Monitoring programs to assess and improve the quality of services is an essential component of any effective program. Yet in Nepal, as in many of the programs AVSC supports, adequate monitoring of programs can often be a challenge.

AVSC's assistance encompasses counseling and informed choice, client-provider interaction, management, and other aspects of ensuring that services are safe, accessible, and of high quality.

A Changing Role

As programs mature, many of our partner organizations and governments are demonstrating an increased capacity to monitor and support their own services. While this means more sustainable programs, it also means that our monitors are constantly challenged to find a new role--that of training, mentoring, and lobbying for the changes they feel are required.

A main part of this new role requires a better understanding of local norms and the environment in which women and men make reproductive health choices. It also requires that monitors understand the working conditions and aspirations of the providers they support and develop an ability to engage with them to promote change.

A monitoring team meets at the end of the day to reflect and share observations.

Mobile Services

In Nepal, as demand for sterilization services has increased, many communities have hosted mobile outreach services, or "camps," in cooperation with the district health office and the Ministry of Health's Family Health Division. These service sites, which are unique and often operate under severe resource constraints, present unique challenges for quality of services.

Mobile outreach services may be provided in a health post, school, or any nonmedical site. Large numbers of clients, often traveling great distances, are served in a relatively short period of time. The providers who staff the sites often have not worked together, may not be from the area, and may not have a clear understanding of how best to structure the service team.

These conditions have caused concerns about the quality of the services. Given the number of clients served and the temporary nature of the service, monitors are concerned about how counseling can be effectively provided and how informed choice, proper screening, and postoperative care can be ensured.

Combining Cultures

One approach has been to rely on intercultural monitoring teams, which always combine an expatriate with local staff. Team members focus on the various aspects of service quality (such as clinical services, client perspectives, and management), and they function together to identify appropriate ways to support the entire service site.

Monitors see many advantages to working in intercultural teams. For one thing, it allows them to learn other perspectives and understand local issues and priorities while being exposed to international standards.

Sometimes having an expatriate on the team adds "weight" to the visit and initiates different kinds of discussion with the service staff. At the same time, the work could not be done without local members, who lend credibility and are knowledgeable about local customs and language.

AVSC's monitors play a critical role in establishing linkages with communities, strengthening relationships, and finding new ways to improve the quality of services. Every time they listen to a client's story, work alongside a provider, or attend a meeting with district health staff and community volunteers, monitors add to our understanding and impact.

Harriet Stanley, who formerly managed AVSC's program in Nepal, is now based in the Bangkok office, where she provides support to AVSC's country programs in informed choice, client perspectives, and program management.