Fundamentals of Quality of Care - A Training Mannual for NGOs :: PFI Publication :: KNOWLEDGE MANAGEMENT CENTRE PORTAL, POPULATION FOUNDATION OF INDIA

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Fundamentals of Quality of Care - A Training Mannual for NGOs

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Fundamentals of Quality of Care - A Training Mannual for NGOs

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Fundamentals

of Quality of Care...

A Training Mannual for NGOs

PFI

POPULATION FOUNDATION OF INDIA

B-28, Qutab Institutional Area

Tara Crescent, New Delhi-110016

Phone: 42899770

Regional Resource Centre

Population Foundation Of India

New Delhi

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Guidance

A R Nanda

Almas Ali

Kumudha Aruldas

Sharmila Neogi

Contributors

Dinesh Singh

Sanjit Nayak

Sudipta Mukhopadhyay

Bhairavi Buch

Matish Kumar

Assistance

Arun Kumar

Amrit Rawat

Prema Ramesh

Sudhir Kumar

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Foreword

The importance of assessing the quality of reproductive health services

and developing appropriate mechanisms to continuously monitor and

improve the quality of services need no emphasis. ICPD Cairo conference

also emphasised the need to address quality of care issues from both

clients and [providers perspectives.

Population Foundation of India has been supporting involvement of NGOs in reproductive

and child health programmes with the changing paradigm shift of making programmes more

relevant to the peoples needs. As a Regional Resource Centre (RRC) the Foundation has

been undertaking capacity building of MGOs/FNGOs under the MNGO scheme of

government of India to improve NGO effectiveness in RCH programmes. These efforts

include improving technical and managerial skills of the MNGOs/FMGOs under various

thematic issues including quality of care.

The manual covers all the generic and specific quality of care elements within a gender

sensitive and rights based framework. The manual describes, the process of ensuring quality

assurance in a simple user friendly and participatory manner. Wherever necessary, case

studies, stories, games, role play have been sued to make the sessions more interactive and

meaningful.

I hope this manual will be a portent tool for district level managers from government and

civil society including RRC trainers, MNGO and FNGO staff to monitor the quality of

reproductive health services in a systematic manner. In addition the manual can be used as a

basic reference document for policy makers and civil society institutions.

I also take this opportunity to acknowledge the contribution of the PFI RRC team without

whose contribution this document would not have been possible. A special thanks to Dr

Dinesh Singh for his technical assistance in shaping this document. Finally I extend the

Foundations gratitude to MoHFW for providing the financial support for this document.

A R Nanda

Executive Director

CONTENTS

Chapters

I Quality of Care:

• Definitions of quality of care

• Quality of care: framework

• Why is it important to be concerned about quality of care?

• Who does it benefit?

• Who should be involved? Is it something new?

• Quality assurance cycle

• Elements of quality of care

• Dimensions of the health system

II Reproductive and Sexual Health Rights

• Reproductive Rights

• Clients Rights

• Needs of service provider

• Ensuring quality of care and rights based approach in service delivery.

III Gender

• Differentiate between sex and gender.

• Discuss different attributes associated with male and female roles.

• Explain the contribution of society in determining roles and the consequent

discrimination based on gender.

• Discuss the role of the service provider in mitigating gender discrimination

IV Communication Skill

• Skills of good communicator

• Barriers in communication

V Counseling skills

• What is counseling

• Components of counseling

• Skills in Counseling

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RATIONALE TO CONDUCT THE TRAINING

Quality is the central issue in the health care. Rising expectations of the people, advances in medical and

diagnostic technology, competition in health care industry, and increasing cost have made quality of

care an important issue today. There is a growing realization that quality improvement is essential for

enhancing efficiency and effectiveness of health services both in the public and private sectors.

Quality, a relatively new concept in health care, is a dynamic and complex phenomenon. There is an

extensive need for capacity building in planning, implementing, and managing quality assurance in

health care. Also, there is a great deal to be understood about the dimensions of the quality and the

standards and indicators, assessments and measurement, and management of the quality improvement

process.

AIM OF THE TRAINING MANUAL

The purpose of this manual is to provide practical assistance to the trainers for imparting the training on

quality of care. The manual can be used in the context of training workshops, which could target

different groups such as healthcare providers, guideline developers, NGO workers and managers. The

manual can also be used as a template for developing training manuals in languages other than English.

OVERALL OBJECTIVES OF THE QUALITY OF CARE TRAINING

The broad objective of the training programme is to develop knowledge and basic skills of different

stakeholders in quality assurance in health care. The specific objectives of the program are:

· To develop an understanding of the concepts of quality and its importance in health care

· To develop an understanding of standards and indicators of quality

· To equip the trainers with the required skills to integrate the provision of quality services in all

the Reproductive health program

· To develop the basic skills in assessment and measurement in quality

· To develop skills in monitoring quality of services and in planning and implementing quality

assurance program

Participants

The program will cater to the needs of health care planners, district level health officials, PRIs, NGO

service providers in developing basic competency in planning and managing quality of care in RCH

programs.

Batch Size:

The group size should be kept small. Not more than 20-25 participants at the time should be trained.

This increases the chances for a better outcome and more engaged participation.

Duration of the Training:

The manual provides thirty four hour curriculum and can be covered in full five days. If necessary

the trainers and participants can adopt as per their need and requirement.

Chapter 1

Session I Quality of Care

Objectives:At the end of this session the participants will be able to

· Understand meaning and concept of quality of care in general and specifically in health sector.

