AVSC Working Paper
No. 13 / January 2001

The Quality of Care Management Center in Nepal: Improving Services with Limited Resources

Harriet Stanley, Dirgha Raj Shrestha, Mark Barone, and Mary Linehan


[TOP] [INDEX] [Bibliography] [Authors] [Acknowledgments] [Case Studies] [Figure 1] [Figure 2]

INTRODUCTION

Policymakers and providers increasingly view quality of care for service delivery as a critical element of improved reproductive health services. They recognize the fundamental human right to control one's own body and fertility and to have access to services that allow one to do so. International studies show that clients are deeply concerned about the quality of the family planning services they receive (Barnett and Stein 1998) and confirm the relationship between improved quality and utilization of services (Finger 1998). Programs have begun to adopt quality improvement strategies because they want to improve client satisfaction, increase use and safety of services, and positively affect reproductive and general health.

Quality of care in reproductive health services encompasses a variety of concepts, approaches, and interventions; one general definition of quality of care is "meeting the needs of clients." Quality issues include informed choice, access and availability of services, safety of services including infection prevention, and appropriate counseling services and privacy. Providing quality services is fundamental to sustainable services. Yet quality is often assumed to be expensive, to be technically sophisticated, and to require modern equipment and facilities. It can be difficult to persuade policymakers of the importance of quality service delivery, especially in developing countries where scarce resources and unmet demand for family planning services strain the capacity of reproductive health services.

Since 1994, AVSC International has provided technical assistance to His Majesty's Government (HMG) Ministry of Health (MOH) for reproductive health, in particular clinical family planning services. This important niche in service delivery in Nepal has resulted in a successful program model for assuring quality of care and has yielded valuable lessons in how to supervise and motivate service providers and clinic staff. Beginning in 1996, in association with AVSC and the Nepal Fertility Care Center (NFCC), the Family Health Division (FHD) of the MOH launched the Quality of Care Management Center (QOCMC) in Nepal as part of the government's family planning program. Over the years, the center has developed into an effective and innovative institution that helps to promote high-quality service delivery in 24 family planning service centers of 21 districts of the country. The success of this program demonstrates that services can be improved with limited local resources.

BACKGROUND

In Nepal, the quality of health care in the public sector has always been challenged by a wide range of seemingly overwhelming obstacles. Nepal is among the poorest countries in the world, with 80% of the population engaged in subsistence agriculture. Rates of malnutrition are among the highest in the world: 46% of children are underweight, 48% exhibit stunting, 29% of mothers have a low body-mass index (UNICEF 1996). Life expectancy is among the lowest in the world: 55.0 years for men, 53.5 for women (His Majesty's Government, Nepal, Central Bureau of Statistics 1995). Nepal is one of only two countries in the world where the life expectancy is shorter for women than men, due to an extremely high rate of maternal mortality and pervasive discrimination against women. Many of Nepal's 20 million people live in geographically remote and isolated areas, where health and social welfare infrastructure is weak or nonexistent. Many people do not have access to reproductive health services. The low status of women, very low literacy, and limited access to medical personnel, particularly in rural areas, also contribute to poor health care.

When addressing quality of care in Nepal, a broad range of political, financial, cultural, and clinical issues must be considered. Since the government changed from a monarchy to a parliamentary democracy in 1989, government leadership has changed frequently; all types of government services, including assignment of staff to health care facilities, have been repeatedly disrupted. Because of scarce national resources, per capita health spending is less than US $1.00 per person annually (Research Group for Health Economics and Labor 1997). Health facilities are often in very poor repair, without adequate equipment, supplies, and drugs, and without critical staff. Medical personnel often lack the training, supervision, and resources needed to provide quality care.

