DISH II Strategy for Improving
Quality of Care In Health Facilities

In July, 2000, representatives from the Ministry of Health, District Health Services, DISH II, and Population Council developed a strategy to improve and maintain basic standards of care at health facilities in the districts of Kampala, Jinja, Kamuli, Luwero, Nakasongola, Masindi, Masaka, Rakai, Ssembabule, Mbarara, Ntungamo, and Kasese. Based on successful interventions in Egypt and Brazil, the strategy is designed to:

• Enhance service provider self confidence and performance,
• Institute a team approach to support better quality services,
• Involve communities in quality improvements, and
• Maintain quality through a system of certification and reward.

The strategy will be evaluated so that the Ministry of Health can expand similar interventions to other districts.

Rationale: The quality of health services in the DISH II districts needs improvement. Health services in the DISH II Districts continue to be underutilized, and according to recent analysis of HMIS data from 80 sentinel health facilities monitored by the DISH II Project, utilization has been declining for several reproductive health services in the past year. Typically, low utilization occurs when service quality is poor. Studies and supervision visits to health facilities have found need to improve services in a number of key areas. Studies of community members show that clients often do not use the services because they doubt their quality.

The Strategy:
The strategy developed during the July 2000 workshop is based on projects in Egypt and Brazil that successfully improved the quality of services and maintained improvements through a system of certification and public recognition. The strategy involves 6 steps:

1. Improve quality of services: DISH II will continue to provide support to the districts and health sub-districts to:
• Train nurses, midwives, nurse aides, medical assistants, and medical officers to provide good quality reproductive, maternal and child health services.
• Supervise health facilities on a regular basis, including on-site supervision by In-Charges
• Improve management, storage, and distribution of drugs and contraceptives
• Maintain and analyze data from the health management information system (HMIS)
• Make available information, education and communication materials on reproductive maternal and child health topics, and
• Provide essential equipment.
  
  These inputs are expected to enable health facilities to provide good quality reproductive, maternal and child health services.
  
  
2. Set Basic Standards of Quality
   
   The Ministry of Health has developed guidelines and standards for the essential health care package of services, and has developed National Supervision Guidelines to monitor these standards. Under the DISH Quality of Care Strategy, a task force comprised of Ministry and District representatives will develop a set of "Basic Standards of Care", which will include a small number of essential standards that all health facilities must meet. These standards will include quality indicators from the client's perspective as well as the provider's perspective.
   
   For example, in Brazil the Proquali Project developed a set of 61 "accreditation criteria" that could be monitored regularly. These criteria included 18 on service delivery; 9 on infection prevention; 12 on interpersonal communication; 14 on physical plant and supplies; and 8 on management systems.
   
   
3. Communicate Basic Standards throughout the Health Care System
   
   Once a set of "Basic Standards" has been agreed upon, the DISH II Project will prepare posters and handouts describing the program and listing the "Basic Standards". These materials will be distributed during briefing meetings with DDHS's, HSD In-Charges, health unit In-Charges, community leaders, and development partners. Posters and materials will be developed for clients and community members in vernacular, which can be posted on health facility walls and distributed to clients attending the health facilities. The intention is to familiarize all members of the health care system with the "Basic Standards" and gain commitment to the strategy.
   
   
4. Monitor and reward facilities that meet and maintain "Basic Standards"
   
   Attainment of the "Basic Standards" will be monitored during routine integrated supervision visits, using checklists. A database of all facilities will be established to track which standards each health facility has attained during each supervisory visit. Once a health facility has met all the "Basic Standards" on two consecutive quarters, members of the DHT will verify that the health facility is meeting all the criteria, and award the facility with a "Seal of Quality" during a public ceremony. The DDHS will also award certificates to each health provider working at the health facility. In order to retain the "Seal of Quality", health facilities will have to continue to maintain the "Basic Standards." If the standards are not met during a supervisory visit, the seal will be removed.
   

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