· List the elements of quality of care and its determinants.

· Ensure quality of care services in reproductive health programs.

· Relate and integrate essential elements of quality of care in their day to day to work.

Methodology:

· Group Discussion and Brain storming

Resources:

· Papers and Marker Pens

· Chart papers

· Flip chart Board and Pen

· Hand outs

Time:

Two hours

Process:

Activity1: Brain storming on the word “quality of care”. Discussion on the definition, concept,

meaning, elements of quality of care.

Facilitator encourage the participants to talk about quality in the general sense and relate it to why they

buy certain products or why they shop from certain stall holders. And then come up with a list of quality

factors such as:

· Reputation

· Prompt service

· Customer friendly

· Right price

· Good standard

Activity 2: Group work on Quality of care in Health Care services especially in reproductive health

programs.

Facilitator divides the participants in to groups of two. Depending on the situation, the allocation of

groups can be systematic or random.

Each group is asked to list based on the above discussion the elements or standards and determinants of

quality of care in reproductive health programs.

Group Presentation:

The group work exercise is followed by group presentation on the results of discussion

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Facilitators Brief;

The presentation is then followed by facilitator's discussions and presentations on elements of quality

of care its determinants its importance and relevance in health sector especially the reproductive health

issues.

Session II Quality Assurance and Dimensions in Health system

Objectives:

At the end of this session the participants would be able to:

· Understand the importance and need for quality assurance

· Understand the dimensions in health system

· Relate and integrate the measures of quality assurance into the health sector program in

reproductive health issues from all the perspectives.

Methodology

· Group Discussion

Resources:

· Papers and Marker Pens

· Chart papers

· Flip chart Board and Pen

· Hand outs

Time:

Three hours

Process:

Activity 1: Group discussion on what is quality assurance and the steps in quality assurance

Facilitator would initiate and involve the participants in the discussion of quality assurance, its

importance and its need. The discussion can emerge around points as;

· QA is a continuous process aimed at assessing, monitoring and improving the quality of health

services

· It focuses on process, activities and style of working.

· It has a team work approach towards problem solving and improvement.

· It analyses through use of data any or all of the quality of health care dimensions.

Activity 2: Group work on dimensions in health care system

Facilitator divides the group into three

Each group will work separately on identifying important quality factors from their perspective.

Group 1 would represent client's perspective and list down various areas that a client/ patient expect

from clinic/hospital services.

Group 2 would represent professional perspective and list down various areas that the professionals

need as a provider to ensure highest quality standards

Group 3 would represent management's perspective and list down various areas that are needed from

administration and management point of view in order to ensure better quality services.

Group Presentation:

The group work exercise would be followed by presentation by each group and discussion on it.

Discussion

The facilitator would the leave the session open for discussion and brief the participants about various

dimensions in health system. The facilitator would also orient the participants towards various aspects

of quality of care and its measurement. For example the structural quality measure, process quality

measure and outcome quality measure. The session can be made open for queries too.

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Chapter 2

Session 1 Gender and Health

Objectives: At the end of session the participants would be able

· Differentiate between sex and gender

· Discuss various attributes associated with male and female roles

· Discuss the role of service provider in mitigating gender discrimination

· State how sex and gender impact on health of individual

Methodology:

· Quiz

· Group exercise

· Discussion

Resources:

· Papers/ Marker Pens

· Handouts

Time:

Two hours

Process

Activity 1 Quiz 'Sex and Gender'

Facilitator asks the participants to state what they understand by term gender and lists these responses

on one side of board. Facilitator asks the participants to state what they understand by term sex and lists

these responses on side of flip chart board. From the lists of the responses then facilitator highlights the

difference in two concepts. Facilitator then presents and explains characteristics of gender.

Facilitator conducts quiz on Sex/Gender statement by reading out each statement and

asking participants to say whether its sex or gender

Statements For Quiz

Ø Women are gentle by nature

Ø Men are better at playing cricket than women are

Ø Women menstruate

Ø Men are violent in nature

Ø Women are better cooks then men.

Ø Women have long hair

Ø Men have moustaches and beard

Ø Women are better housekeepers then men

Ø Men cannot do housework

Ø Men cannot contro; their sexual desires

Ø Men get bald as they grow older.

Ø Women are protected from heart diseses.

Ø Women have ovaries

Ø Women eat after men have eaten their food

Ø Men are not able to look after children

Ø Voice changes in boys as they grow up

Ø Women leave their parents house after marriage.

Activity 2 Group exercise on gender discrimination

Facilitator will provide for zopp cards prepared in advance containing various statements. Each

statement would be repeated three to four times. and each pair would have one statement each.

Facilitator would ask the participants to divide into pairs. And distribute the cards to each pair.

Facilitator asks them to discuss the statement with their partner, and write down their main points:

· Do you agree with the statement?

· If yes, then why is the situation/statement true?

· If not, then why do you disagree?

· What impact does the statement have on the health of women and the development of

communities and the nation?

· What can be done to improve situation

The group exercise would be followed by group presentations.

This would be followed by group discussion and the facilitator would discuss how gender affects

various spheres of life cycle of an individual. How the differences in biological sex and gender interact

to produce different categories of health conditions. Brainstorm with the participants how they can

contribute towards minimizing the gender discrimination.