Providing health services in such a difficult environment has been a great challenge for the government. After decades of external financial and technical assistance, only slow progress has been made to address the growing needs of Nepal's burgeoning population. Population pressure on natural resources, limited arable land, and an overburdened social welfare system have elevated the government's concern for family planning. Since 1968, HMG has worked, with support from donor agencies, to reduce fertility and provide family planning services throughout the country. The 1996 Nepal Family Health Survey found that 29% of married couples were using some kind of family planning method, an impressive increase from just 3% in 1976. However, the 1996 survey also found that 60% of couples would like to delay pregnancy and estimated unmet need for contraception at 31% (His Majesty's Government, Nepal, Family Health Division et al. 1996). A growing body of evidence suggests that it is not enough to make family planning services more accessible and available; the quality of care must significantly improve to address unmet needs of couples for contraception and to attract couples to seek family planning services (Kaufman 1997).

In Nepal, sterilization is the most prevalent method of family planning, due in part to a widespread practice among couples to have their children soon after marriage and to obtain permanent or long-term contraception after a number of children have been born (Stash 1999). Women as young as 19 years old request sterilization to limit family size and prevent unwanted pregnancy once they have had the desired number of children. The popularity of sterilization, however, is also a result of too few other options (Stash 1999). Lack of access to other methods, inadequate counseling, concerns about side effects, and poor client-provider interaction have all been identified as reasons for the low use of temporary and long-term methods other than sterilization (New Era 1996a, 1996b). HMG has been working with donors and international agencies to improve access to a broader range of methods across the country.

To improve the quality of care, the government and AVSC have worked together to establish and strengthen static clinics that provide a range of methods on an ongoing basis. However, mobile outreach for family planning is still needed in Nepal. Such services are usually offered at temporary facilities and reach a large number of clients, creating a range of conditions that can lower the quality of care. Monitoring reports indicate that poor sanitation, poor infection prevention practices, crowding, lack of privacy, long travel and waiting times, and a stressful working environment are some of the problems encountered at mobile service sites. AVSC is working with the FHD to look at ways of providing quality of care support to mobile, as well as static, service sites.

At present, most sterilization services are provided through mobile outreach teams on a seasonal schedule. Figure 1 describes the seasonal nature of these services at six selected sites. At these sites, services are provided over a four-month period during the winter months. At other times of the year, services continue to be available, but are used at a much lower rate. From 1995 to 1998, provision of sterilization services did increase at static facilities in non-winter months.

The Family Health Division, with support from several agencies including AVSC, has published national medical standards, guidelines for mobile voluntary sterilization services, and a policy statement on family planning service delivery. AVSC has also supported regional workshops, where district health officers and family planning assistants (FPAs) worked together to develop a plan for mobile outreach services. A separate short-term training program was also conducted for all FPAs working in district health offices, to strengthen their ability to manage family planning services. All of these efforts have played a significant role in improving mobile outreach services.

The experience of AVSC worldwide has shown that inappropriate training, poor follow-up, and weak supervisory systems are often key factors in poor quality of care (Dwyer and Jezowski 1995). These issues have also been important obstacles in Nepal, as illustrated by an effort in the 1990s to improve infection prevention activities in 15 districts of Nepal. Training was conducted in infection prevention for staff working in family planning services. Key district-level staff traveled to Kathmandu to attend a comprehensive training workshop. They were expected to return to their respective districts, train other staff in infection prevention standards, and implement proper techniques at their site. This approach met with little or no success—infection prevention was not measurably improved in the districts. Several key problems were identified:

The experiences of these early attempts to improve infection prevention shaped the design of the QOCMC program.

 

THE QUALITY OF CARE MANAGEMENT CENTER

During the 1990s, it became clear that in-stitutional change to improve infection prevention would not occur unless a new approach was used. AVSC proposed site-by-site training and supervision, or a whole-site training approach (Bradley et al. 1998), to be implemented in collaboration with the Nepal Fertility Care Center, a local nongovernmental organization (NGO). Over an 18-month period, a team of AVSC and NFCC staff undertook intensive 2-3 day supervisory visits to each district family planning service center, to train and reinforce infection prevention skills. During these visits, a broad range of barriers to quality service delivery (over and above inappropriate infection prevention practices) became apparent, including lack of basic facilities, equipment, and supplies; management problems; and low morale among staff. The team worked with the MOH to address many of these problems: repairing buildings, installing water systems, repairing equipment, remodeling facilities, and providing on-site training for staff. At the same time, the team began to develop a system that would provide ongoing support for quality of care.

