ISBN: 1-882839-04-8
Library of Congress Catalog Number: 92-75465

A front-line health worker
Photo by P. Almasy for WHO
Dedicated to Dr. Duane L. Smith (1939-1992), Dr. William B.
Steeler (1948-1992) and all other health leaders, managers and
workers who follow their example in the effort to bring quality
health care to all in need. A PHC concern: the preparation of food by street vendors
Photo by Ph. Merchez for WHOAn overview of PHC MAP 
The main purpose of the Primary Health Care Management 
Advancement Programme (PHC MAP)  is to help PHC management teams
collect, process and analyse useful management information.   
Initiated by the Aga Khan Foundation, PHC MAP is a collaborative
programme of the Aga Khan Health Network and  PRICOR.  An
experienced design team and equally experienced PHC  practitioner
teams in several countries, including Bangladesh, Chile,
Colombia, the Dominican Republic, Guatemala, Haiti, India,
Indonesia, Kenya, Pakistan, Senegal, Thailand and Zaire, have
worked together to develop, test and refine the  PHC MAP
materials to make sure that they are understandable, easy to use
and helpful. 

PHC MAP includes nine units called modules. These modules focus
on essential information that is needed in the traditional 
management cycle of planning-doing-evaluating.  The relationship
between the modules and this cycle is illustrated below. 

PHC MAP modules and the planning-evaluation cycle

PHC MAP MODULES
1. Information needs
2. Community needs
3. Work planning
4. Surveillance
5. Monitoring indicators
6. Service quality
7. Management  quality
8. Cost analysis
9. Sustainability



1 The Aga Khan Health Network  includes the Aga Khan Foundation, 
the Aga Khan Health Services, and the Aga Khan University, all of
which are involved in the strengthening of primary health care 

2 Primary Health Care Operations Research is a worldwide project 
of the Center for Human Services, funded by  the United States
Agency for International Development<MS> 
Managers can easily adapt these tools to fit local  conditions. 
Both new and experienced programmers can use them. Government and
NGO managers, management teams, and communities can all use the 
modules to gather information that fits their needs.  Each module
explains how to collect, process and interpret PHC-specific
information  that managers can use to improve planning and
monitoring.  The modules  include user's guides, sample data
collecting and data processing  instruments, optional computer
programs, and facilitator's guides,  for those who want to hold
training workshops. 
   The health and management services included in PHC 
MAP are listed below. 

OTHER HEALTH CARE   
Water supply, hygiene and 
  sanitation
School health
Childhood disabilities 
Accidents and injuries 
Sexually transmitted diseases HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable 
diseases

HEALTH SERVICES
Planning
Personnel management
Training
Supervision
Financial management
Logistics management
Information management
Community  organisation

MANAGEMENT SERVICES
Health and management services
GENERAL        
PHC household visits          
Health education      
          
MATERNAL CARE       
Antenatal care      
Safe delivery       
Postnatal care      
Family planning     

CHILD CARE
Breast feeding      
Growth monitoring   
Nutrition education 
Immunization        
Acute respiratory infection   
Diarrhoeal disease control     
Oral rehydration therapy


   Several manager's guides supplement these modules.  These are:
Better management: 100 tips, a helpful hints book  describing
effective ways to help managers improve what  they do; 
Problem-solving, a guide to help managers deal with common 
problems; Computers, a guidebook  providing useful hints on 
buying and operating computers, printers, other hardware and
software;  and  The  computerised PRICOR thesaurus, a compendium
of PHC  indicators. 
A midwife in Ulan Bator, Mongolia, calls at a "yurt" to see how
mother and child are doing
Photo by D. Henrioud for WHO
The Primary Health Care Management Advancement  Programme has
been funded by the Aga Khan Foundation Canada, the Commission  of
the European Communities, the Aga Khan Foundation U.S.A., the Aga 
Khan Foundation's head office in Geneva, the Rockefeller
Foundation,  the Canadian International Development Agency,
Alberta Aid, and the  United States Agency for International
Development under two matching  grants to AKF USA.  The first of
these grants was "Strengthening the  Management, Monitoring and
Evaluation of PHC Programs in Selected  Countries of Asia and
Africa" (cooperative agreement no. OTR-0158-A-00-8161-00, 
1988-1991); and the second was "Strengthening the Effectiveness,
Management  and Sustainability of PHC/Mother and Child Survival
Programs in Asia  and Africa" (cooperative agreement no.
PCD-0158-A-00-1102-00, 1991-1994).  The  development of Modules 6
and 7 was partially funded through in-kind  contributions from
the Primary Health Care Operations Research project  (PRICOR) of
the Center for Human Services under its cooperative agreement 
with USAID (DSPE-6920-A-00-1048-00).  
     This support is gratefully acknowledged.  The views  and
opinions expressed in the PHC MAP materials are those of the
authors  and do not necessarily reflect those of the donors. 
@BODY A LEFT =    All PHC MAP material (written and computer
files)  is in the public domain and may be freely copied and
distributed to  others.  Contents 
QUICK START     1 
INTRODUCTION  
What is service quality assessment?      3 
How you can use this module    4 
Checklists      6 
Some limitations     13 

SERVICE QUALITY ASSESSMENT PROCEDURES 
Step 1: Specify the scope and the objectives 15 
Step 2: Select the unit of observation and data collection
        techniques   17 
Step 3: Select and adapt the appropriate service quality
        checklists   21 
Step 4: Develop the sampling procedures and select sample    23 
Step 5: Carry out the assessment    29 
Step 6: Compile and analyse the data     31 
Step 7: Report the findings, provide feedback, and take 
        corrective action      34 
 
APPENDICES 
A.  Rapid service quality assessment checklists (short form) 
      37 
B.  Rapid service quality assessment checklists (long form) 
      61 
C.  Service quality assessment, discussion guidelines   123 
D.  Multiple observation checklists      147 
E.  Other PHC MAP tools   151 

REFERENCES AND BIBLIOGRAPHY    157 

ACRONYMS AND ABBREVIATIONS     160 
 
Acknowledgements 

The prototype of this module was first presented to  participants
at a PHC MAP workshop in Dhaka in May, 1990. Their feedback  and
suggestions were invaluable. Special thanks go to the staff of 
the Aga Khan Community Health Programme for their help in field
testing  draft materials. 

The first draft of this module was reviewed and tested  in 1991
by a number of PHC specialists and field managers. The module 
was also reviewed and critiqued by the Project's Technical
Advisory  Committee at a PHC MAP meeting in Bangkok in September
1991. The module  was completely restructured and tested again.
Feedback from those  tests led to two more revisions. The module
was reviewed again by  participants at the International
Conference on Management and Sustainability  of PHC Programmes,
held in Bangkok in May 1992. Minor changes resulted  in this
final version. Special thanks are due to Jack Reynolds for  his
help in conceptualising the module, preparing the Quick start 
and developing the analysis procedures; to Paul Richardson, who
participated  in several field tests and summarized the field
test results, and  Mary Millar, who developed the facilitator's
guide for the module,  which was very helpful in preparing this
revised draft. All of these  contributions were invaluable and
greatly appreciated. 
 