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Chapter 3

Session 1 Reproductive Rights

Objectives: At the end of the session the participants will be able to

· Know the reproductive and sexual health rights of the individual

· Know what are clients rights

· Would be able to integrate a rights based approach in daily service delivery.

Methodology

· Exercise

· Brain storming

· Documentary/Video showing or Role Play

Resources:

· Chart Papers/Pen

· Hand Outs

· Television, Video Player

Time:

Two hours

Process:

Activity 1 Exercise on Rights in general and reproductive rights

Facilitator divides the participants in to four groups. Generate the discussion on general rights that we

enjoy in day to day life. Ask them to brain storm about reproductive rights and discuss among

themselves and record it on the flip chart

The exercise is followed by group presentation and discussion

The facilitator then presents the background regarding the origin of reproductive rights, about the ICPD

conference and lists the reproductive rights of individual. It states that

Reproductive Rights

The right of individuals and couples

• To freely and responsibly decide

Whether to have or not to have children

The number and spacing of children

And have the information and services to do so

• To have a safe and satisfying sex life free from violence, pregnancy and disease

• To have the information and services to ensure a safe outcome for pregnancy

Activity 2. Clients rights and Needs of Service Provider

The facilitator involves the group in brain storming about the clients rights and needs of the service

provider while ensuring quality of care. The activity is for 30 minutes and the responses are listed down

on a chart paper and after the brain storming is completed discussion takes place.

The facilitator orients the group regarding rights based approach in reproductive health issues, its need

and importance. Facilitator also presents the clients rights in a situation, what are they and how they are

to be protected in order to provide better and effective service delivery and receive better health

outcome. The discussion should highlight following points.

· Freedom of choice

· Accurate information

· Confidentiality and Privacy

· Compassion, respect and understanding

· Freedom to express opinions

· Access, Continuity and follow up.

The facilitator then generates the discussion regarding needs of the service provider while providing

quality services. The following points should be stressed upon

· Facilitative supervision and management

· Information, training and development

· Adequate and timely supplies, of equipments and drugs

· Adequate and well maintained infrastructure

Activity 3. Video film viewing/ Role play on Client provider interaction.

A video film on reproductive rights and clients rights to be shown to the participants. Before viewing of

the film the facilitator should orient the participants regarding the issues in the film and also ask them to

take notes regarding how reproductive rights are violated, what is lacking and how one can improve

upon the shown situation.

After the film the participants would be given time to list down the responses to questions and then they

can present the views and a discussion is held on the same.

In lieu of video viewing, The facilitator can conduct the session with a role play.

Facilitator asks the participants to volunteer themselves for a role play and then the situation is

explained to the volunteers. The situation would be the following:

A married couple comes to the Primary Health centre with issue an concern of unwanted pregnancy

and abortion related services. The couple in the first visit talks to the doctor about heir concerns and

the medical officer is not able to pay attention, getting disturbed by phone calls etc. The couple on

their exit approaches the ANM regarding it and the ANM pays a home visit. The home visit shows the

involvement of the family the in-laws on the issue.

The facilitator asks the participants to observe and list responses to following questions

1. What kind of reproductive rights are involved in the situation?

2. How the rights violation is done at the family as well as at the service provision level?

3. What can be done to improve the situation?

This is followed by discussion regarding the responses and also how the participants can integrate the

knowledge of the same in their own routine of providing care and service.

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Chapter 4

Communication skills

Objectives: at the end of this session the participants will be able to:

· Understand the process of communication

· Make an effective use of two way communication process

· Understand the barriers in communication

Methodology

· Discussion

· Role Plays

· Exercises

· Group Discussion

Resources

· Chart Papers/Pens

· Hand Outs

Time:

Two hours

Process

Activity 1. Group discussion on qualities of good communicator

Facilitator asks the participants to recall an individual who is a good communicator. Ask them to recall

on qualities of such a person. Facilitator writes the responses on Board. The discussion should reflect at

least following responses

· Clarity in speech

· Easy simple language

· Positive attitude

· Ability to express ideas and feelings clearly

· Good listener

· Friendly

Facilitator summarizes the qualities of effective and good communicator. One quality common to all is

the ability of empathy Also quality to convey message effectively to receiver. And sincerity are always

associated with effective communication.

Activity 2. Exercise on communication

Facilitator instructs participants to close eyes and recollect five people they had met and write down

what they said to them. After five minutes the facilitator asks the participants asks participants to read

out what they have written. Generally it happens that they write and remember what they themselves.

said than what they heard. It is explained that most of the time one does not remember what others said

because many times messages are transmitted but not listened to.

Activity 3. Role Play on Patient doctor communication

Facilitator asks two volunteers from the group. They are asked to do a role play in which following

situation is described.

A patient comes to health clinic to ask about Facilitator discusses about barriers in communication

missed periods. There is lot of noise around

while staff is going in and out of room. The

doctor is talking to two or three people

Chapter 5 Counseling Skills

Session 1 Counseling skills

Objectives: At the end of this session, the participant will be able to:

· Describe what counseling is.

· Identify qualities and skills of a counselor.

· State the client's rights in a counseling situation.

· Begin to practice some specific skills of counseling

Methodology:

· Brainstorming

· Group exercises

· Role Plays

Resources:

· Chart papers/Pens

· Hand outs

Time:

Three hours

Process:

Activity 1. Brainstorming on concept of counseling.

Facilitator brainstorms with the group about the concept of counseling. The possible responses are

· Advising

· Telling them what to do

· Giving Information

· Exchange of ideas · Motivation.