The QOCMC was the result. AVSC and NFCC staff recognized that a broad range of problems needed to be addressed in order for clinic staff to implement appropriate infection prevention practices and to make other improvements in quality of care. While infection prevention is still an important focus, the QOCMC now takes a comprehensive approach to quality of care. At the outset, QOCMC needed to address several chronic problems at district family planning service centers, including management issues, timely flow of funds, maintenance of facilities and equipment, training, supervision, and monitoring. Integrating facilitative supervision (Ben Salem and Beattie 1996) and technical support, QOCMC was structured to work with staff from district health offices, central-level MOH, and family planning service centers to identify and overcome a variety of barriers to quality of care.

STRUCTURE AND GOVERNANCE OF THE QOCMC

The QOCMC has 11 staff. A program coordinator trained in public health manages the center's activities and assures strong relationships with the MOH. The coordinator is based in Kathmandu and travels regularly to the field. Four program officers (a field coordinator, a senior field officer, a family planning officer, and a program officer for voluntary sterilization) and two support staff are also located in the Kathmandu office. Four field officers, based in regional offices, are responsible for various regions of the country and visit their respective family planning service centers each month. Two of the field officers are trained health assistants. Two are nonmedical staff who previously managed family planning services at the district level. Each field officer provides regular monthly monitoring and supervision visits in 4-5 districts of his or her region; central-level supervisors conduct quarterly monitoring and supervision visits in the districts with the field officers. The QOCMC is located in offices of the MOH's Family Health Division in Kathmandu. Referrals for technical assistance, training needs, and monitoring data are all sent to this central office for computerized tracking and follow-up.

The QOCMC is overseen by a steering committee that develops policy and provides programmatic and implementation guidelines. The committee, chaired by the director of the Family Health Division, Ministry of Health, is comprised of MOH directors and representatives of donor organizations, cooperating agencies, and NFCC. The committee meets annually to discuss program progress and constraints.

The Office of Health and Family Planning, U.S. Agency for International Development/ Nepal (USAID), has from the outset played a critical role in the conceptualization and establishment of the QOCMC. The strong support and assistance of the office has done much to assure government commitment and ownership of the center. In addition, USAID has facilitated collaborative relationships among the agencies that implemented its health and family planning initiatives in Nepal; this has benefited QOCMC and, more generally, the Ministry of Health. For example, QOCMC field officers are able to use the facilities of another USAID-funded health program, rather than having to set up and maintain their own offices. USAID staff have encouraged the center to be innovative and creative. They have also promoted strong working relationships among steering committee members and reinforced FHD's management authority over QOCMC.

Although the FHD clearly "owns" the QOCMC, the center is, in fact, a joint NGO-government program. QOCMC staff are employed by NFCC, but are under the direction of the Family Health Division. As employees of NFCC, they are outside the government's human resources system, which allows greater flexibility in hiring and reduces staff turnover (a problem in the public sector which is intensified by frequent changes in government). Locating the QOCMC in the offices of the MOH, rather than in NFCC, helps to ensure that planning, implementation, and monitoring are done with the complete participation of MOH staff and reduces concerns that QOCMC "belongs" to NFCC. Until such time that the MOH is able to fully staff the FHD, the QOCMC will continue to rely on NFCC staff seconded to the FHD.

The joint agency status of QOCMC has certain advantages. The center is able to initiate creative links between government family planning service centers and nongovernmental organizations, and it has the necessary authority to implement change within the government system. For example, because NFCC is a sub-grantee to AVSC, QOCMC is able to access short-term technical assistance from AVSC to deal with a medical issue without delay. QOCMC is also an important link between the district sites and the central MOH. In addition to responding to the needs of district sites, the center provides technical assistance to the central level in management, planning, monitoring, supervision, and evaluation. QOCMC helps district sites to obtain technical and financial resources from the central level, while managing and implementing quality of care interventions in the sites. Because of USAID support, QOCMC is able to access resources of other USAID-funded projects and to coordinate with complementary program activities. If senior district medical staff occasionally resist a new policy, QOCMC field officers, as MOH program officers, can rely on high-ranking, central-level MOH physicians to reinforce their efforts.