Reviewers: 
Donald Belcher 
Veterans Administration, Seattle, WA, USA  
Gilbert M. Bernham 
Johns Hopkins School of Public Health, Baltimore, MD, USA 
David H. Peters  Johns Hopkins School of Public Health,
Baltimore, MD, USA 
Paul Zeitz  Johns Hopkins School of Public Health, Baltimore, MD,
USA 
Micheal Bernhart  University of Puget Sound, WA, USA 
 
Field tests: 
Countries  Participating organisations, field test facilitators 

Bangladesh     Aga Khan Community Health Programme; Concerned
               Women for Family Planning; The Asia Foundation;
               Facilitator: Barkat-e-Khuda,  URC/Bangladesh,
               Dhaka, Bangladesh 
Pakistan       Aga Khan University (AKU), Karachi, Pakistan; 
               Facilitator: Khatidja Husein 
Thailand       Ministry of Public Health, Srisaket; Health and
               Population  Research Corporation (HPRC); Somboon
               Vacharotai Foundation (SVF);  ASEAN Institute for
               Health Development (AIHD); Facilitator: Narawat 
               Suwannapong, AIHD, Bangkok, Thailand 
India          Junagadh PHC Project; Sidhpur Sustainable Health 
               System Project, Gujarat; Aga Khan Health Service
               India (AKHS, I); Facilitators: Neeraj Kak,
               University Research Corporation (URC), Bethesda, 
               Maryland, USA; Vijay Moses, AKHS, I. 
Kenya          Mombasa PHC Project; Kisumu PHC Project
               Facilitators: Paul Richardson, URC; Esther
               Sempebwa, Mombasa PHC Project; Matthew Onduru,
               Kisumu PHC Project
Colombia       Fundacion Santa Fe de Bogota; Facilitator: Jorge 
               E. Medina  Guatemala Instituto de Nutricion de
               Centro America y Panama (INCAP); Facilitator:
               Jorge Hermida 
Senegal        Ministry of Health; Facilitator: Mounir Toure 
Zaire          Ministry of Health; Facilitator: Kipasa Mungala 
 
Review and/or development of PHC checklists:  Aga Khan
University, Pakistan: Khatidja Husein,  Aamir Sidiqui, 
Ghazala Parveen  Thailand: Jumroon Mikhanorn, SVF; Yawarat
Porapakkham, AIHD; Chaweewon Boonshuyar, AIHD; Narawat
Suwannapong, AIHD; Som-Arch Wongkhomthong, 
AIHD; Orapin Singhadej, AIHD; Peerasit Kamnuansilpa, HPRC;
Butsabar  Subongkot, HPRC  PRICOR Staff: Lynne Miller-Franco,
David Nicholas, Linda Ashburne,  Neeraj Kak, Maria Francisco,
Martine Hilton, Kim Ashburn. 
 
The following clinicians and specialists provided technical 
inputs to the PHC checklists in their area of expertise:  

STDs, HIV, AIDS: Gilbert M. Bernham, Department of International 
Health, Johns Hopkins School of Public Health; William Brady,
Division  of STD/HIV Prevention, Centers for Disease Control
(CDC); Maryanne  Neill, Training and Materials Development
Specialist, CDC.  

Childhood disabilities: David Marsh, Salma Alam, Ghazala Parveen, 
Shafiq-ur-Rab, Mohammad Zahid, Aga Khan University, Pakistan;
Pasquale  Accardo, Chair, Section on Children with Disabilities,
American Academy  of Pediatrics  

Chronic, non-communicable diseases: Marilyn Hartsell, Education 
Specialist, National Heart, Lung and Blood Institute, Bethesda,
MD, USA Quick start
Basic PHC service quality assessment

Introduction 
What is service quality assessment? 
This module puts forth methods to assess the quality of PHC
services. 
This type of assessment is different from an ordinary evaluation
of  programme performance. Evaluations often focus on resources
(supplies,  personnel, equipment) or inputs, and service delivery
outputs (number  of children vaccinated, number of people
treated). The tools and methods  in this module are designed to
assess the process of service delivery  in order to assess the
quality of the services provided. Quality health  care has been
defined by Roemer and Aguilar (WHO, 1988) as follows: 

"Proper performance [according to standards] of interventions
that are known to be safe, that are affordable to the society in
question and that have the ability to produce an impact 
on mortality, morbidity, disability, and malnutrition."

Service quality assessment is the process of determining whether
PHC  services are provided according to established norms for
quality care.  By using explicit process criteria, in the form of
observation checklists,  the service quality assessment tools and
methods presented here can  help managers determine whether
specified procedures are being carried  out, how well they are
being carried out, and which tasks need improvement.  This module
concentrates on the quality of PHC services. A companion 
module, Module 7, follows a similar process to examine management
support services. Another  module (2: Assessing community health
needs and coverage) can be used  to assess the effects and
impacts of these processes on the knowledge,  behaviour, and
health status of the target population. 

How you can use this module  
You can use service quality assessment to monitor and  strengthen
the quality of care in your PHC programme. This module  is
designed to help managers and supervisors assess the quality of 
all or part of each PHC service by using simple checklists. The
module  also includes instructions and worksheets to aid in the
planning and  implementation of service quality assessment.
Guidelines analysis,  interpretation, feedback, and corrective
action are also included.  Service quality checklists can be used
in a variety of  ways. Examples include: 

A framework for supervision.
Supervisors  can use these checklists during regular supervisory
visits to identify  specific deficiencies in the quality of
services, counselling, and  health education. Afterwards, the
completed checklist can serve as  a discussion guide to give
feedback to the service provider on the  strengths and weaknesses
of the service. Because of the way the checklists  are
structured, they also make it easier to identify solutions to 
the most common problems. For more complex problems, the
checklists  provide the basis for a discussion of the causes of
problems and their  solutions. Each checklist includes a space
for comments and actions  taken so that supervisors can use the
forms to record supervisory 
activities. 

A self-assessment tool. Programme staff  can use these checklists
to assess their own strengths and weaknesses. For example, a
service provider could use a checklist to assess a  given service
and to identify areas for improvement. Based on the  results, the
service provider might revise technical norms, ask a  supervisor
to provide technical support, or request additional training. 

A job aid for service providers. A job aid  is a set of written
or pictorial  instructions  that  prompt  action   and  @BODY =
guide decision-making during service delivery. Checklists  can be
modified for use during service delivery or while carrying  out a
management activity.  

