National Health MissionMaharashtra

Quality Assurance Project

Provision of a package of quality Reproductive Health Services was one of the key issues in the International Conference on Population & Development (IPCD) held in Cairo during 1994. Quality of Care (QOC) has been perceived as an integral & major component of people's reproductive rights. Reproductive and child health (RCH) concept is based upon the plan of action of the IPCD and provision of package of quality services is the anchor pillar of RCH Programme.

Various initiatives have been started in country as well as in the State for monitoring of quality of Health & RCH Services. Under UIP, Cluster survey methodology was introduced to assess & evaluate the immunization coverage and performance in other indicators. State used to organize multi indicator cluster surveys with the support from UNICEF. District & block level committees were established during 2001 for assessing the quality of RCH Services. Validation exercises had been conducted in the field based on the samples drawn from state level.

State started concurrent Evaluation system during 1989 through teams headed by Asst. Directors at State level. The exercise included assessment of quality of Services with supportive supervision in the field as well as validation of beneficiaries of various methods & immunization. The system also assessed the readiness of the institutions to provide RCH Services.

National Family Health Survey & District level RCH Surveys are being conducted periodically which give the picture of evaluated performance under various RCH Services as well as Socio Economic indicators. Under MHSDP, modalities have been developed for assessment of Quality of Services provided by different hospitals.

Govt. of India has introduced the standards of sterilization methods & standards for sterilization camps. District level Quality Assurance Committees have been constituted for maintaining quality under sterilization services.

Govt. of India initiated a system of monitoring quality of services at health facilities and outreach services as a part of RCH II. UNFPA provided technical assistance for implementation quality assurance project in selected districts of the country including Ahmednagar in Maharashtra during 2006-07.

Monitoring & evaluation strategy formulated by Ministry of Health & Family Welfare, Govt. of India for RCH II, envisages continuous assessment of the quality of RCH services as an important element. It is based on the presumption that any sustainable change in terms of institutionalization of Quality Assurance (QA) should come from within the system and not from outside. In Maharashtra Quality Assurance project was initiated in Ahmednagar district with the technical and financial support from UNFPA & it was implemented through Population Council.

Orientation of State and District Nodal Officers, Orientation of State Officers (Advocacy), which was done in April 07

Training of DQAG members Orientation of MS / MO

First Quality Assessment visits of the identified Health Institutions in May 07 to Oct 07 and Second QA visit during Nov 07 to June 08.

The QA Assessment revealed deficiencies pertaining to the following points.

At SDH/RH/PHC

Training, counseling skills, vacant posts, functional, labs, repairs required, equipments, cleanliness, BMWM, records, protocols Citizen Charters

At Subcentre

Knowledge, repairs, equipments, records, BMWM,

Average number of Action points emerged during Ist & IInd QA Visits for

SDH/RH/PHC were – 28(I) & 15(II) and for
Subcentre were– 16 (I) & 12(II)

Overall quality of the health institutions based on the grades improved from

A 24% , B 69%, C 7% (I) during Ist visit. to
A 72% , B 25%, C 3%(II) during IInd visit for SDH/RH/PHC and for
In Subcentres it improved from -
A 9% , B 48%, C 43% (Ist visit)
To A 39% , B 58%, C 3%(IInd visit)

The improvement in process related grades was

from A 0% , B 34%, C 59% during initial visit to
A 70% , B 25%, C 5% during IInd Visit

Strengths

Regular visits & continuous review at various levels

  • Assimilation within district level monitoring system
  • Proper use of checklists by Managers as well as providers
  •  Follow up of Actions taken  report was encouraging
  • QA was an agenda item for review meetings

Encouraged with the findings of the pilot project in Ahmednagar the State government decided to expand QA Activities in five more districts with the support from UNFPA Public Health Institute, Nagpur was identified as nodal agency (implementing partner)

An Orientation & planning meeting was organized at Mumbai on 13-08-09 under the chairmanship of Secretary & Commissioner (Family Welfare) in which, District Health Officers & Civil Surgeons from all the six project districts participated.

The quality assessment and improvement under Quality assurance project consists of the following interventions:

  • Formation of District QA Group from officers within the health system
  • Setting up QA cell at district level
  • Identification of a nodal officer from the system (DRCHO / MODTT/ADHO)
  • Contractual appointment of State level Consultant & District QA Coordinators
  • Training of DQAG members, MS/MOs & district level officials.
  • Use of appropriate standardized tools  developed by Govt. of India & UNFPA
  • Selection of Health Facilities for Periodical Quality Assessments
  • Periodical field visits,  identification of short comings & Preparation of Action Plan
  • Bridging the gaps through a series of actions
  • Periodical review & Monitoring
  • Ensure Quality improvement through field visits
  • Enhancement in utilization of RCH Services

Milestones

Phase I Districts(2009-10)

Akola, Ahmednagar, Aurangabad, Kolhapur, Raigad, Chandrapur

  • State QA Consultant joined (21.7.2009)
  • Orientation Meeting of DHOs & Civil Surgeons from 6 districts (13.8.2009)
  • District QA Coordinators join (Sept. 2009)
  • Planning Meeting Thane.
  • Four days Training of DQAG Members 4 batches – Sept.09, Oct.09, Nov.09,

March 10. (Few DQAG Members have also been trained during 2010-11 along with Phase II district members)

Sr. No. Dist. Trained
1 Ahmednagar 29
2 Aurangabad 35
3 Akola 19
4 Chandrapur 28
5 Kolhapur 26
6 Raigad 22
Total 160

One day Training of MS/MOs at District level.