The facilitator then presents definition of counseling and steps in counseling. Errors in counseling are

also presented.

Activity 2. Discussion clients Rights

Facilitator presents what are clients rights. A discussion is generated on what actually happens at the

health clinics and dispensaries. Feasibility of operationalisation of these rights at the level and possible

difficulties are discussed.

Facilitator then lists down concrete steps with the help of participants on operationalisation of clients

rights at the health clinics. Following could be the possible responses:

· Ensuring responses

· Separate place for counseling

· Ensuring confidentiality

· Provide complete information

· Alternatives to make informed decision

Activity 3. Role Plays on Counseling Skills

The facilitator divides the participants into three groups. Role play situations are given to the

participants to practice the skills of counseling. The role play situations are:

· Awoman comes to the clinic with missed period

· An adolescent girl comes with heavy bleeding complain.

· Acouple comes with doubts on use of contraceptive.

Role plays are followed by presentation and discussion on it.

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Notes And Guidelines:

Chapter 1 Quality of care:

Introduction:

Quality means different things to different people. It might mean reputation, durability of a product,

right price, prompt service, high standard, friendly reception, availability of services.

"Quality of care does not mean sophisticated or exclusive care, but is concerned with fully meeting the

needs of those who need the service most, at the lowest cost to the organization, within the limits set by

higher authorities

The health care provider is supposed to provide technically appropriate health care to the patient. To

ensure that the patient receives appropriate care the system of health care delivery is divided into

specialities and there is supposed to be an arrangement of referrals that ensures that the person with a

particular kind of problem reach a particular practitioner. Each provider in terms provides what she or

he knows as the most appropriate course of therapy. The provider is supposed to be the expert and

his/her advice and treatment reflects this expertise. The more qualified the provider, the more up-to-

date the investigations and drugs the more high quality it is supposed to be. However most patients

know, that at times the treatment from two doctors with the same professional degree, is slightly

different. The doctors use their own judgment to make what they feel is the most appropriate treatment.

How can the patient then case be sure which of these treatments is of better? Is the doctor who has a

better bedside manner better? Is the doctor who has a more well equipped clinic better? Or is the doctor

who prescribes more tests and gives more drugs better? The basic question is how do we judge between

different kinds of healthcare services? Understanding quality of care is one way in which we can make

such a judgment, and as managers, providers or clients we can make choices about what kind of service

to provide or use.

There are a number of definitions of quality of care and some of these are given below.

Ø Quality of care is the degree to which health services for individuals and populations increase the

likelihood of desired health outcomes and are consistent with current professional knowledge.

(Institute of Medicine 1990)

Ø Quality of care can be defined by the way the clients are treated by the system, or the actual process

of care-giving, and by the focus on the client's or user's perspectives of services (Hull, 1994).

Ø The degree of match between the client's view of the performance of the services and the service

providers view determines clients satisfaction (Ishikawa, 1985)

Ø Quality of care is

Doing the right thing

Doing things right

Doing things at the right time

Doing things with the right attitude (Abou-Zahr, 1994)

From the different definitions given about it is clear that providers attitude towards the client, the clients

satisfaction and perspective, as well as technical appropriateness and the desired health outcomes are

important components of quality. Another important issue of quality especially in a community health

care setting are management issues like access, training, infrastructure.

Ensuring Quality of Care

In order to improve quality of care of service or to measure it different authors have suggested looking at

different aspect of services. Among the different frameworks that have been proposed to define quality

of care the most notable in the context of Family Planning programmes has been the one proposed by

Judith Bruce (1990) which incorporates six elements. These include

(1) Choice of methods

(2) Information given to users

(3) Technical competence

(4) Interpersonal relations

(5) Mechanisms to encourage continuity

(6) Appropriate constellations of services

The Judith Bruce formulation is a very robust definition and has been applied to measure quality of

services for a long time. However in recent years the increasing focus of client's perspectives has led to

the addition of other components to this framework. UNFPA developed a reproductive health quality

framework which includes nine elements. Of these nine elements five are applicable in all situations

while four are specific to the different reproductive health conditions. An important feature of this

framework in the inclusion of client's participation in management decisions which goes well beyond

the concept of client provider interaction. This framework is given below

GENERIC ELEMENTS (common to all RH services)

4 Service environment

4 Client provider interaction

4 Informed decision making

4 Integration of services

4 Women's participation in management

SERVICE SPECIFIC ELEMENTS (specific to each RH service)

4 Access to services

4 Equipment and supplies

4 Professional standards and technical competence

4 Continuity of care

What this framework implies is that the generic elements have to be improved and ensured in all service

environments while equipment, supplies, technical competence will depend upon the level of service as

well as the reproductive health condition for which services are being provided. Thus at the Sub Centre

the ANM will provide a different level of service while at the District Hospital the specialist will

provide another. Similarly for the same RH condition (for example obstructed labour) will be dealt

differently at the PHC ( with referral) compared to the Emergency Obstetric Care Centre ( with

Caesarian section).

What is Quality Assurance?

Quality Assurance is a systematic and planned approach to assessing, monitoring and improving the

quality of health services on a continuous basis. It promotes confidence, improves communications and

allows clearer understanding of community needs and expectations.