An instrument for area-wide assessment of service  quality.
Supervisors or other observers can use these checklists  to
conduct a study of service quality in an administrative area,
such  as a district or province. The results would identify
system-wide  strengths and problems that need to be addressed.
Although these results  would usually be of most interest to
local managers, such studies  could be carried out at regional
and national levels as well. 
As guidelines for training. Service quality checklists  can serve
as a framework for training. The checklists make a convenient 
reference for trainers because they organise and summarise the
essential  knowledge and skills that must be addressed during
training.  

Tools for pre-test and post-test assessments of service 
enhancing efforts. Service quality checklists can be used to
measure  changes in service quality that result from training
efforts, improved  supervision, or other management improvements.
If action is taken  to correct problems discovered during an
initial assessment, a second  assessment can be done to determine
the effectiveness of the actions 
taken. 
A combination of the above methods. For example,  supervisors
could use checklists during regular supervision, and,  at
periodic intervals, compile the observations into a data set to 
assess area-wide service quality. Or, supervisors could
distribute  checklists to health workers as a self-assessment
tool to reinforce  points made during their visits. 

The frequency with which supervisors use the checklists can vary
widely,  depending on the time and resources available. They can
be used routinely  or on an ad hoc basis. Problems identified
during community  assessments (see Module 2), activity monitoring
(Module 5), personnel  performance assessments (Module 3), or
cost analysis (Module  8), can be explored in more detail using
quality assessment checklists  so that appropriate action may be
taken. 

Checklists 
The service quality checklists provided in this module  are
designed to record the observation of service delivery encounters 
between providers and clients. The checklists are made up largely 
of lists of tasks that providers are expected to carry out in
clinical  assessment, treatment, and health education. The
checklists also include  a few key questions to ask providers and
clients to check their knowledge  of important bits of
information. The items that make up each checklist  for some
services are based on more detailed lists taken from the  PRICOR
thesaurus. For services not covered in the thesaurus, checklists 
were developed based on the format of the thesaurus. They
represent  key tasks that should be carried out in providing
quality care. The  thesaurus was developed and tested over a
three-year period in consultation  with experts in PHC service
delivery and are consistent with WHO norms.  Checklists have been
developed so far for 21 PHC services. They can  be used
individually or in various combinations according to the needs 
of the user, and they can be easily adapted to fit different
programme  norms. 
In addition to using service quality checklists to assess  the
clinical performance of providers, it is useful to assess
provider  performance from the patient or client perspective.
This module includes  a client satisfaction questionnaire which
will allow managers to assess  whether clients' needs and
expectations are being met, and will enable  managers to identify
opportunities to improve the quality of care  as it relates to
patient satisfaction. Client satisfaction is important  because
it enhances the likelihood of compliance with the treatment 
regimen and follow-up visits. Also, it may be an important
determinant  of whether or not patients seek future care for
themselves or their  family members. Finally, client satisfaction
contributes to overall  programme sustainability, having
implications for utilisation as well  as client willingness to
pay in cost-recovery efforts.   
This module includes short and long checklists for the following:

OTHER HEALTH CARE
Water supply, hygiene and
sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
Malaria    
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable 
diseases
CLIENT SATISFACTION
GENERAL
PHC household visits
Health education    
MATERNAL CARE
Antenatal care
Safe delivery  
Postnatal care      
Family planning                    
CHILD CARE
Breast feeding 
Growth monitoring
Nutrition education
Immunization   
Acute respiratory infection  
Diarrhoeal disease control   
Oral rehydration therapy

These service quality checklists are made up of "yes" and "no"
questions  that can be answered by observation of the interaction
between health  workers and their clients, inspection of the
health facility, supplies  and equipment, review of health
records, and brief interviews with  providers and/or clients. The
questions are phrased so that all "no"  responses indicate
potential problems. These potential problem areas  should be
evaluated further by the manager and the service provider.  The
checklists can, in many instances, be used as they are. But most 
managers will want to modify them to fit their own needs and
programme  norms. Also, it will be necessary to determine the
requirements of  each question in operational terms. What
conditions must be in place  for a "yes" response? What precisely
is a "no"? Through discussion  with staff and by referring to
programme norms, managers should be  able to clarify these
issues. In some cases it may be desirable to  create an
instruction sheet which explains the purpose of questions  when
it is not obvious, and give guidelines about what constitutes  a
"yes" and "no" response.  
Four types of quality assessment tools are included in  the
module: short checklists for rapid service quality assessment; 
longer checklists for more detailed assessment; multiple
observation  checklists for assessing one or more units one or
more times; and  discussion guidelines, which permit a more
qualitative assessment. 

When to use the short checklists. Checklists  which include only
essential tasks for a PHC service have been developed  for rapid
assessment of service quality. Each includes 10-15 key items 
which can be easily observed during service delivery or included
in  an interview. The short form is recommended for the following
uses: 

This form may be used when the observer  is an expert who can
make reliable implicit judgments about clinical  performance. For
example, the rapid form for growth monitoring asks,  "Did the
service provider correctly calculate the age?" An expert 
observer could make a judgment about this, while a non-expert
observer  might prefer to use the more detailed checklist, which
lists all the  components of correct age calculation.  

This form may be used when the observer  has a great deal of
practice with the detailed checklist, and prefers  to use the
short checklist simply as a memory aide. 

This form may be used if the purpose of  the assessment is to
screen for problems which will be studied in  more detail at a
later stage. Rather than providing the precision  of the detailed
checklist, this tool gives a quick overview of service  quality
so that priority areas can be identified. 

This form may also be used when there is  a need for rapid data
analysis. Because of the small number of items, documentation and
data analysis are quicker, and results can be summarised 
rapidly.  

Exhibit 1, a short rapid service quality  checklist for
immunization, provides an example. Short checklists  for all 21
services are included in Appendix A. 

Exhibit 1:  Rapid service quality assessment checklist 
- <R>
Short form 

IMMUNIZATION 

 
This checklist is intended for rapid assessment of  service
quality in the observation of service delivery. To use the 
checklist, mark "yes" if the service provider carries out the
task  during service delivery. For interviews, mark "yes" if the
respondent  answers correctly. If you would like to assess this
service in more  detail, please refer to the appropriate service
quality checklist.  The checklist item numbers below correspond
to that list. 

1. Health facility<R>
3. Observer/supervisor<R>
4. Date 

Did the service provider: 
13.  YES       NO  Use a sterile needle for each injection? 
14.  YES       NO  Use a sterile syringe for each injection? 
17.  YES       NO  Give the child all vaccinations needed today? 
19.  YES       NO  Record the vaccination on the child's health
card? 

Ask the service provider: 
36.  YES       NO  Was the registered temperature between 0 and 8
degrees (C) at all times during the last month? 