Careful selection of staff has been an important element of the center's success. Chosen for their ability to work closely with the MOH, they have achieved a higher profile for the Family Health Division and strengthened management of the program. The personal commitment and energy of the program coordinator and other team members have been essential to QOCMC's success. Constantly seeking to improve the program and the quality of service delivery, the team has assured that the center responds consistently to district providers, wins their confidence, and establishes excellent working relations between the central and district levels.

In the early days of QOCMC, district providers lacked confidence in the government support system. Many providers believed that, once supervisors returned to Kathmandu, problems would not be followed up, and requests for assistance would be forgotten. Demoralized by past experience, district staff were often unwilling to implement new ideas or procedures. QOCMC worked hard to establish systems that would address district needs. By successfully responding to the needs of both central- and district-level MOH staff, the center has created a sense of confidence and trust among those it serves.

For example, maintenance and repair of facilities and equipment were chronic problems for the district centers, despite the fact that USAID had allocated funds for this purpose through a grant to the government. District centers had difficulty obtaining these funds because of complicated and slow financing procedures. Furthermore, there was no mechanism for repair or replacement of broken equipment. As a result, clinic facilities were in severe disrepair, essential equipment was broken and unusable, and staff were frustrated and demoralized.

With direct access to the USAID funds, the QOCMC established a link with NFCC's repair and maintenance center in Kathmandu. District family planning centers were then able to obtain maintenance services, and facilities are now in better repair. The center's early efforts to clean up and establish better-functioning facilities noticeably improved staff morale and helped to change the resigned attitude among staff. A simple but effective system allows QOCMC to keep track of repairs and to respond to district inquiries.

QOCMC responds quickly to problems. These efforts have established the center as a reliable, supportive resource in the eyes of once-skeptical district staff. It has become clear that QOCMC is serious about improving quality—the quality of the working environment as well as the quality of services provided by family planning clinics.

TRAINING, SUPERVISION AND SELF-ASSESSMENT

During their monthly 2-3 day visits to clinics, QOCMC field officers provide on-site training and supervision. They observe routine practices, demonstrate proper techniques, reinforce appropriate practices, and (in compliance with the National Medical Standards for Reproductive Health) correct problems over time, focusing mostly on family planning services provided by paramedics and other staff. During their visits, they also pass on new information. They return repaired equipment and discuss maintenance that is needed and other center needs.

Since QOCMC field officers are not doctors, they have limited ability to influence the practices of physicians. If they identify a potential issue of concern, they refer it to a physician-trainer in FHD or NFCC or to an AVSC physician. That individual then visits the site, as appropriate.

Through on-site training activities, QOCMC staff include all levels of clinic staff in efforts to improve the standard of care, increasing the likelihood of sustained improvement. For example, at one site, storeroom workers were hesitant to stock powdered bleach for infection prevention because the product was new and expensive and because they did not understand why it was needed. On-site discussions enabled all concerned staff to understand the importance of using bleach powder and to appreciate each staff member's role in contributing to quality of care.

One of the key elements of QOCMC's approach is to avoid trying to teach too much at once. Because field officers visit district family planning service centers frequently, they can introduce new ideas slowly over time, building on skills already mastered, reinforcing proper techniques, and correcting mistakes. Another important factor is respect for the staff. Field officers do not correct workers or take notes while staff are working; this prevents staff from becoming embarrassed or feeling self-conscious.

In most cases, clinical skills training is conducted off-site, with QOCMC linking staff to training opportunities. While not providing such training itself, QOCMC works closely with the FHD and the National Health Training Center (NHTC). This mechanism increases the likelihood that appropriate individuals will receive not only the training they need but also support for using new skills once they return to their sites.