1. Quality Assurance is oriented towards meeting the needs and expectations of the patient

and the community

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2. Quality Assurance focuses on the way we work, our activities, and processes of health care

delivery

3. Quality assurance uses data to analyse how we are working and delivering health services

4. Quality assurance encourages a multi-disciplinary team approach to problem solving and

quality improvement

In practice Quality Assurance is a continuous process and the quality assurance cycle can be used to

guide your activities. There are various different stages in the cycle which are explained

Quality Assurance Cycle:

Quality Assurance is systematic way of ensuring and maintaining “quality” of services and has proved

useful globally. The process of quality assurance has three major steps

1. Realizing and acknowledging the problem

2. planning an intervention and its implementation

3. Reviewing the outcomes of the intervention

If the desired outcome is not achieved, the process is repeated thus making it cyclical and continuous

one.

A composite and comprehensive way of looking at Quality of Care is to consider factors at three points

in time - upstream at systems (structures and capacities); at the time of client- provider interactions

(procedures and performance); and beyond at outcomes. The different factors which contribute to

quality of care are indicated in the table below.

Quality of Care - determinants

Structures/capacity Processes/Performance Outcomes

Policy intention Program

design Laws, regulation

and licensing

Training of providers and

competence

All the above include

gender and rights

perspective

Protocols and standards

Service infrastructure and

access

MIS

Supplies and logistics

Client (especially

women's) participation in

management decision-

making

Diagnostic and

therapeutic

appropriateness

Timeliness of care

Integration

Continuity of care

Interpersonal aspects

Involving clients in

decision making

Attending to client

comforts - cleanliness,

privacy, confidentiality

etc.

Special provisions for

women and their needs

Therapeutic outcome

Unintended outcomes

Client awareness and

knowledge

Fulfillment of client

expectations

Client satisfaction

Client behaviour

Opportunity for

feedback

(especially for

women's opinion)

Structural Quality Measures

This is the availability and quality of resources, management systems and policy guidelines. These

things are quite easy to measure, but are not always very informative unless they can be related to

processes and outcomes.

Structural aspects refer to the inputs absorbed in the production of health services. They include the

conditions of the workplace, service providers qualifications, available equipment and drugs. The

structural aspects of health care delivery are the easiest to be studied. Even in the most troubled

environments, some indicators related to structural aspects may be found, from routine data or in

evaluation and supervision reports. Checklists designed to collect indicators of this class abound.

The value of these indicators is mainly negative, in the sense that the absence of basic inputs suggests

inadequate quality, whereas their presence does not ensure it. In many cases, expressing the availability

of basic inputs as proportions of health care delivery points endowed with them is preferable than as

averages. For example, the finding of 60% of PHC facilities lacking a functioning sphygmomanometer

is more telling than stating that the average PHC facility is equipped with 0.8 sphygmomanometers.

Thus, structural measures include number of qualified staff, functioning X Ray equipment, number of

road worthy vehicles, amenities, etc.

Process Quality Measures

This is the actual process of health care delivery. The measurement of services provided is more

difficult to make, but this information is more useful because it tells us what happened to the patient.

Process aspects refer to the way available inputs are transformed into health activities. They depend on

a host of factors, including service providers' competence, work organization, incentives at play,

information to the public. Whether a certain condition is correctly identified, the right treatment is

prescribed, the patient complies with instructions, drugs and vaccines are properly stored, all fall within

this group. Additionally, patient perceptions of care belong to this category. The majority of process

indicators are collected through direct observation and interviews. Routine information systems

produce some process indicators, like case fatality rates, or the success rate of a treatment schedule.

Given the shakiness of routine figures, considerable caution is needed before related process indicators

are retained as reliable.

Collection of the data depends on having monitoring systems. Process measures include things such as

waiting time, being given a clear diagnosis, examining the patient properly, etc.

Outcome Quality Measures

This is the end result of health care; the outputs and health status. Outcome measures include things

such as mortality, patient satisfaction, coverage, attendance levels etc.

The outcomes of health care are obviously the ultimate quality criterion. Unfortunately, their study is

technically demanding and usually expensive. Moreover, their interpretation is fraught with

difficulties. Long-term outcomes are particularly difficult to assess in unstable environments, where

few or no variables can be controlled. Measures of outcomes of health care are therefore scarce in

distressed health sectors. Reliance on the assessment of structural and process aspects is commonplace,

on the assumption that if all needed inputs are available and working practices are sound, the outcome

of health care is likely to be satisfactory. Before embracing wholeheartedly this assumption in a

troubled health environment, multiple checks are recommended. Caution is needed with single

disease-control programmes, which by nature leave untouched a vast array of environmental and

violence-related risk factors. The health gains expected from reducing the burden of morbidity and

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mortality of the targeted disease may be offset by concomitant losses in other area, induced or

magnified by the crisis.

The important thing to remember is that we should focus our attention on all 3 dimensions and not just

concentrate on one aspect. For example, if we want to improve health outcomes, we must understand

the processes and structures that contributed to achieving the outcome.

Therefore when we start seriously looking at quality we have to remember that:

· quality has many dimensions

· quality can be viewed from different perspectives

· we can measure quality at different points in the health system.