(For outreach sessions):
41.  YES       NO Were vaccines transported in cold boxes with
ice packs? 

Ask mother 

43.  YES       NO When should you return for the next
immunization? 
 
 
When to use the long checklists. More detailed service quality
checklists, which include about 50 tasks each, have also been
developed. These detailed checklists are recommended for the
following uses: 

When the observers are not familiar with  the technical norms
being applied it is advisable to use the detailed  checklists.
Because the checklists include only explicit observable 
criteria, the resulting information will have a high level of
reliability. 

The detailed checklists may be preferred  for peer review because
the service provider being evaluated may feel  more comfortable
being judged by explicit, objective criteria. This  is less
important if the observer has expert status, because expert 
judgments are often more easily accepted. 

These detailed checklists may be preferred  for pre-test and
post-test assessments during training, for self-assessment  and
job aids, or for in-depth supervision. In all these situations, 
specificity is preferred because it leads to specific, focused
action for improvement.  
Detailed checklists could also be used to  follow up on problems
identified by the rapid assessment tools, or other problem
identification methods. For example, if a rapid assessment 
revealed that health workers were not performing a complete
physical  exam, further study might be needed to determine which
tasks were  being performed and which ones were omitted. The
detailed checklist,  or the relevant portion of it, could be used
for this purpose.  
Some managers may prefer to start with a  detailed checklist
initially, since it would make it unnecessary to  do two
assessments. This is especially important if supervision or 
assessment takes place over large distances or time intervals.  
Exhibit 2, a long checklist for growth monitoring, illustrates 
this second type of checklist. Detailed service quality
checklists for all 21 services are included in Appendix B.  

Exhibit 2: Rapid service quality assessment checklist 
- Long form 

GROWTH MONITORING 
This checklist is intended for use in the observation  of service
delivery. Before using it, the national treatment protocol 
should be reviewed in order to adapt the tool to the local
situation  if necessary. It is also recommended that you review
the checklist carefully before using it to be sure that you
understand the questions  and know how to use the form. For
observation of service delivery,  mark "yes" if the service
provider carries out these activities during  service delivery.
For interview questions, mark "yes" if the respondent  answers
correctly. 

1. Health facility  
2. Service provider  
3. Observer/supervisor  
4. Date   

Age calculation  
Did the service provider: 
5.   YES   NO         
Base calculation on a reliable date of birth? Reliable 
sources for date of birth: growth chart health record or birth
certificate. 
Rely on mother's memory only when these  are not available.> 
6.   YES            NO     Correctly calculate date of birth? The
accuracy of age calculation and weight reading should be
determined by comparing the health worker's reading with the
supervisor's  reading.> 
7.   YES             NO        Correctly record age? 

Weighing
Did the service provider: 
8.   YES             NO        Set scale to 0? 
9.   YES             NO        Remove child's clothing? 
10.  YES             NO        Place child correctly on 
scale? 
11.  YES            NO        Correctly read scale? Reliable 
sources for date of birth: growth chart health record or birth
certificate.  Rely on mother's memory only when these  are not
available.> 
12.  YES            NO        Correctly record weight? 
Locating the child's growth on chart  
Did the service provider: 
13.  YES            NO        Plot or locate the  child's age at
correct age? 
14.  YES            NO        Plot or locate the child's weight
at correct weight? 
15.  YES            NO     Connect to previous growth 
point? 

Referral and follow-up 
16.  YES             NO  Refer sick/malnourished child for
medical attention? 
17.  YES             NO        Refer malnourished child 
for nutritional rehabilitation? 
Growth monitoring and nutritional education 
Did the service provider do the following for all children 
weighed:  
18.  YES            NOTell mother whether child has gained, lost,
stayed the same since last weighing? 
19.  YES            NOTell mother the nutritional status of the
child? 
20.  YES            NOUse growth card to explain to mother how
her child is growing? 
Did the service provider do the following for malnourished 
children and for children who have not gained weight since the
last  session:  

21.  YES       NO Ask if the child has had any health problems
since last weighing? 
22.  YES       NO Make recommendations regarding child feeding
and care? 
23.  YES       NO Explain importance of good breast feeding and 
weaning practices? 
24.  YES       NO Explain which locally available foods
constitute a  balanced diet for children? 
25.  YES       NO Explain how to feed children during illness? 
26.  YES       NO Tell mother when to take child for next
weighing?  
27.  YES       NO Verify that mother understands key messages? 
28.  YES       NO Ask mother if she has any  questions? 
 
For outreach education session, did the service provider: 
29.  YES       NO  Explain the importance of gaining  weight for
health? 
30.  YES       NO  Explain the purpose of growth monitoring?
31.  YES       NO  Explain when and where to go for growth
monitoring  services? 
32.  YES       NO  Use appropriate health education techniques
and  materials? 
33.  YES       NO demonstrate preparation  of weaning foods? 
34.  YES       NO Verify that attendees understand key messages? 
35.  YES       NO Use visual aids in transmitting key messages? 
 
Supplies
Ask the service provider about the following supplies: 
36.  YES       NO Working scale 
37.  YES       NO Growth charts 

Exit interview with mother 
Mark "yes" if the respondent answers correctly: 
38.  YES       NO How much does your child weigh? 
39.  YES       NO Did your child gain weight, lose, or stay the
same  since the last weighing? 
40.  YES       NO When will you return for growth monitoring? 

 
The exhibit continues with five more questions on interviewing
the service provider
When to use discussion guidelines.  Some service  quality issues
are difficult to understand fully with a yes/no question. 
Discussion is a good way to open a dialogue with service
providers  and engage them in the quality improvement process.
Discussion guidelines  complement the checklists by helping
managers to explore the complexity and diversity of service
quality issues and to study the problems  in more depth.  
Exhibit 3 is an example of a discussion guideline for acute
respiratory  infection. Discussion guidelines for all 21 services
are included in Appendix C. 

Multiple observation checklists.  Checklists for  multiple
observations have been developed for selected PHC services.  This
form is designed to record up to ten observations for each task
or  health worker. It also includes space for comments and
actions taken. This checklist  can be  used, for  example, to
record  ten observations  of the same worker or 2-3 observations
of several workers at one facility.  It can be used to follow a
worker over time, recording 2-3 observations during an initial
visit, and 2-3 more during follow-up visits. With  minor
modifications these checklists can be used to observe group 
sessions. For example, the form could be enlarged (or several
copies  made) to observe all of the children immunized or weighed
in a clinic  session. Exhibit 4 is an abbreviated example of a
multiple observation  checklist for a general PHC visit. Multiple
observation checklists  for five of the 21 services are included
in Appendix D. 

