP quality of care framework. Health and FP services may be integrated but contraceptive usage should not be at the expense of health care. The obstacles are not just in developing countries where it would appear that access to FP far outweighs the risks of maternal mortality from pregnancy. Providers are not the target is creating a win-win-win situation for the client, the provider, and organized public health.
SOURCE: LANCET.. 1992 Nov 28;340(8831):1334-5.

337.
DOCUMENT NUMBER: PIP/079096
AUTHOR: Simmons R ; Simmons GB
TITLE: Moving toward a higher quality of care: challenges for management.
ABSTRACT:
Quality of health care in family planning programs is measured in the Bruce framework as the "goodness" or "badness" of the program. Other considerations are the identification of issues confronting managers concerned with quality of care and the best way of optimizing services. Quick fixes don't work. Change is gradual and understanding must be developed. The real opportunities and constraints of settings affect how much can be achieved and the time required to reach the goals. Even where there are limited resources some change is possible. The idea that services come before quality loses sight of the longterm benefits. There is recognition that conditions vary between programs; prescriptions are offered from theories of Peters et al.: 1) The commitment of top management must be developed. This commitment should be manifested in daily interactions; quality of care will motivate subordinates. 2) Client-staff relations must be personal and value must be placed on the clients as human beings. Avoid "thinly disguised contempt" for customers, which may take the form of believing that women do not need or want information and are not capable of making an informed decision. Waiting times should be as short as possible. 3) The field staff and service provider should be considered as program heroes and their needs heeded. Rewards and support are necessary to maintain quality. Tools of their trade must be accessible to workers. 4) Measure quality; what is not measured is not accomplished. Management information systems must include quality of care information. 5) Reward quality. Typically, quality in counseling, educational effort, maintenance of high septic standards, cleanliness of centers, and provider's willingness to provide choices are not rewarded and should be. The number of acceptors recruited is not a quality measure. Certificates can be given in lieu of financial rewards. Cost effectiveness can be achieved when behavioral change and quality are emphasized; quality yields high contraceptive continuation and prevalence. Morale improvements involve training, not substantial cost increases. Poor quality programs are wasteful of human and physical resources.
SOURCE: In: Managing quality of care in population programs, edited by Anrudh K. Jain. West Hartford, Connecticut, Kumarian Press, 1992. :23-34. (Kumarian Press Library of Management for Development)

376.
DOCUMENT NUMBER: PIP/081551 ; IND/8024268
AUTHOR: Vera H
TITLE: The client's view of high-quality care in Santiago, Chile.
ABSTRACT:
The meaning of quality care for the women who receive reproductive health services at a family planning and maternal and infant care clinic in Santiago, Chile, was examined to describe the clinic's service from the women's point of view. A participatory research project with the staff of the clinic was conducted. The central part of that study, reported here, consisted of interviews with 60 of the 330 women who came to the clinic during 2 weeks in June 1991. The women defined high quality of care as "being treated like a human being." Among specific elements of care they identified were cleanliness, promptness, and availability of service, time made available for consultation, learning opportunities for themselves and their partners, and cordial treatment. Clients' view of quality of care must be supplemented by professional judgments about how well services meet clients' needs. But the client's view is determinant if improvements are to result in greater acceptance and sustained use of the services offered. The issues identified by the clients involve only minor costs for the clinic. (author's)
SOURCE: STUDIES IN FAMILY PLANNING.. 1993 Jan-Feb;24(1):4

383.
DOCUMENT NUMBER: PIP/141450
AUTHOR: Winter L ; Boucar M ; Stinson W ; Mason D ; Murphy G
TITLE: Quality Assurance Project. Niger country report: Tahoua project.
ABSTRACT:
This study evaluated the Tahoua Quality Assurance (QA) Project in Niger. The project aimed to improve the delivery of critical primary health care service by training, clarify clinical and management standards, monitor, and put in place a process for preventing and correcting problems during 1993-97. Regional directorate staff and teams from each of the 7 regions were trained in process improvement skills and in initiating QA improvement projects. 76 health workers and another 168 health personnel were trained by June 1996. A Quality Council was set up. A new supervision system was initiated. A manual of norms and standards for vaccination, administrative functions, and job aids for tuberculosis and malaria case management were developed. Progress and evaluation documents were disseminated widely. Decentralization was enhanced by a QA process that focused on increased responsibility for problem solving at the local level. This report is organized into units on the nature of the project, the steps toward institutionalization (prioritizing, structure development, training, supervision, standards, dissemination, and collaboration), results, lessons learned, and conclusions. Constraints included excessive mobility of personnel, a need to upgrade pre-service training, lack of donor coordination, and a strong fatalistic attitude in society. The project learned that success is possible despite resource constraints. Workers could be empowered from a top-down approach. A long-term technical advisor assured local adaptation of training and other activities. Seeing positive results motivated teams. The project had flexibility in allocating funds.
SOURCE: Bethesda, Maryland, Center for Human Services, Quality Assurance Project, [1997]. ix, 28 p. (USAID Cooperative Agreement No. DPE-5992-A-00-0050-00)