Frequent visits by the same staff are essential in order to achieve intensive, continuous, facilitative supervision and skill development of site staff. Field officers develop ongoing, facilitative relationships with clinic staff and are viewed as members of the clinic team (see discussion of facilitative supervision in Ben Salem and Beattie 1996 and Bradley et al. 1998). One staff member described a QOCMC supervisor: "He is the person who always visits our clinic and provides feedback, suggestions, and supports us. Whenever we need to consult someone, we remember him."

QOCMC's approach recognizes that quality improvement goes far beyond instruction in how to properly wash one's hands or use educational materials in counseling sessions. It means working closely with staff to identify problems and solutions.

Monthly monitoring data for each facility is collected on simple forms that rate performance by quality of care indicators, such as appropriate infection prevention measures, proper setting and techniques for client counseling, availability of supplies, and the physical condition of the clinic; selected indicators are listed in Figure 2. QOCMC staff record findings from site visits in collaboration with the clinic team during a meeting near the end of the visit. This joint assessment allows clinic staff to identify problems, develop potential solutions that they themselves can implement locally, and set goals for the next month. The system also strengthens the skills and capacity of clinic staff to solve their own problems. Field officers refer problems that cannot be resolved locally to Kathmandu. This collaborative approach has enhanced relationships between field officers and staff at the district centers. Because providers participate in data collection, they are more interested in the results and more attentive to the quality of the data provided—and more likely to work to make improvements.

MONITORING, EVALUATION AND TRACKING SYSTEMS

Over time, QOCMC has developed some simple and highly effective monitoring tools to evaluate quality of care in the district family planning service centers, follow progress of the program, and enhance performance of the QOCMC and the district clinics. By tallying scores for the quality of care indicators, QOCMC and the clinics can track the performance of each site, monitor changes over time, and plot performance on a graph, which gives the MOH, QOCMC, and the district staff a visual reference for performance. Figure 2 provides summary information for 1997-1999. The system is standardized across all clinics. After a site visit, QOCMC staff complete the indicator checklist with district center staff and send it to the QOCMC's office in Kathmandu. In the central office, the findings from all 24 district centers are immediately entered into the computerized database and used to provide rapid reports that are shared with the facilities. Providing timely, constructive feedback on performance is critical to program success because it gives the district centers a tool for identifying problems and areas for improvement. Using this simple system, QOCMC provides timely information to the Family Health Division, USAID, and other donors for planning and resource allocation.

The monitoring system also allows QOCMC to rank each district center in order of performance by each indicator and by service quality as a whole. Sharing this ranking system with all of the centers can be a very useful tool for motivating them to improve their performance. Seeing how they rank compared to centers in other districts adds a competitive element to the monthly assessment and encourages district teams to improve. For example, a center that provides only four or five temporary contraceptive methods can increase its ranking by adding the fifth method to the center's range of services. Consistent hand washing by all staff improves the score for cleanliness. Raising the overall ranking of the center for quality of care becomes a team-building effort, enhancing morale and commitment of the staff.

Other systematic tracking systems have also been put in place to increase the efficiency of the QOCMC. In the past, QOCMC staff would sometimes make a request of the central office only to be told that the responsible person was not available and that no one else knew what to do. A computerized system now tracks all requests for equipment, supplies, and repair and maintenance. All QOCMC staff know how to use the system, so that when a district staff member calls, anyone answering the phone can check the system and provide the answer.

The request-tracking system reinforces the idea that the entire QOCMC office (rather than individuals in the office) is responsible for supporting the districts. Not only does QOCMC provide improved service, which earns it appreciation and positive relations with district staff, but the center also serves as an excellent example of client-oriented service delivery for the districts. District staff are treated as customers, a marked shift from the traditional relationship with the central-level MOH, where bureaucratic procedures and hierarchy are often obstacles to information exchange and timely support. QOCMC deals with district staff in a professional, respectful manner, providing a high-quality service-precisely the manner in which district staff are encouraged to deal with their clients.