Some limitations  
Service quality checklists aid supervisors by making the
assessment  more specific and objective. However, proper use of
the checklists  requires sound technical judgement and such
supervisory skills as  problem-solving and giving constructive
feedback. Programme managers  may find it advisable, in some
cases, to combine the introduction  of quality assessment
activities with additional training for supervisors.  Such
training might include a refresher course on technical service 
norms and basic supervisory skills. Some of the potential uses 
of the checklists imply a participatory team approach to service
quality improvement. If such  approaches are to be used,
managers, supervisors and health workers  will need to complement
their technical and managerial skills with team-building and
group facilitation skills. 

Exhibit 3: Service quality assessment discussion guidelines 
ACUTE RESPIRATORY INFECTION 
Introduction: Welcome the group and briefly give  the purpose of
the discussion.

Ground rules:  Explain the following ground rules to the group: 
Ground rules for group discussion
Everyone's ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.  
Participants should feel free to disagree with one another so
that all points of view are heard.
Don't wait to be called on; it's a group discussion.
Please speak one at a time.   

These discussion guidelines are provided to help you  to lead a
group discussion about the quality of your services for  Acute
respiratory infection. You may also refer to the detailed version 
of the PHC service quality checklist (Appendix B) as a resource
for  the discussion. 
Discussion: 
What works well in the way we provide ARI services? 
Guidelines          :  
What does not work well in the way we provide ARI  services? 
What standards, guidelines or protocols are used  for providing
ARI services? 
To whom would you go if you had questions about a  standard or
how to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
What treatments do you prescribe for what types of  ARI? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or  counselling
your clients? 
Key questions 
Are at least two medical history questions asked? 
Did the service provider ask about any treatment  administered? 
Is the respiratory rate counted? 
Is the child classified by severity of illness? 
Are antibiotics for pneumonia, strep throat or otitis  given? 
Did the service provider refrain from using antibiotics for
colds? 
Are clients told about at least three signs of pneumonia?<$FSigns 
include stridor, chest indrawing/rapid breathing, inability to
drink,  cyanosis, anxiety, and weakness or lethargy>  If
antibiotics are prescribed, is the client asked,  "How will you
administer the medicine, how much, how often, for how long?" 

EXHIBIT 4: RAPID QUALITY ASSESSMENT
Rapid service quality assessment checklist  
PHC household visit 
 
1.   Health facility                                           
2.   Observer                                                  
3.   Regular supervisor                                   
4.   Date                                            
 
Observation number/registration and documentation, +, 1, 2, 3, 
4, 5, 6, 7, 8, 9, 10, TOT, Problems identified, 
Actions taken 
5., Are all children under 5 registered on the family health
card?, , , , , , , , , , , , ,  
6., Are all women over 16 registered on the family health card?,
, , , , , , , , , , , ,  
7., Was information updated during the visit?, , , , , , , , , ,
, , ,  
Immunization, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
8., Was this visit recorded in health centre records?, , , , , ,
, , , , , , ,  
9., Discuss the importance of vaccination?, , , , , , , , , , , ,
,  
10., Review the immunization status of all children << 5?, , , ,
, , , , , , , , ,  
11., Vaccinate or arrange for vaccination of children who need to
be immunized?, , , , , , , , , , , , ,  
12., Review vaccinations needed and the appropriate dates with
mother?, , , , , , , , , , , , ,  
13., Answer mother's questions about vaccination?, , , , , , , ,
, , , , ,  
Growth monitoring, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
14., Review the growth cards of all children << 5?, , , , , , , ,
, , , , ,  
15., Weigh children or refer them as appropriate?, , , , , , , ,
, , , , ,  
16., Discuss changes in weight with the mother and give
nutritional advice?, , , , , , , , , , , , ,  
17., Answer mother's questions about growth monitoring and
nutrition?, , , , , , , , , , , , ,  
18., If there are any malnourished children in the house did the
health worker check to be sure that nutritional counselling, food
supplementation,, and/or medical attention are being received as
indicated?, , , , , , , , , , , , ,  
RT, , +, +, +, +, +, +, +, +, +, +, +, +, + 
19., Ask if any children in the household have diarrhoea?, , , ,
, , , , , , , , ,  
20., If yes,, recommend ORT,, and help the mother to prepare and
administer 
it?, , , , , , , , , , , , ,  
21., If no,, review the importance of ORT and encourage mother to
use it in future diarrhoea episodes?, , , , , , , , , , , , ,  
22., Answer mother's questions about ORT?, , , , , , , , , , , ,
, 
23., Demonstrate how to make ORS solution,, or invite mother to a
demonstration if necessary?, , , , , , , , , , , , ,  
Observation number/registration and documentation , +, 1, 2, 3, 
4, 5, 6, 7, 8, 9, 10, TOT, Problems identified, 
Actions taken 
Antenatal care:, +, +, +, +, , , , , , , , , ,  
24., Discuss the importance of prenatal care?, , , , , , , , , ,
, , ,  
25., Ask if any women in the household are pregnant?, , , , , , ,
, , , , , ,  
26., Talk with each pregnant woman about her well-being?, , , , ,
, , , , , , , ,  
27., Ask if  each pregnant woman is receiving prenatal care and
arrange for a prenatal visit if necessary?, , , , , , , , , , , ,
,  
28., Give nutritional advice and iron/calcium supplementation to
each pregnant woman?, , , , , , , , , , , , ,  
29., Answer pregnant woman's questions?, , , , , , , , , , , , , 

Family planning, +, , , , , , , , , , , , ,  
30., Provide information about family planning services?, , , , ,
, , , , , , , ,  
31., Refer interested women or couples for family planning
services?, , , , , , , , , , , , ,  
32., Ask women who already use contraception if they are happy
with their method?, , , , , , , , , , , , ,  
33., Refer current users for advice or follow-up if necessary?, ,
, , , , , , , , , , ,  
34., Answer questions about family planning?, , , , , , , , , , ,
, ,  
Water and sanitation, +, +, +, +, , , , , , , , , ,  
35., Ask about access to water and provide information about
community efforts to address problems (if necessary)? , , , , , ,
, , , , , , ,  
36., Ask about water storage practices and give appropriate
advice?, , , , , , , , , , , , ,  
37., Ask about latrine maintenance and use and give appropriate
advice?, , , , , , , , , , , , ,  
38., Ask about refuse and excreta disposal and give appropriate
advice?, , , , , , , , , , , , ,  
General, +, +, +, +, , , , , , , , , ,  
39., Ask if anyone in the household is ill and give appropriate
advice?, , , , , , , , , , , , ,  
40., Follow up on recent illnesses?, , , , , , , , , , , , ,  
41., Verify that the client(s) understand key information from
today's visit?, , , , , , , , , , , , ,  
42., Establish good rapport with the mother?, , , , , , , , , , ,
, , 


Service quality assessment procedures 

This section describes the process of designing and carrying out
quality  assessment activities.  The process, consisting of seven
steps, can  be followed by managers and supervisors at all
levels. 

