Lessons Learned

Africa

• Address supply problems when promoting quality services. Plan ahead or develop special initiatives to address contraceptive stock out problems when doing promotional activities directing people to health facilities for FP services (Uganda DISH II project, 2000).



• Logo promotion isn't enough. The campaign needs to inform the public about the range of services and the improved quality that is newly available at health facilities displaying the logo (Uganda DISH project, 1997).



• Breaking down the walls between the clinic and the community leads to real quality improvement. Joint participation of providers and community members in committees brings about a better understanding of each others' values, roles and needs. Committees may be difficult to form but their impact is undeniable (SFPS Gold Circle campaign).



• Involving health workers in the design of a quality improvement tool is a key factor in its use and acceptance. Getting buy-in from the community health workers from the development stage of a BCC health kit in Senegal contributed to its success (Senegal, 1998-1999).



• Regular supervision and monitoring allows for joint and efficient problem solving to maintain quality. Consistent supervisor/provider interaction can prevent small problems from becoming big ones, and improve the quality of the working environment (SFPS Gold Circle Campaign).



• Where benefits seem small and costs seem high, bring HIV voluntary counseling and testing (VCT) to the client/ community. Where there is little support and no antiretrovirals to offer, bring low-cost and convenient VCT services to the community. Plan to provide quality information and post-test counseling as well (Uganda DISH project, 1999).



• Yearly recognition contributes to maintaining quality. Having an annual award for which FP service sites compete generates pride and excitement. Through this technique the level of quality within the sites is likely to be maintained or improved (SFPS Gold Circle Campaign).



• Quality improvements in FP can positively affect other health services. When Gold Circle was promoted at FP sites that offered other health services, all services showed increased utilization, and providers were also motivated to improve their performance when offering other services (SFPS Gold Circle Campaign).



• Keeping providers motivated is a challenge. Building motivational techniques such as incentives and/or professional recognition into new quality programs may help to maintain provider motivation over the long term (SFPS Gold Circle Campaign).



• Maintaining a client-centered approach is a challenge. Medical/health approaches still prevail when designing quality interventions. Continual advocacy is needed to ensure that the “voice” of the clients and the community continues to be represented (Burkina Faso).

For more information contact: Susan Krenn, Chief, Africa Division, skrenn@jhuccp.org

Asia

• There is a viable market for the private sector to provide high quality services to middle and lower income people. (FriendlyCare Foundation, Inc., Philippines)



• Provider behaviors/skills in counseling were most improved when both the providers were trained through radio distance education and clients were exposed to the same content and messages in the radio drama at the same time. (Nepal, Distance Education, Radio Communication Program)



• In a highly decentralized health care system, a quality of services initiative, which relies on early adopters to motivate those who are potential adopters, is an example of the diffusion of innovation model. This model allows for earlier success. (Philippines, Sentrong Sigla Program)



• In a highly decentralized system, combining local politicians, decision-makers and leaders with health staff to make decisions about health care together provides the best results for improving quality and assuring its delivery. (Philippines, Sentrong Sigla Program)



• Motivating groups, in a variety of locations and settings, to adopt family planning or health behaviors has the advantage of group support to create community norms rather than the provider being the main motivating force encouraging behavior change. (Jiggasha, Bangladesh)



• In TV drama, modeling expected provider-client interactions creates an expectation on the part of the client which can increase providers skills at providing quality services. This creates a higher demand for services (pull) and supply of well trained health providers (push). (E-E dramas, radio and TV, Nepal and Bangladesh)



• The use of popular folk forms to entertain promoted health workers, trained in inter-personal communication skills, to receive instant recognition as friendly health providers, capable of providing quality services to clients doorsteps. (India, "Come Let's Talk" multi-media campaign).

For more information contact: Edson Whitney, Chief, Africa Division, ewhitney@jhuccp.org

Europe and Eurasia

• In spite of initial reluctance on both sides, combining midwives and doctors in training resulted in increased counseling opportunities by maximizing each group's experiences and expertise. (Ukraine)



• Doctors recognized that IPC skills combined with Quality Customer Service increased client demand and volume therefore, training not only improved the clinic environment but doctors saw the benefit of CPI and providing clients with quality customer service. Doctors were eager to use these skills to generate demand. (Armenia/Georgia)



• Realistically, it is necessary to present the situational obstacles to CPI so as to include those items in the design of the counseling training and plan. (Ukraine)



• "Quality" materials and tools are not normally accessible in the language of the region thus, the translation of the materials has to be factored into the program both logistically. (Regional)

For more information contact: Karen Angelici, Acting Chief, Europe and Eurasia Division, kangelic@jhuccp.org

Latin America

• Quality improvement requires leadership, a multi-disciplinary team approach, community and client involvement and commitment of all levels of service staff. (Regional)