INITIATION OF CLIENT-ORIENTED SERVICES

During its first three years, QOCMC primarily focused on addressing management of service facilities, needs of service providers, and improvement of basic clinical skills, including infection prevention. Over time, QOCMC has realized that addressing only the needs of providers does not achieve real quality improvement. It is also critical to meet the needs of clients. QOCMC staff now see themselves as entering a new phase: focusing on how to make services more client-oriented. During recent years, the QOCMC has worked towards adopting a more comprehensive definition of quality. With encouragement and technical support from AVSC, it has worked with the MOH to promote a deeper understanding of what quality of care can encompass. New concepts were first raised many months before staff were able to incorporate them into the existing conceptual framework. And yet gradual change is taking place.

Currently, the QOCMC is developing tools to obtain client-satisfaction information and to educate providers about the importance of clients' rights. New indicators, such as privacy, respectful and effective client-provider interaction, and appropriate, comprehensible postoperative instructions, have been added to the monitoring form.

A variety of innovations are being introduced, and efforts are being made to make clinics more "client friendly." For instance, clients are encouraged to comment on services, and clients' rights are posted in clinics. Waiting rooms now contain interesting and informative materials, and signs describing services and listing providers are posted.

Such simple innovations represent dramatic change in Nepal. Providers in the districts have been reluctant to post a list of available services because they did not want to be held accountable to provide them. Similarly they are sometimes reluctant to advertise clients' rights because they are concerned that clients may become too demanding. For providers to see patients as clients is a revolutionary concept in a society where the status of physicians is so much greater than that of clients.

It remains to be seen how quickly the new client focus will have an impact. QOCMC staff are themselves only beginning to conceptualize the implications of client-oriented services. They recognize that the greatest challenges are to educate clients and to change the attitude of the providers; as one QOCMC staff member stated, "Quality improvement is a continuous exercise in improvement, not a one-time activity." Such radical attitudinal changes will require time and consistent reinforcement, as well as external support to deal with problems and new situations. QOCMC has earned the trust and confidence of the districts and may indeed be in a position to make it happen.

SUPPORT FOR OTHER ORGANIZATIONS

QOCMC has been recognized in Nepal as a leader in quality of care. Because of this, many organizations have approached the QOCMC for assistance in conducting orientations and training and for help in upgrading the quality of family planning services. QOCMC has worked to improve infection prevention practices in hospitals supported by the Nepal Safer Motherhood Project (NSMP), another development partner of the Family Health Division funded by the Department for International Development (UK) and managed by Options Consultancy Service Limited. The center developed curricula for medical and support staff, conducted whole-site training, provided monitoring and supervision, and developed guidelines for hospitals. NSMP staff were trained in conducting COPE (client-oriented, provider-efficient services), AVSC's self-assessment approach to improving the quality of services, which was then successfully implemented in their hospitals. QOCMC has also provided support and training for the National Health Training Center, nursing schools, and various family planning clinics, especially regarding infection prevention practices and general concepts of quality of care in family planning services.

CONCLUSION

District family planning service centers have made significant improvements in most quality of care indicators, including infection prevention practices, availability of temporary and permanent methods, emergency preparedness, use of informed consent forms, and availability of equipment (see Figure 2). Over time, QOCMC adds new indicators as it works with staff and clients to refine the working definition of quality services. QOCMC continues to seek new ways to improve its capacity to assist the district clinics, including development of new educational materials for clients and manuals for providers.

The success of the QOCMC in Nepal highlights the fact that even in resource-poor settings, quality of care in health service delivery can be achieved. This model for a quality of care center that provides timely, appropriate, and ongoing support to clinical facilities may be especially useful in countries where centralized systems are in place for allocation of resources or where maintenance and supply capacity is limited to central locations.

There are several ongoing obstacles to sustained quality of care in Nepal. One of the most frustrating factors is the continual change of staff in the districts. Neither the FHD nor the QOCMC can directly influence the placement of staff, and the QOCMC must continually provide training to new staff in all aspects of quality of care. An additional problem is that the MOH is under great pressure to expand the availability of family planning services throughout the country. Preoccupied by trying to provide enough services, policymakers may see quality as a luxury that the country can ill afford. There is a continuing role for QOCMC to advocate for quality of care, especially among senior MOH staff and providers.