Step 1:  Specify the scope and objectives
Step 2:  Select the unit of observation and data collection 
techniques
Step 3:  Select and adapt the appropriate service quality
checklist(s) 
Step 4:  Develop the sampling procedures and select sample
(optional)
Step 5:  Carry out the assessment 
Step 6:  Compile and analyse the data
Step 7:  Report the findings,, provide feedback,, and take
corrective action

  A worksheet for developing quality assessment procedures has
been  developed and appears in its complete form in Appendix D. 
Portions  of the worksheet are included in the steps described
below.     
Step 1:   Specify the scope and objectives  
The usual objective of quality assessment is to identify
strengths  and weaknesses in service delivery and to make
subsequent corrections  in order  to improve overall service
quality.  The first step in developing  quality assessment
procedures, therefore, is for the manager or management 
team to define specific objectives and the scope of the assess- 
  ment.  This is important because they have implications  for
design, analysis, and documentation.  The following questions 
may help you define what you want to assess and why.   
What is the purpose of the assessment? 
The purpose of the assessment may be to monitor individual
performance,  to assess service quality in a group of health
centres within a district,  or to establish a baseline in order
to monitor improvement over time.  The  purpose will have
important implications for the design of the assessment. What
services will be included? As noted  previously, the assessment
can be of one or more PHC services (immunization,  antenatal
care, etc.).  It can also focus on a specific set of service 
tasks, e.g., weighing sessions, ANC counselling.  Managers may
want  to do a quick assessment of priority PHC services and then
follow  up with a more detailed assessment of those that are the
most problematic.  Who will use the information gathered?  The 
information resulting from a quality assessment can be used by
local  managers, the board of directors, regional or national
directors,  and/or donors.  It can also be used by health workers
themselves and  the communities.  Who will use the information
will affect decisions  about what information to collect, how
much to collect, and how to  report it.
How will the information be used? The information  can be used in
a variety of ways.  For example, it might be used to  identify
problems so that plans can be made for training, supervision,  or
technical assistance. The specific use of the information will 
have implications for what is collected and how it is analysed. 
What geographic area will be covered? Quality  assessment can be
carried out at any level, from a single health centre  to a
province, state, or nation.  Some managers may want to pick a 
pilot area to start out and expand to other areas.  Over what
period of time will the assessment  take place? When will the
information be needed?  That will help  answer this scheduling
question.  How often will the assessment be  done: once, twice,
on a regular basis?  Short, rapid assessments may  be appropriate
if time is short.    Also, some assessments may be carried out on
an ongoing basis,  while others may be done once or on an ad hoc
basis.  What additional resources, if any, are available?
Ideally, quality assessment should be carried out with resources
that  have been allocated to management and supervision. 
However, if a  special QA study is planned, it might involve
additional costs for  transportation, per diem, and supplies. In
designing studies, managers  should assess whether additional
resources are available and keep  in mind the importance of
financial feasibility and sustainability. 
 
 
Part 1 of the worksheet for planning quality assessment
procedures  is presented below.  A manager could use this
worksheet to specify  the scope and objectives of the assessment. 
  
Step 2: Select the unit of observation and data collection 
techniques  The next step in planning the assessment is to
determine    the unit 
of observation and data collection techniques.   
Unit of observation.  Quality can be assessed  by following
clients through the system, by observing health workers  provide
services to different clients, and by observing a specific 
procedure multiple times.  In addition, the quality of an entire
clinic  session or health centre can be assessed. 
 
Client/patient.  If the client is the unit of observation, 
managers should design data collection instruments so that they
can  follow clients through the service delivery process.  This
may be  appropriate in cases where different providers carry out
different  parts of the same service. For example, if one
provider gives injections  while another health worker documents
the case and provides health  education, it would be important to
describe the main steps in the  process, often called "patient
flow," so that each can be individually  assessed. 
 
Health worker.  If individual health workers are the  units of
observation, their routines to be observed.  In such a case,  the
instruments should be designed to follow individual health
workers  rather than clients.  For example, a supervisor might
accompany a  Community Health Worker (CHW) on several home visits
to observe how  he or she carries out his or her tasks. 
 
Service elements.  If the unit of observation is a  service, or
specific tasks, then multiple observations of that service  or
those tasks need to be made.  This can be done in many ways.  For 
example, an observer can watch the well-child clinic registration 
routine for several clients to determine what tasks are normally
performed  and how well they are done. 
 
Clinic session.  A variation of this is observation  of an entire
clinic session, which will require assessments of each  of the
major components of a typical session.  A well-child clinic 
might include registration, health education, physical
examinations,  immunizations, growth monitoring, and so forth. 
Observations could  be done by following a number of clients
through the clinic session  or by observing each station in the
clinic. 
 
Health centre.  The health centre may also be the  unit of
observation.  This is particularly appropriate if the objective 
is to conduct an overall assessment of health centre operations,
or  if there are health centre-specific  issues of concern, such
as the adequacy of supplies.  It might  also be appropriate if
the manager has reason to believe that  variations in service
quality relate to differences among health centres  rather than
differences among individual workers.   
Data collection techniques.   Service quality data  can be
collected from direct observations, interviews, or a review  of
medical records.  A brief explanation of each type of data source 
follows.   
Direct observation by supervisor or peer.  Observing  service
providers during service delivery directly assesses how well 
they apply their knowledge, and how well the patient responds to
clinical  treatment and counselling.  It permits a supervisor,
manager, or peer  observer to help the health worker to evaluate
service quality, identify  problems, and measure improvement in
performance.  If actual service  delivery cannot be observed,
health workers can be asked to do a role  play of a client
encounter.  While observation is a good way to determine  whether
service providers can do their assigned tasks, the observer  has
to be unobtrusive so as not to interfere with or distract the 
health worker and client.  There is also a possibility that
people  will behave differently when being observed.  This can
usually be  overcome with multiple observations.  After awhile,
people tend to  ignore the observer and behave normally. 
 