Chapter 2

Gender and Health

Quality of Care from the Gender Perspective

Gender refers to the socially and culturally defined differences between men and women ( sex being the

biological difference). It includes the different roles that are ascribed to the two sexes, the expected

behaviors and also includes the differential power and control vested in each sex. Nominally gender

does not indicate a hierarchy but in actual practice men and women do not have equal access and control

over various kinds of resources and a strict hierarchy exists between the two. This hierarchy is clearly

evident in Indian society. Women are expected to eat only after the men of the house have eaten, girls are

provided fewer years of formal education, women are expected to stay at home and there are strict rules

even about visiting the natal home. It would be a mistake to surmise that these differences will

automatically reduce over time. While gender roles, expectations and behaviors do change over time

the assumption that the difference in hierarchy reduces is somewhat naïve, witness the increase in sex

selective abortions especially among developed states like Punjab, Haryana and Gujarat.

Gender equality is formally defined as a situation or state where there is an absence of discrimination on

the basis of a person's sex, in opportunities and the allocation of resources or benefits or in access to

services. However this is far from what exists in reality where an individual's biological sex often

becomes the basis of enjoying social/economic/cultural advantages or disadvantages. Men and women

live their lives in society accepting and reproducing socially prescribed roles and behaviors. These roles

and behaviors are often strictly enforced and also incorporate a hierarchy between women and men,

giving men a distinct advantage. These differences not only manifest themselves in roles and behaviors

but most importantly in the access to and control over the various kinds of resources that women and

men enjoy. Thus it is assumed that the son will inherit the property of the father, husbands own and

deploy the family resources while women have to remain content with comparatively lesser education

and wives cannot decide whether or not to use contraceptives.

Despite the socially prescribed, acknowledged and encouraged differences in the status of women and

men, the principles of universal human rights, as well as the Indian constitution upholds the equality of

women and men. Gender equality is thus an ideal which is not only universal but also constitutionally

and legally binding in India.

In order to achieve gender equality one must first acknowledge that there is gender discrimination today

and that women are disadvantaged. To reverse and balance this discrimination it is necessary to apply

the principle of equity. Gender equity can be defined as fairness and justice in the distribution of

benefits and responsibilities between women and men. The concept recognizes that women and men

have different needs and power and that these differences should be identified and addressed in a

manner that rectifies the imbalance between the sexes. Thus while equality is an ideal, equity is the

operational principle which realizes the need to make special provisions for the disadvantaged and the

powerless. Without practicing gender equity it may not be possible to achieve gender equality because

of the unevenly shared power and resources between women and men that exists today.

The Linkages between gender and health

The subordinate status of women in society deeply influences their health status. The principal

responsibility of women in many societies including our own is usually restricted to childbearing. This

over emphasis on one biological aspect has led to such situations as early marriage and repeated child-

bearing and its attendant complications. Son preference, another strong trait of Indian society has led to

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the heinous practice of sex-selective abortion and repeated abortions and its attendant complications.

Women's workload in many places is considered minimal, but a careful daily analysis reveals that

women hardly have a moment to spare in the course of the entire day while men are entitled to their

share of relaxation after a days hard work. Women's subordinate status has also led her to be an easy

target of family planning programs in our country with the bulk of sterilizations being tubal ligation

operations. To add to the situation described above women have very little autonomy to decide what

they should do for keeping healthy. Many women's reproductive health issues, which are related to her

genitals are considered dirty and shameful and hence women not only feel uncomfortable in openly

discussing their problems, but they refuse treatment from male medical providers. Medical providers,

themselves are products of the society in which they live and thus carry with them the usual social and

cultural biases regarding women and their abilities. In short the gender differences between men and

women are reflected

· at the level of cause of ill health

· at the level of the individuals own response to the ill health condition

· at the level of family response to the situation

· at the level of the treatment accessibility and availability of treatment as well as the attitude and

behaviour of the health care provider

· at the level of ultimate health outcomes

If we examine any reproductive health condition it will emerge that all reproductive health conditions

either arise from or are complicated by unequal gender relations.

Some important RH concerns in India include

! Unwanted pregnancies

! Maternal Mortality and morbidity

! Contraception as well as infertility

! Unsafe abortion, Sex-selective abortion

! RTI/STI/HIV/AIDS

! Cancers

! Concern for adolescent health and so on

Origin of Differences in Health / Profiles

Biological Differences

• Anatomical/ Physiological

• Anatomical, Physiological

And Genetical

Susceptibilities

• Anatomical, Physiological

and Genetic

Social Differences

· Roles and Responsibilities

· Access and control

· Cultural Influences

and Expectations

· Subjective identity

Health situations, conditions or problems

· Sex Specific

· Higher prevalence in one or other sex

· Different characteristics for men and women

· Generates different response by

individulas/family/institutions depending on

Chapter 3

Reproductive and Sexual health Rights

Introduction

Equal human rights for all human beings are not only a principle of international human rights but a core

principle of the Indian Constitution. In 1993 the Vienna human rights conference was organized and

right to development was also included in the list of human rights. Out of the 1994 Cairo conference on

population and development evolved a clearer and more precise definition of reproductive rights. The

Fourth World Conference on Women organized at Beijing in 1995 tabled the agenda for women's

empowerment. All these changes were possible because of struggles of many national and international

movements spearheaded by women's rights and human rights activists on the one hand and the

willingness of governments to sit together and negotiate a common agenda.

A consensus definition of the rights approach may be found with the UN Commission on Human Rights

which defines it as “an integration of the norms and standards contained in the wealth of international

treaties and declarations into the plans, policies and processes of development”. To this one may add the

component of legislation, because without appropriate legislation, the rights approach looses teeth in

ensuring justice in the case of rights violations and mandating the state to ensure enabling conditions to

enjoy the rights.