• Creating a shared vision, goals and objectives through approaches that foster equity and shared commitment helps build a sense of teamwork and greater accountability for quality. (Regional)



• Quality can be defined, put into practice and measured. (Regional)



• Client and community participation in the provision and monitoring of quality health services creates an ongoing demand for sustained quality. (Regional)



• Empowered providers are the best leaders of quality improvement programs. (Regional)



• In the health reform environment, local and municipal leaders become the stakeholders and take on the role of advocating and mobilizing resources for health: "Cliente satisfeito, Prefeito re-eleito" (Satisfied client, re-elected Mayor). (Regional)



• Psychosocial and cultural barriers to access will diminish dramatically when clients, communities and health staff are the leading force in quality improvement programs. (Regional)



• Quality improvement programs facilitate preventative and timely health care seeking behaviors. (Regional)

For more information contact: Patricia Poppe, Chief, Latin America Division, ppoppe@jhuccp.org

Research and Evaluation

• Providers may overestimate the quality of their counseling.



• The quality of counseling is highest when programs increase both providers' skill levels and clients' expectations of provider behaviors.



• The support of fellow providers may help sustain the impact of provider training.



• Client perceptions of poor quality by providers may limit their use of health services.

For more information contact: Maria Elena Figueroa, Acting Chief, Research and Evaluation Division, mfiguero@jhuccp.org

Near East

• Recognition of Gold Star providers at the local and national level was an important force improving quality throughout the service delivery system. (Gold Star Project/Egypt)



• Raising consumer demand for quality compelled providers and clinics to deliver on a well-publicized promise, driving the entire supply of quality services forward. (Gold Star Project/Egypt)



• Identifying key partnerships and roles and responsibilities within a comprehensive institutional framework is essential for the delivery of integrated quality programs. (Gold Star Project/Egypt)



• The "Ask - Consult" project united the pharmaceutical sector, the private provider community and the public sector population program in a common purpose: to increase the market for family planning. (Private Sector Project/Egypt)



• The direct promotion of contraceptives to consumers, particularly new product categories, increases consumer choice, drives up contraceptive sales, and expands the method mix. (Private Sector Project/Egypt)



• "Here we speak freely and the doctor listens to us" - A loyal client of a CSI clinic. CSI considers each new client as a long-term customer. Relationship marketing has proven to be a key strategy for CSI in retaining customers and in spreading, by "word-of-mouth," the quality services message. As a result, returning clients represent 52% of the RH/FP client visits, up from 44% in 1998. (Clinical Service Improvement Project/Egypt)



• Consistent, high-quality management has made CSI a leader in setting the national standards for family planning and emerging RH services. (Clinical Service Improvement Project/Egypt)



• Advocate first, then build public expectations. The support of policy makers is a prerequisite to mobilizing resources, ensuring sustained effort and creating a strong advocacy base for the prevention of maternal mortality. (Safe Motherhood Project/Morocco)



• Base materials and messages on real stories, and create innovative channels. Real life stories stood as the basis of the Safe Motherhood messages enhancing their credibility and emotional appeal. Messages were further optimized through the use of innovative channels (e.g. long-distance bus lines, mobile units, traveling theatrical production) which grasped the audience's attention, resulting in a greater acceptance of the advocated behavior. (Safe Motherhood Project/Morocco)

For more information contact: Ron Hess, Chief, Near East Division, rhess@jhuccp.org

ACKNOWLEDGEMENTS

JHU/CCP acknowledges with thanks the United States Agency for International Development for its support.

We would like to thank all of the members of the Quality Working Group who worked on the Quality First! Expo Committee for all of their hard work and perseverance in gathering all of the materials on display. This was a real team effort and could not have been done without Jane Koehler and Jane Brown of the Africa Division, Jennifer Bowman and Rachna Nangalia of the Asia Division, Erika Wagner of the E&E Division, Robert Ainslie and Marcela Aguilar of the Latin America Division, May Bezreh of the Near East Division, Marc Boulay of the R&E Division, Judy Mahacheck from Popline and Vidya Setty of Pop Reports. Mark Beisser created our logo and designed our templates and our banner. Hugh Rigby, Peggy D'Adamo, Andrew Plummer, Cynthia Shaw and Sam Feaster provided their support and assistance locating items and arranging the displays. Carl Miller provided technical assistance so that we could preview all of the interactive CD-ROMs. Aaron Brady and Sadia Ahmed provided their A/V expertise in the editing and compilation of the regional videos.

Let us take the opportunity tomorrow to share our experiences in putting Quality First so as to better view our future opportunities to assist our clients, whoever they may be, in their pursuit of successfully seeking quality in family planning and reproductive health care.