Self-assessment.  Service providers can use the  checklist to
assess their own performance by reviewing or filling  out the
checklist after a service delivery encounter.  This type of 
information can support self-improvement efforts and can be used
effectively  when a system of participatory and supportive
management is in place.  However,  if the self-assessments are to
be turned in for review by superiors,  the results may be biased,
especially if the health workers are afraid  that the assessments
may be used against them.  Structured interviews.  The checklists
can also be  used as a guide for interviews with providers by
asking whether or  not they carry out each activity on the
checklist.  Since most of  the items are designed to code "no"
responses as problems, the questions  should  be  phrased  so 
that they are not "leading" questions.  For  example, the
supervisors could ask, "How do you assess a child with 
diarrhoea?"  The supervisor would check off all items mentioned
by  the service provider.  The supervisor would subsequently then
ask  about those items not mentioned and record the answers.   
Open-ended interviews and discussions. The checklists  can also
be used more informally to identify topics for individual  or
group discussion.  For example, a supervisor who discovers a
persistent  problem with accurate recording of children's weights
in growth monitoring  might use the checklist as a reference
guide in a participatory problem-solving  session.     
Record review.  Service quality assessments can also be based on
review of records, especially health records.  While  a record
review has limited value for assessing the service delivery 
process, such important information as whether a treatment was
given  or whether  a required  laboratory  test  was  done can
often be collected  from records.  If health records in a given
health centre are not  adequate, the checklists could serve as a
guide for deciding what  information should be collected during
the observation period.  For  example, health workers might be
asked to fill out a form covering  a 2-3 week period about each
ARI case contacted.  The data generated  could be used as part of
a service quality assessment.  The worksheet  for Step 2 can be
used to help determine the unit of observation and  data sources. 
  
Step 3:   Select and adapt the appropriate service quality
checklist(s) Managers may select the long or short version of the
appropriate  service quality checklist.  While the checklists may
be used as they  are in some cases, the checklists will usually
require some adaptation  to each programme.  Field tests have
shown that it should take no  more than 2-3 hours to revise the
checklists.  Adaptation can include  omitting items that are not
relevant, revising, rearranging and rephrasing  items to fit
local conditions, and adding items that are important  to your
programme.  In certain cases you may wish to combine items  or
sections from several checklists to form a new one.  The format 
and layout may also be modified, of course. Several managers have
found it useful to make these changes in  a group session
involving the users who are usually supervisors and 
administrative staff.  Group work helps to ensure that the key
users  become familiar with the instruments and the procedures
and to develop  a sense of "ownership" of the quality assessment. 
It is also quicker.  When  an instrument is prepared by one
person it is often circulated for  comment, revised,
recirculated, etc.  A form has been developed for  managers who
want to make up their own checklists.  Exhibit 5 on the 
following page shows how the form might be used.  A blank form 
is included in Appendix E. 
Exhibit 5
Step 4:   Develop the sampling procedures and select sample
(optional) 
This step is only necessary if the objective is to conduct a
study or evaluation of quality in an administrative area, such as
a district or province.  The purpose of sampling is to make an
objective assessment of a large group without having to assess
every member of that group.  For example, if there are only ten
health centres it might be best to do an assessment of each one. 
But if there are 100 and the manager wants to have an idea of the
overall quality of the group, then a sample would be appropriate. 
It would also require much less time and effort to gather the
needed information. 
Detailed instructions for drawing random and cluster samples can
be found in Module 2: Assessing community needs.  The Appendices 
of Module 2 include instructions for determining sample sizes and
computer programs that managers can use to calculate sample
sizes, generate random samples, and select clusters.  An
excellent discussion of the technical issues surrounding sampling
techniques can be found in an article by Lemeshow and Stroh.
Lemeshow, S. and Stroh, G. Sampling techniques for evaluating
health parameters in developing countries, Washington, DC,
National Academy Press, 1988.

When is sampling unnecessary? When checklists are used to
structure the performance evaluation of individual workers,
sampling is not necessary.  The purpose of such an evaluation
should be to identify strengths and weaknesses and to support the
service provider so that performance can be improved.  For
example, supervisors could use the checklists with each health
worker, each health centre, and/or at selected PHC sessions in
order to conduct quick assessments of the quality of each one. 
The results could be analysed immediately and discussed with the
local staff or managers, and recommendations for immediate action
could be made  on the basis of these discussions.  It would not
be necessary to select a sample of workers, health centres, or
sessions in this case. The following discussion summarises
procedures that might be appropriate for drawing a sample for
quality assessment, when sampling is required. 

Developing the sampling frame.  The sampling frame is the
complete list of all the potential units of study.  This could be
a list of health centres, health workers, PHC sessions, or
scheduled PHC services.  For example, if the objective is to
assess the quality of services provided by CHWs, then a list of
all of the CHWs would be needed.  If the objective is to assess
the quality of immunization services, then a list of scheduled
immunization sessions would be required.  In most cases managers
will have such lists readily available.   However, they should be
reviewed to be sure that they are complete and up-to-date. 
In some cases, such as where services will be provided by
different individuals in different locations, lists of each will
be needed.  For example, prenatal care could involve CHWs who
identify pregnant women, provide prenatal education, and make
referrals; TBAs who do initial examinations, home deliveries, and
make referrals; and nurse-midwives at health centres who see
referred cases and make deliveries.  A sampling frame would be
made up of a list of all CHWs, TBAs and nurse-midwives.  
Determining sample size.  When choosing the sample size, managers
should consider how much precision is required as well as the
resources and time available.  Larger samples are more likely to
be statistically valid and generalisable than smaller ones.  But
if the manager would be satisfied with a rough estimate, then a
small sample may be adequate. 
For the purpose of service quality assessment, these issues are
only important when the number of units is very large (say 100
CHWs) and high levels of precision are needed.  For example, if a
baseline study of a service is to be carried out, and a manager
would like to be able to detect small changes in performance
during a follow-up assessment, the precision of the sampling
would be very important.
Most managers will be satisfied with rough estimates.  A 
suggested rule of thumb is: if the number of units is very
large (say 500-1,000), take a ten percent sample; if it is of
medium size (100-500), take a 15-20 percent sample; if it is
small (50- 100), take a 20-30 percent sample; and if it is very
small (less than 50), take a 30-50 percent sample.  

Sampling procedures. The most important principle of sampling is
that the units selected for observation be representative of all
of the units.  For example, if there are 20 health centres and
ten are going to be selected for the assessment, those ten should
not be the best or worst of the 20.  They should include the same
proportion of good and poor centres as exists overall so that
they represent the entire group. 
There are four main sampling procedures that are appropriate for
quality assessment.    

Random sample. A simple random sample can be drawn by first
assigning a number to each unit included in the sampling frame. 
Second, the units should be selected randomly until you reach the
required sample size.  For example, if the sampling frame
includes 200 TBAs, each TBA would be assigned a number from one
to 200.  If the sample size chosen is 20, 20 numbers from one to
200 would be chosen randomly, and the corresponding TBAs would
constitute the sample.  The random selection could be done by
pulling numbers from a hat, consulting a random number table, or
by using a computerised random number generator. 