The strong, productive relationships among QOCMC, AVSC, NFCC, USAID, and the MOH have been critical to the success of the center. Located in the Ministry of Health offices, QOCMC staff are able to continually strengthen MOH skills, respond to needs for technical assistance for planning and coordination of family planning activities, and promote conceptual shifts that are needed to bring about real change. The flexibility inherent in the joint NGO-MOH status of the center has enabled the center to respond quickly, to link with other agencies and resources, and to help ensure continuity of skilled and talented staff; this may not have been the case if the QOCMC were strictly an MOH program. The client-oriented approach of the QOCMC is also a distinct departure from traditional government bureaucracy.

In Nepal, establishing formalized systems for repair and maintenance was a critical first step, so that trained staff have what they need to perform their duties. Renovating facilities so that they function more effectively and are comfortable, pleasant places to work has boosted worker morale and performance. Ongoing and timely support from QOCMC has strengthened relationships with clinic staff; as a result, field officers are viewed as part of the clinic team, not as outsiders.

QOCMC learned early on that it was not enough to provide good training. Facilitative supervision that strengthens the problem-solving and technical skills of staff through ongoing reinforcement, gradually introduces new concepts and ideas, and provides long-term support has been essential to assuring that quality of care skills are institutionalized. It is hoped that, as time goes, this approach will also assure that a new client-oriented focus will be instilled in family planning service center staff. Consistent long-term follow-up is essential in any setting, especially when staff are transferred between sites.

An ongoing simple, useful monitoring system has provided rapid, useful feedback to providers and supervisors and has given all team members critical tools for decision making and planning. It has also helped motivate staff. A comprehensive list of quality indicators has proven valuable in tracking performance over time. Integration of all clinic staff members into problem solving has increased the likelihood that problems will be solved, especially since management problems often contribute to problems that may first appear to be technical or clinical in nature. The QOCMC approach focuses on the performance of the whole site rather than on individuals, promoting and fostering teamwork and a sense of shared responsibility.

Consistent investment over time has yielded significant improvements in the quality of family planning services in Nepal. Strengthening local capacity requires a variety of elements to be in place, not the least of which is receptivity among providers and policymakers. These changes take place slowly and require continued guidance, encouragement, and careful management. Consistency and the long-term building of local skills and capacity have been the major contributions of AVSC. The development of this successful model highlights the possibilities for improving quality of care when the necessary mix of leadership, political will, and well-managed resources are brought together.


[TOP] [INDEX] [Bibliography] [Authors] [Acknowledgments] [Case Studies] [Figure 1] [Figure 2]

BIBLIOGRAPHY

Aitken, J.-M. 1994. Voices from the inside: Managing district health services in Nepal. International Journal of Health Planning and Management 9:309–340.

Baker, J.; Friedman, R.; Thapa, S.; and Rai, T. 1994. Understanding quality of care in family planning in Nepal. Journal of the Nepal Medical Association 32:154–174.

Barnett, B., and Stein, J. 1998. Women’s voices, women’s lives: The impact of family planning. Research Triangle Park, NC: Family Health International.

Ben Salem, B., and Beattie, K. J. 1996. Facilitative supervision: A vital link in quality reproductive health service delivery. AVSC Working Paper No. 10. New York: AVSC International.

Bradley, J.; Lynam, P. F.; Dwyer, J. C.; and Wambwa, G. E. 1998. Whole-site training: A new approach to the organization of training. AVSC Working Paper No. 11. New York: AVSC International.

Bruce, J. 1990. Fundamental elements of the quality of care: A simple framework. Studies in Family Planning 21:61–91.

Dwyer, J. C., and Jezowski, T. 1995. Quality management for family planning services: Practical experience from Africa. AVSC Working Paper No. 7. New York: AVSC International.

Finger, W. 1998. A “client perspective” helps improve services. Network 19(1):10–13.