India has one of the most progressive constitutions in the world incorporating many of the features of

the rights approach within its framework. There are many appropriate laws in the penal code. The

changes in international understanding that took place in the 1990's were also readily endorsed by the

Indian Government by the formulation of National Policies and programmes meant to translate these

principles into action. The Target Free and Community Needs Assessment Approach, the Reproductive

and Child Health Programme, the National Population Policy (2000), the National Policy on the

Empowerment of Women (2001) and the National Health Policy (2002) are testimony to the states

commitment. At the same time redressal mechanisms like the National Human Rights Commission and

the National Commission on Women were also set up to safe guard human rights. The Indian legislative

and courts too have adopted a pro-human/women's rights approach. The Pre Natal Diagnostic

Techniques Act ( 1996), the Vishakha judgement ( 1997) are some examples of this change in approach.

Rights Approach in Reproductive Health:

Reproductive health, especially that of women is area shrouded with ignorance, shame, silence and

mystery. At the same time it is one area where there are large number of societal expectations and

prescriptions, at least in traditional societies like India With societal expectations and norms on the one

side and woman's own needs and desires on the other, reproductive health becomes one of the most

contested area of 'rights'. Who will decide whether or not to marry? Who will decide the age at

marriage? Who will decide whether to have children or not? Who will decide the number and spacing of

children? Who will decide whether to wait for a son or not? Who will decide whether to use

contraceptive? Who will decide whether to carry a pregnancy or abort it? These and many similar

questions form the crux of reproductive rights.

However reproductive rights are not limited to these decisions alone. The ability of an individual to

make these decisions depends upon the amount of information that is available to make these decisions.

Informed choice, a key element of reproductive rights, is the outcome of the possession of adequate

knowledge and information, the ability to make abiding decisions, and having access to the appropriate

services that are needed. The role of the state or the government in providing the

knowledge/information as well as ensuring the services is key to the enjoyment of reproductive rights.

At the same time the state also has a responsibility to ensure that women are able to make decisions in

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the context of their reproductive lives, which in actual practice are curtailed by family members and

societal norms. Thus education of family members, making legislation to prevent discriminatory

practices is also a role of the state.

Clients Rights

Just like any other services the health sector also is one of kind of service sector only dealing with the

technical parts of human lives. Thus just like other sectors have consumer protection and all the health

care sectors also has to view its patient as customer and the clients has its rights and these rights should

be protected. Thus all the clients whether they are taking services in the private sector ot at the

government set up they have following right for better quality of care.

1. Right to Information

Clients should be given complete, correct and latest information. The Information should be

understandable to the client. Merits and demerits of different alternatives, where they are

available; How to get access to; at center in community should be provided. Clear cut

information should be given regarding the available services, timings, how the clients can

access over the services, place of available services etc. Information should be given that who

can provide the services at which level. .All the relevant information should be displayed at the

common place of the center

2. Right to access over the services:

The services should be available to all the people irrespective of any Socio- economic status

including adolescents, youth of marrying age, pregnant women and post natal women,

physically challenged people, refugees, migrants, displaced people, victims of physical and

sexual violence, sex workers, homosexuals, marginalized people(who don't get service in

time) people relegated from society

3. Right to Confidentiality

Safe, comfortable, feeling of confidentiality, environment should be comfortable should be

provided.. There is a great deal of medical and personal information sharing by the client

during seeking service. Thus utmost attention should be paid regarding the information being

kept confidential.

4. Right to Trust

Every client has the right to get trust into the provider that the service provided would be as per

expectation and of good quality.

5. Right to Dignity

All clients should be treated with respect, regardless of their social status or way of thinking. If

compassion and understanding are difficult because of cultural or religious differences

between the client and provider then it may diminish the providers ability to be objective.

6. Right to Safe services

Clients must see that all safety standards are followed properely.. and if not then he/ she has

the right to reject unacceptable procedures.

7. Right to freedom of Choice

Freedom of choice implies, “informed choice”. Therefore the clients are entitled to

information that will help them in making decisions. According to their choice alternatives

should be explained with their contraindications and merits

8. Right to Expression

Clients hold the right to express good or bad feelings, right to suggest as per convenience and

also express their opinions.

9. Right to Continuity

The clients should be provided uninterrupted continuity of service as per the need, right to take

service from others, right to be referred and follow up

10. Right to redressal of grievances

The health seeker has a right to redressal of his/her losses regarding deficiency in service,

deficiency in due care and caution, negligent services and damages caused so far.

Implementing And Integrating a rights based approach in Reproductive health service

delivery.

Implementing a rights approach in reproductive health is a multidisciplinary initiative requiring a

knowledge and appreciation of technical health issues, policy and programme provisions and legal

positions around different reproductive health areas.

A simple framework that can be used for implementing a rights approach is to see each reproductive

health condition in terms of entitlements of the individual and the responsibilities of

individual/community. The entitlements and responsibilities emerge out of the technical health

interventions, government laws, policies and programs. Two examples are given below.

Antenatal Care

Entitlements (Right)

• Registration

• 2 TT injections at the

appropriate time

• 100 iron and folic

acid tablets

• Three antenatal

examinations for high

risk screening

• Advice for minor

problems

• Referral for major

problems / high risk

• Etc

Responsibilities

• Rest

• Contact ANM for

Antenatal check up and

injections

• Diet and IFAas per advice

• Contact the ANM for

problems

• Follow other ANM

advice

• Follow referral advice

• Husbands support and

sharing of responsibility

• Etc..