Sr. No. District Medical Supdts./ MOs Trained
1 Aurangabad 47
2 Ahmednagar 67
3 Akola 47
4 Raigad 44
5 Kolhapur 61
6 Chandrapur 53
Total 319

  • Quality Assessments Started from Oct. 2009.
  • Planning meeting Nagpur, Nov.09.
  • DQAG Meetings at District level.

Health facilities selected for QA

Sr. No. District SDH/ RH PHC SC Total
1 Ahmednagar 10 12 24 46
2 Aurangabad 7 20 21 48
3 Akola 4 15 30 49
4 Chandrapur 7 14 28 49
5 Kolhapur 8 14 28 50 (Initially 39 facilities were selected for 1st round.)
6 Raigad 6 14 28 48

Health facilities visited Month wise

Sr. No. Dist. Oct. 09 Nov. 09 Dec. 09 Jan. 10 Feb. 10 March 10 Total 09-10 Apr. 10 May 10 June 10
1 A’nagar 3 6 8 11 3 15 46 17 12 17
2 A’bad 7 5 12 9 13 4 50 12 7 17
3 Akola 4 8 10 13 10 13 58 11 4 9
4 C’pur 6 10 14 17 4 10 61 11 13 16
5 Kolhapur 5 4 13 12 6 6 46 11 10 15
6 Raigad 3 3 12 14 9 7 48 9 9 12
Total 28 36 69 76 45 55 309 71 55 86
Sr. No. Dist. July 10 Aug. 10 Sept. 10 Oct. 10 Nov. 10 Dec. 10 Jan.11 Feb. 11 Mar. 11 April 2011 Total 10-11 Grand Total
1 A’nagar 16 16 14 12 12 10 12 0 17 145 191
2 A’bad 3 8 8 17 10 8 13 6 13 13 135 185
3 Akola 18 7 8 7 07 6 11 14 9 9 120 178
4 C’pur 7 8 8 9 17 5 9 12 23 10 148 209
5 Kolhapur 11 11 13 11 13 6 15 10 15 9 150 196
6 Raigad 7 11 15 12 11 10 8 14 9 10 137 185
Total 62 61 66 68 70 45 68 62 77 51 835 1142

State decided to expand QA Activities in 6 more districts Amaravati, Satara, Jalna, Wardha, Nashik & Thane as a component of RCH-II PIP 2010-11 (Budget head A.10.3.3.5).

Phase II Districts ( 2010-11)

Jalna, Wardha, Amravati, Nashik, Thane, Satara

  • RCH-II PIP Approved. (June 2010)
  • UNFPA AWP Approved. (Feb. 2010)
  • DO Letters from Principal Secretary & Commissioner FW. to CEOs ZP.
  • District QA Coordinators join (July 2010)
  • Orientation Meetings of District level officers at District level (July & August 2010)
  • Four days Training of DQAG Members (5 batches) August 2010, Sept. 2010., Oct.2010, Nov 2010 & Dec. 2010
Sr. No. Dist. Trained
1 Jalna 27
2 Amaravati 25
3 Wardha 30
4 Nashik 34
5 Satara 27
6 Thane 23
Total 166

One day Training of MS/MOs. Sept., Oct., Nov.10

Sr. No. District Medical Supdts./ MOs Trained
1 Amaravati 95
2 Jalna 68
3 Wardha 55
4 Nashik 59
5 Satara 84
6 Thane 127
Total 488
  • Govt. circular & SFWB Circular issued.
  • Quality Assessments started (Oct. 2010)

Health facilities selected for QA

Sr. No. District SDH/ RH PHC SC Total
1 Amaravati 10 16 24 50
2 Jalna 6 16 28 50
3 Wardha 6 16 30 52
4 Nashik 10 15 30 55
5 Satara 9 16 25 50
6 Thane 8 15 30 53
Total 49 94 167 310

Institutions visited during Oct. & Nov. Dec. 2010. & Jan.11

Name of District Oct. 2010 Nov. 2010 Dec. 2010 Jan.11 Feb.11 March 11 April 2011 Total
Amaravati 1 4 4 4 4 8 9 34
Jalna 8 12 13 17 11 11 10 82
Thane 2 3 8 0 7 5 10 35
Satara 6 6 7 8 11 12 7 57
Wardha 7 10 9 10 10 11 13 70
Nashik 3 9 11 11 13 13 9 69
Total 27 44 52 50 56 60 58 347

Jalna District has completed 1st round of Quality Assessments of the selected health facilities by Jan. 2011.

UNFPA has been extending technical support & guidance to State & Districts level functionaries from time to time. It has also been supporting the Training activities, Contractual positions of State level Consultant and twelve District level Coordinators, software development printing of checklists as well as Documentation Activities.

The Checklists & Guidelines for Quality Assessments have been developed by Govt. of India, UNFPA & Population Council and have been modified to certain extent at State level. So as to make them maximum objective, covering maximum services possible & also covering NRHM initiatives.

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