Kaufman, A. 1997. Client and service provider perspectives on quality of care in family planning: An exploratory inquiry (unpublished paper). Kathmandu: AVSC International.

Kaufman, A. 1999. Enhanced monitoring of mobile outreach sterilization services: Client perspective report (unpublished paper). Kathmandu: AVSC International.

His Majesty’s Government, Nepal, Central Bureau of Statistics. 1995. Population monograph of Nepal. Kathmandu.

His Majesty’s Government, Nepal, Family Health Division, Ministry of Health. 1995. National medical standards for reproductive health. Volume 1: Contraceptive services. Kathmandu.

His Majesty’s Government, Nepal, Family Health Division, Department of Health Services, Ministry of Health; New Era; and Macro International. 1996. Nepal Family Health Survey. Kathmandu and Calverton, MD.

His Majesty’s Government, Nepal, Family Health Division, Ministry of Health, and Nepal Fertility Care Center. 1998. Quality of care program in Nepal (unpublished paper). Kathmandu.

New Era. 1996a. A study on clients’ satisfaction with Norplant services in Nepal. Kathmandu: AVSC International.

New Era. 1996b. A study on clients’ satisfaction with sterilization services in Nepal. Kathmandu: AVSC International.

Research Group for Health Economics and Labor. 1997. Health statistics of Nepal. Lalitpur, Nepal.

Shrestha, D. R. 1998. Quality of care in family planning program of Nepal (unpublished paper). Kathmandu: Nepal Fertility Care Center.

Stash, S. 1999. Explanations of unmet need for contraception in Chitwan, Nepal. Studies in Family Planning 30:267–287.

United Nations Children’s Fund. 1996. State of the world’s children. New York.

[TOP] [INDEX] [Bibliography] [Authors] [Acknowledgments] [Case Studies] [Figure 1] [Figure 2]

Working Paper #13 Authors:

Harriet Stanley is senior director, AVSC International, Bangkok; Dirgha Raj Shrestha is program coordinator, AVSC International, Nepal; Mark Barone is program manager for research, AVSC International, New York; and Mary Linehan is a consultant.


[TOP] [INDEX] [Bibliography] [Authors] [Acknowledgments] [Case Studies] [Figure 1] [Figure 2]

The purpose of AVSC Working Papers is to capture on paper AVSC's experience and to disseminate the results of AVSC-supported operations research. We welcome your comments and suggestions.

ACKNOWLEDGMENTS

The authors wish to acknowledge the commitment and guidance of the Family Health Division, Ministry of Health, and in particular the leadership of Dr. Laxmi Raj Pathak in making quality improvement a reality in Nepal’s family planning program. We also greatly appreciate the pioneering role of the Nepal Fertility Care Center, under the direction of Dr. Tika Man Vaidya, in establishing effective and creative partnerships between nongovernmental organizations and government health services.

The program described in this paper was developed with funding from the U.S. Agency for International Development/ Nepal. The authors gratefully acknowledge the technical guidance and support that USAID has provided to quality improvement initiatives. In particular, the authors express deep gratitude to Matt Friedman for his thoughtful and consistent commitment to improving quality at the service sites and for his role in establishing the QOCMC.

The AVSC Nepal Country Office and the staff of the QOCMC were key partners in the data collection and writing of this paper. Special thanks go to Ashoke Shrestha, AVSC’s country representative in Nepal, and Sabitri Joshi, field coordinator, Quality of Care Management Center. The following AVSC staff and consultants were instrumental in supporting the QOCMC at different stages of its development: Radha Friedman, Joan Venghaus, Lynn Poole, and Anne Kaufman. AVSC staff members Evelyn Landry, Maj-Britt Dohlie, Terrence Jezowski, and Dr. Sangeeta Pati provided valuable review comments. Pamela Beyer Harper edited the paper. Anna Kurica was responsible for layout and production.

EDITORIAL COMMITTEE
Lynn Bakamjian
Karen Beattie
Vanessa Cullins
Andrea Eschen
Sara Gardner
Pamela Beyer Harper
Evelyn Landry
Rachael Pine
Santiago Plata

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