Legal Policy and

Program fFramework

· CNA Approach

· RCH Programme

· National Population

Policy

· National Health

Policy

· Articles 38, 39 and

42 of the Indian

constitution

Etc.

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Contraception

Entitlements (Right)

· Information about

variet of contraceptive

options to both men and

women

· Advantages and

disadvantages ( side

effects) of different

contraceptives

· Access to contraceptive

of choice with clear

instructions about how to

use it

· Good quality service and

compliance with the

standards of care

• Services for

complications and

failures

Responsibilities

· To use the

contraceptives as

directed

· To inform the

provider when new

supplies are

required

· To inform the

provider in case of

side effects,

complications and

failure.

· Male partners

sharing

responsibility

and so on

Legal Policy and

Program fFramework

· RCH Programme

· National Population

Policy

· National Health

Policy

· National Policy on

Empowerment of

Women

· MTP Act

· PNDT Act

· Article 14 and 15of

the Indian

Constitution and so

· Article 14 and 15of

the Indian

Constitution and so

In order to implement a rights approach it is necessary to inform both health providers and the

clients/community of their rights and responsibilities and the legal or policy/programme framework

which applies

Chapter 4

Communication Skills

Introduction

Effective interpersonal communication between health care providers and clients/patients is one of the

most important factors for improving patient satisfaction, treatment compliance and outcomes. There

is evidence of better treatment outcomes with effective communication skills.

However effective communication may not come naturally or easily. It is seen that though the health

care provider and client belong to same geographical area, there may be differences in social status and

education and cultural background. Due to this the message may not be interpreted correctly. Factors

such as lack of privacy, and time constraints also affect effective interpersonal communication.

Health care providers by virtue of their training tend to use jargons while talking to the patients, which

increases the feeling of inequality between the health care provider and patient/client. Health care

providers have to be constantly aware that they wield considerable power in their relationship with

patients. Effective communication will help in bridging the gap between provider and patient by

listening, empathizing with them, sharing information and helping them to come to decisions related to

their health.

Communication Process:

It is a two way process. There is a sender and receiver in it. The sender is the originator of the message.

To be effective the sender must be clear about

· The objective of communication

· Needs, interests and abilities of receiver

· The content and usefulness of message

· The channel to be used

It is important that the message is sent in language understood by receiver. The message should be clear

and free from ambiguity.

And the receiver has to be good listener. To be a good listener

· Be attentive, look at speaker.

· Absorb clearly

· Listen to the underlying feelings in message is important.

Barriers in Communication

· Socio cultural gaps

· Language differences, terminology and mannerisms

· Lack of privacy, sensitivity

Skills in effective interpersonal communication.

· Effective listening leaning forward, eye contact, head nod

· Encourage dialogue ask open ended questions

· Avoid interruption

· Avoid being judgmental

· Probe for information

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Chapter 5

Counseling skills

Introduction

Counseling is a process of communication, involving two or more persons who meet to solve a

problem, resolve a crisis or make decisions regarding personal intimate matter.

What Counseling Is?

There are many interpretations of what counseling is. The best represents for reproductive health issues

is, “a mutual exchange of ideas, opinions etc, discussion and deliberations.”

What Counseling is not?

Counseling is not telling a client what to do. A counseling session is not a question and answer period.

Components of Counseling

Counseling has both process and content components, all directed towards achieving th purpose of the

counseling session which is defined by clients.

Process Components

· Establishing Rapport

· Listening and

Questioning

· Discussion

· Decsion making

Content Component

· Obtaining

information

• Giving information

The process and content components of a counseling session are dependent on each other. The process

components are more numerous but they are dependent on content to give them substance. In a like

manner the content components depend on process for transmission.

Skills In Counseling

Macro Skills in Counseling

· Clarification: This is is to ensure that you have understood the client's message correctly. It is

important to ask for such feedback from the client frequently during the communication.

· Asking open ended questions: Begin Questions. As far as possible avoid questions beginning

with why, where, etc. Ask questions which will encourage the client to speak and not to give

monosyllabic answers. Do not ask directive or leading questions

· Conveying Empathy: Empathic understanding involves accurately sensing the clients world

and being able to see the way he or she does and verbally sharing your understanding with

client.

· Reassurance: The client could be agitated, depressed or anxious and the counselor needs to

reassure the client in verbal and non verbal way such as keep faith or things should be fine.

· Summarizing: Clients who are agitated or are in state of shock may talk fast and about many

topics. The counselor should summarize points.

· Recapitulizing: Asking the client to recapitulate the information given is usually done in

concluding session, after information about an investigation or treatment procedures has been

given to client.

Micro Skills in counseling

· Paraphrasing of Content: A paraphrase is saying the clients primary words and thoughts in

another way. It involves selective attention and response to the clients message content by

rephrasing it.

· Reflection of feeling: A counselor reflects the client's feelings in her own words. By this it can

assured that you have understood the client accurately. And help the client to recognize her

feelings.

· Appropriate use of silence: Silence in counseling session gives the client opportunity to reflect,

integrate the feelings, think through an idea and absorb new information.

· Focusing: A counselor should help the client to focus on his/her thoughts on most important

issue on hand. The aim of focusing is to prioritize what needs immediate attention.

What makes Good Counselor

Good counseling consists of two elements. One establishing a trusting and caring relationship with

clients and another of giving and receiving relevant, accurate information to help client to make

decisions.

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