PROQUALI: Improving Reproductive Health Services in Brazil

Project Dates: 1996- ?

• Overview
• What is PROQUALI?
• The PROQUALI strategy
• Project Impact
• Lessons Learned

Overview

"Your future is in your hands," predicts the fortuneteller from a tarot card that has a picture of an IUD on it along with a short explanation. The fortuneteller mingles with dancers, musicians, and actors among a joyful crowd of people gathered in the central plaza of Redenção, in Ceará, Brazil. "The best place to get correct reproductive health information is from the professional providers at the health clinic," proclaims the fortuneteller as she distributes her tarot cards among the crowd, which also includes dignitaries, TV crews and press photographers.

This festive community-wide event is being held to honor the director and staff of the Redenção health center for achieving accreditation as one of the selected centers for the PROQUALI Project. Initiated in late 1996, the PROQUALI Project is a collaborative effort among Johns Hopkins University/Center for Communication Programs, JHPIEGO, Management Sciences for Health, and the State Secretariats of Health of Bahia and Ceará to improve the quality of reproductive health services in the public sector of these two states.

What is PROQUALI?

PROQUALI, meaning to pursue quality, moves beyond the traditional approach of focusing solely on clinical changes for improvement in the quality of health services to a model that is based on the principle of supply and demand. It is a process that actively involves clients and providers in identifying problems and solutions in delivering health services in a decentralized system by providing tools to implement, measure, and evaluate improvement.

The PROQUALI strategy

The PROQUALI strategy uses an accreditation model to improve and verify the delivery of reproductive health services and a communication strategy to promote those services. The communication strategy focuses on two phases of the campaign. First, the clinic campaign is designed to raise expectations and stimulate interest among clients while motivating providers who participate in the improvement process. After accreditation, the community campaign promotes awareness of the improved reproductive health services, supports ongoing client demand for the new level of quality service delivery, and publicizes providers as caring professionals who provide quality services.

In the initial phase of the PROQUALI Project, five health clinics in two states were chosen to participate in the accreditation process, three in Ceará and two in Bahia, of which the Redenção health clinic is one. Using client input and tools of the PROQUALI model, such as job descriptions, self-assessment checklists, and team-building techniques, the health clinic staff is able to identify, correct, and improve weaknesses within their service delivery system. When a clinic has made its improvements, a Quality Improvement Team visits the site and, using an external assessment checklist (another PROQUALI tool), determines the accreditation status.

A site achieves accreditation within 12 months on average, when it meets 90% of 61 criteria in five core areas:

1. clinical services;
2. client counseling, orientation, and information;
3. infection prevention;
4. management systems; and
5. facilities and supplies.

Upon accreditation, a ceremony, like the one described for the Redenção health clinic, is held to honor the providers of the clinic whereupon they are presented with a "quality symbol" plaque.

For all of the health centers participating in the PROQUALI Project, the slogan developed for the clinic campaign was "Health for you, satisfaction for us," which was emblazoned on banners and printed on T-shirts, hats and buttons worn by providers. Some of the materials produced in the community campaign for the clinics included: five 5-minute radio dramas, street theater presentations, client-painted murals on clinic walls, cue cards for providers, referral cards for health agents, clinic posters and signs, family planning tarot cards, and informed choice materials.

Project Impact

Quantitative data demonstrate that the PROQUALI Project has had a positive impact on actual clinic and provider performance as shown by accreditation results and on increased demand for services depicted by increased number of family planning visits. Qualitative research demonstrates similar results with clients perceiving services as being improved.

Figure 1. shows the results of the total accreditation assessments for the five pilot clinics. The 61 quality criteria were observed and rated during each of the five clinic's accreditation process. Only 12% of the criteria had been achieved at baseline, whereas after 12 months of participation in the PROQUALI Project, the average percentage of service quality criteria achieved was 94%. This represents a 700% increase. At that 12-month point, four of the five pilot clinics had achieved accreditation.

Figure 1.

Project activities began in the second half of 1997. As shown in Figure 2, the number of clients visiting all of the pilot health centers combined was already steadily increasing prior to project initiation. The increase was maintained during the first year of project activities (1997-1998) and leveled off in the second half of 1998. By mid-1999 following accreditation and community campaigns, the total number of clients visiting the clinics increased by 74%, compared to the end of 1998.

Figure 2.

Qualitative research was accomplished through focus group discussions with clients before and after accreditation of the health clinics. Clients were asked what they saw and perceived as service improvements. "Better attention given to women" was mentioned as an improvement. This included better communication between providers and clients, more information about services, and an increased number of methods consistently available.

An important finding of the qualitative data was that as the quality of the services improved and as clients' earlier needs were met, clients' expectation of quality became more specific. For example, as waiting times decreased, being treated "well" changed to "calming ones fears, clarifying doubts and conversing with clients"; "fixing" the bathroom lock became wanting "separate" bathrooms.

With the completion of the initial phase, the current expansion phase of the PROQAULI Project has an additional 25 to 30 health clinics throughout Brazil that should be accredited within the next year. The PROQUALI methodology - its accreditation process and its tools - is being institutionalized across the country. In Ceará, the Secretariat of Health has institutionalized the PROQUALI model as its quality improvement approach in providing primary health care to children and adults. The State Secretariat of Health in Bahia has designated a facility to serve as the Reproductive Health Reference Center from which the PROQUALI model will expand in Bahia and to other states using the Internet and a PROQUALI CD-ROM.

Lessons Learned

The PROQUALI Project has proven that public sector clinics can offer quality reproductive health services, while inspiring all those involved. During the project, the three cooperating agencies advanced in partnership and technical innovation. The role of the Secretariats of Health in Ceará and Bahia in delivering improved services was strengthened. The participating service providers were empowered to solve health center weaknesses and take pride in their work. Municipal leaders were able to mobilize scarce health care resources, while gaining political support in the community - "Cliente Satisfeito, Prefeito Re-eleito" (satisfied client, mayor re-elected). Most importantly, the women and communities in Bahia and Ceará states were encouraged to make informed choices and actively participate in their own health care, ultimately sustaining quality reproductive health services.