GDS staff have been pioneers in quality assurance in primary healthcare.
Our country-level projects typically begin with the development and adoption of clear standards of care which form the bases for detailed surveys of current practice. These surveys are conducted by trained health professionals who directly observe the provision of care and score it for compliance with the adopted standards. The distance between best practices and current practices – often appalling to the HWs involved – provides the impetus for development of correctives, correctives that are designed by the HWs themselves. Within a few weeks, compliance with best practices has climbed from initial levels of 20 - 30 percent to over 80 percent, and remain at that level in followup surveys conducted at six and twelve months.
MNCH - public sector
This project addressed the quality of care for ANC, vaccination, management of diarrhea and management of ARI in primary healthcare facilities in two provinces. in Pakistan. The initial activity – common to all of our QA work – was to develop with the MoH and gain widespread buy-in of practice standards. Direct obser-vation was then carried out in 53 health facilities; in-home interviews were conducted with 1,300 women of child-bearing age.
The results led to a revision of pro-cedures, increased supervision, and added training for clinic staff.
Primary care - public sector
Our staff's largest and most complex undertaking in QA was conducted in 1,488 health centers in Indonesia. Standards of care were developed by the MoH for ANC, ARI, vaccination, management of diarrhea, management of malaria, TB, and family planning.
Here the adoption of best practices by facility staff was even faster and more complete than in smaller projects. Within 60 days almost every facility brought into the program was posting compliance levels above 80 percent. A review of patient records found that polypharmacy was down 40 percent in the QA facilities. And patients recognized the improvements in care; service statistics showed a five percentage-point annual increase in utilization of QA health centers.
After nine to twelve months of work on improving technical compliance with clinical practice guidelines, facility staff formed quality-improving teams – with our support – to address more complex problems for which there are no univer-sally accepted guides. These included the usual topics (amenities, waiting times) but also took on enduring and challenging primary care problems such as the referral system and patient compliance with home treatment regimens.
RH - Private sector
Our staff introduced QA into several private sector settings in Jordan. As always, Practice Guidelines were developed with experts in the MoH and field tested for practicality. Given the absence of supervisory mechanisms in the private sector, mystery clients/patients were employed to verify service quality. Two examples:
Female OB/GYNs and General Practi-tioners (550 participants). Following completion of a weekend course and competency exam in reproductive health, the physicians' performance was assessed by mystery patients (themselves female physicians). The incentive to participate was award of a framed certificate of service quality upon successfully passing the course exam and the mystery patient assessment (sadly, quality itself does not seem to be a sufficient enticement for some).
Pharmacists (1,500 participants). Acknow-ledging the role of private-sector phar-macists in advising clientele (a doctor's prescription was never demanded) a short course in screening and counseling was given and job aids were distributed. Again, mystery clients checked the quality of service 45 - 60 days after the course. The modest, but effective, incentive for successful completion of the exam and mystery-client assessment was a counter display created by a popular cartoonist.