Quality of care has been a central focus of the international family planning (FP) programs for the past two decades. Consistent with the major theme of the 1994 ICPD Conference for more client-focused services, many governments and NGOs worldwide designed and implemented initiatives to improve quality of care  within their service delivery environment to ensure clients receive the care they need and deserve. The Bruce-Jain framework, developed in 1990, is often considered the central paradigm for quality in international FP and defines the six elements of quality of care: choice of methods, information given to clients, technical competence, interpersonal relations, follow-up and continuity mechanisms, and the appropriate constellation of services.

With the increased interest in quality that developed during the 1990s, many organizations searched for means to evaluate quality for the purposes of (1) underscoring to staff the importance of quality, (2) identifying problems they needed to address, and (3) measuring the effectiveness of interventions designed to improve quality.  According to WHO (2006), a health system should seek to make improvements in six areas or dimensions of quality. These dimensions require that health care be:

• • effective, delivering health care that is adherent to an evidence base and results in improved health outcomes for individuals and communities, based on need;
  • efficient, delivering health care in a manner which maximizes resource use and avoids waste;

• • accessible, delivering health care that is timely, geographically reasonable, and provided in a setting where skills and resources are appropriate to medical need;
  • acceptable/patient-centred, delivering health care which takes into account the preferences and aspirations of individual service users and the cultures of their communities;
  • equitable, delivering health care which does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location, or socioeconomic status;

• • safe, delivering health care which minimizes risks and harm to service users.

Service Provision Assessment (SPA)

The most comprehensive tool for evaluating quality of care is the SPA from MEASURE DHS, a national survey of a representative sample of facilities that provide maternal, child, and reproductive health (RH) service.  In addition to quality, it also measures the general functioning of a network of public and private facilities, and it provides an inventory of available equipment and supplies.  The SPA provides a means of assessing strengths and weaknesses in the service delivery environment, which (1) may explain the impact (or lack thereof) of the services on health behaviors in the catchment area, and (2) may guide policy makers and program administrators in prioritizing resources for better health outcomes.

The SPA uses four different data collection methods. The first is an inventory of resources and support services, which provides information on the “preparedness” of a facility to provide each of the priority services at an accepted standard of quality.  As part of the inventory (also known as a facility audit), interviewers ask staff about their qualifications, training, perceptions of the service delivery environment, and related issues.

The second is a provider interview, during which interviewers ask health service providers for information on their qualifications (training, experience, continued education), supervision they have received, and perceptions of the service delivery environment.

The third is observation of services provided. The observation assesses the extent to which service providers adhere to service delivery standards.

The fourth is exit interviews with clients who have received services.  The exit interview assesses the client’s understanding and perceptions of the consultation/examination, as well as recall of instructions regarding treatment or preventive behaviors.  Recall of key messages increases the likelihood that the client will successfully follow treatment or will perform the preventive behaviors that optimize healthy outcomes.

The SPA not only measures quality of care but also overall functioning of the facility, as reflected by the set of questions it addresses:

1) To what extent are the surveyed facilities prepared to provide the priority services?

2) To what extent does the service delivery process follow generally accepted standards?

3) To what extent do support systems for maintaining or improving the existing services exist, and how well are they functioning?

4) What are the issues the clients and service providers consider relevant to their satisfaction with the service delivery environment?

The SPA provides the following information on five types of health services: FP, sexually transmitted infections (STIs), maternity and newborn care, child health, and HIV/AIDS:

• Preparedness to provide good quality services;
• Adherence to standards for provision of services; and
• Client understanding of the consultation

Other data, specific to these topic areas, are as follows:

• Preparedness to offer both basic and higher level diagnosis and treatment of suspected STIs;
• Preparedness to diagnose and to treat HIV/AIDS-infected persons, including specific program components related to HIV/AIDS prevention, treatment of opportunistic infections, palliative treatment, and family and client support services
• Preparedness to provide good quality basic and higher level antenatal care;
• Preparedness to provide basic and higher level delivery services;
• Preparedness to provide good quality immunization services; and
• Preparedness to provide good quality basic diagnosis and outpatient treatment of the seriously ill child

For each of these health services, the SPA covers the following specific components:

(1) Staff:  What is the qualification of staff who provide the service?  Have the service providers received periodic continuing education on relevant topics, and how recently has training occurred? Have the service providers received a minimal level of supervision?

(2) Process:  Do protocols and standards of practice for each service meet generally accepted quality standards for basic as well as advanced level services at referral facilities? Do providers adhere to the standards of practice for service delivery?  The process assessed includes procedures followed, components of physical examinations, as well as the information exchanged between the provider and client (history, symptoms, advice).   The SPA assesses if the process during service delivery meets the standards; it does not assess if providers correctly diagnose the problems.

(3) Facility resources, equipment, and supplies: What specific equipment and supplies are available for meeting various levels of service delivery? What are the basic systems and infrastructure that may impact utilization and capacity to provide standard level services?  Are the elements required to provide the services meeting the minimum standard, present, functioning, and in the appropriate location for use during service provision? Are there systems for maintaining adequate availability of supplies (inventories; appropriate storage, equipment maintenance and repair/ replacement systems), and is there evidence of their effectiveness?

(4) Systems for evaluating and monitoring services: Are routine information systems up-to-date and able to provide basic client and service provision data? Are there systems for monitoring community coverage if community coverage is expected of the facility?

(5) Facility management: Does the facility have basic management systems in place, and do they include community representation?  Does the facility participate in any financing mechanism that impacts the cost to the community or client?

(6) Client understanding:  What information regarding the consultation, instructions, or follow up can the client recall?

(7) Service provision environment:  Does the facility collect very basic information about the problems staff think should be addressed to improve their working situation and services?  Does the facility collect data revealing the opinion of clients regarding issues related to satisfaction with their consultation and the service delivery environment?

The SPA yields data from different instruments for the five areas of RH and child health.  (In fact, the sheer volume of data generated in this type of survey led to the creation of the Quick Investigation of Quality (QIQ), an instrument less comprehensive in scope, based on 25 indicators and focused exclusively on FP.) Although evaluators provide the most complete picture of quality and service availability when they assess the service areas together, a number of factors (e.g., limited human and financial resources, local interest in a particular service area) may dictate a limited scope of the SPA. The SPA has been developed so that evaluators can use each of the modules separately.  In the About section of the database is a full list of the indicators available from the SPA for four areas.  In addition, several composite indicators assess the service delivery environment across these service areas.

The SPA module measures the service delivery environment. First, it identifies strengths and weaknesses of a set of clinical facilities at a given point in time, and if repeated, the data can demonstrate changes over time (as in Tanzania in the 1990s).  Second, if a program is not achieving its desired outcome, the SPA data may reveal service-related reasons for this shortcoming. Third, the SPA data play an important role in a relatively new approach to evaluating program effects. Researchers link facility-based data from the SPA to household-level data from the DHS to demonstrate that changes (improvements) in the service delivery environment improve outcomes at the population level.

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References:

World Health Organization, 2006.  Quality of Care: a process for making strategic choices in health systems.