A stratified random sample may be more appropriate if there are
significant differences in the units to be observed; for example,
if there are rural and urban health centres, if the health
workers are made up of TBAs, auxiliary midwives, and CHWs, or if
the immunization sessions are held in different sites (hospitals,
health centres, schools).  In this case the group should be
divided into these categories and the samples should be drawn
randomly from each subgroup.  The number drawn from each subgroup
should be in proportion to its size.  For example, if 20 percent
of the health workers are TBAs, then 20 percent of the sample
should be TBAs. 
Systematic sample. A systematic sample of size (n) may be drawn
from the sampling frame by choosing a random starting point and
selecting a unit at regular intervals (k). To determine (k),
divide the total number of units on the list by the desired
sample size (n).  For example, if a programme has 100 service
providers and the manager decides to select a sample of 33 then
the manager would make a complete list of the 100 health workers,
choose a random starting point, and then select every third
health worker (100/33=3) until 33 have been selected.  
Lot quality assurance sampling. Lot Quality Assurance Sampling
(LQAS) is a type of random sampling that uses very small samples,
say six to 30 observations, to determine whether the specific
batch or "lot" of finished products produced by a specific
production unit meets a specified threshold of quality.  This
method was developed for industrial production but has recently
been applied to health services.  The "production unit" in PHC
may be an individual health worker, a service delivery group, an
encounter, a session, or a health centre.  Examples are: all CHWs
in a project area; all growth monitoring sessions conducted in
January; all health centres operating in the city.  Managers can
use this technique to determine, for example, whether children
are being weighed properly.  LQAS does not tell a manager what
proportion is weighed properly, just whether the proportion
weighed properly is above or below a designated level. 
The procedure requires the manager to specify a goal that the
"batch" is expected to achieve and a "minimal acceptable" level
of achievement.  The manager must also specify the level of
precision needed and the time and resources available for data
collection. With this information, the manager can use an LQAS
table to determine the required sample size.  For example, if the
goal of a growth monitoring programme is to weigh 85% of children
correctly with a minimum acceptable level of 65%, the required
sample size would be  29 random obser-vations.  The table shows
that 23 of 29 observed weighings would have to be done correctly
to conclude that the programme is meeting its goal. A table of
sample sizes and acceptance thresholds is included in Appendix 
E.  This table is taken from a manual on lot quality assessments
by Wolff and Black, and is recommended for managers who wish to
use this method. Wolff, M. C., and Black, R.<MI>  Manual  for 
conducting  lot  quality  assessments in oral rehydration 
therapy  clinics.  Baltimore, MD. The Johns Hopkins University
School of Hygiene and Public Health, Institute for International
Programs, 1989.  It is important to note that LQAS results should
never be presented as a percentage because they would be very
imprecise.  Instead, the method should be used only to determine
whether or not performance is meeting a given standard.  

Convenience sampling. If a manager wants to gather information
quickly, minimise the amount of time invested in data collection,
and is not too concerned about statistical precision, then a
convenience sample may be an attractive option.  A convenience
sample is made up of units that are convenient to observe,
usually because they are close by or scheduled to occur at a
convenient time.  To choose a convenience sample the manager
selects a time and site for the assessment and makes as many
observations as possible during the visit.  For example, a
supervisor might decide to spend one day in each of three nearby
clinics to observe scheduled MCH sessions.  The health
facilities, MCH sessions, and service providers are not chosen 
randomly, and therefore the MCH sessions observed may not be
representative of all MCH sessions.  Nevertheless, many managers
know their programmes well enough to spot extreme discrepancies
and to interpret the results realistically. 
Two common variations of convenience sampling are purposive and
quota sampling.  The former involves selecting each unit "on
purpose", i.e., not randomly or systematically.  For example, a
manager may decide to examine three of the best, three of the
worst, and three average health centres. 
A quota sample involves deciding how many observations will be
made and then observing those that  occur first until the "quota"
of observations is met.   For example, a supervisor might decide
to make ten observations, and then observes the first ten women
who come into an ANC session. NOne of the convenience sampling
techniques produce probability samples.  This means that it is
not possible to determine the probability that the results
obtained are correct. Following is a worksheet for planning the
sampling procedures. 

WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 4. Develop the sampling procedures and select sample
(optional)
Number of units in sampling frame: 4  
Sample size       (%) =        (N)
Sampling method:
     Census (100 percent sample)   X   all 4 centres
     Random sample                                               
     Systematic sample                   
     LQAS sample                    
     Convenience sample                       
     Purposive sample                    
     Quota sample                   
What is the minimum number of observations that should be made
for each unit?   10        

WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 5. Carry out the assessment
8/10     Preparation for the visit
8/16     Select and train observers
8/14     Produce data collection forms
8/16     Conduct a pretest of the checklists
8/12     Select dates for the assessment
8/14     Inform health centres and service providers (optional)
8/20     Arrange for transportation for data collection



Step 5: Carry out the assessment 
The preceding worksheet for planning quality assessment lists
several important tasks that the manager or supervisor should do
in preparation for the assessment visit. Appendix E of Module 2
includes some guidelines for training and supervising field
interviewers, which also apply to field observers.  Data
collection with service quality checklists. Before the
assessment, the manager and/or observers should review the
service quality checklists to be sure  that they are comfortable
with the format, procedures, and content.  Most managers and
supervisors may want to use the checklists as a part of routine
supervision, but some may also want to use them periodically to
do scheduled, formal assessments.  Some may want to make
unannounced visits so that staff do not make special preparations
for the assessments.   It is usually a good idea to explain what
the observer will be doing and why, thus avoiding
misunderstanding and anxiety.  Experience has shown that most
workers want to improve their performance and welcome help and
advice that is constructive.  But they will also resist
cooperating when they suspect that the information will be used
against them.  Ideally, quality assessment should be carried out
in a supportive, constructive manner to help staff improve the
way services are delivered. Exhibit 6 shows a hypothetical
example of a completed checklist.  Each item requires a response
of "yes" (Y), "no" (N), or "don't know/didn't observe/not
applicable" (DK), and (NA, leave blank). The supervisor used the
immunization quality assessment checklist during a routine
supervisory visit.  It shows that three health workers were
observed at North West Health Center as they gave vaccinations. 
KB was observed three times, LD was observed three times, and SF
was observed four times.  It also records the responses of
mothers, who were interviewed after the immunization, as well as
the response of service providers who were interviewed at the end
of the day.  The cold chain and supplies were also inspected with
the aid of the checklist. Based on these observations, the
supervisor noted the following problems: health workers were
missing opportunities to identify women and children who need
vaccinations,  health education about side effects and what to do
about them was not adequate; but mothers did not know what
vaccine their children had received and when to come back for the
next shots.  Also, the administration of the vaccine was done
very well. The checklist also shows that the supervisor addressed
some problems immediately by pointing out errors and reminding
health  workers of  vaccination  norms.   He then planned an
in-service training session to review educational messages and
techniques that go along with immunization. He also decided to
check on the educational component of ORT and growth monitoring
because he suspected that the problems identified were not
limited to immunization.  

Gathering information with discussion guidelines. If group
discussions are to be held, the manager should give participants
as much notice as possible and provide them with a brief
description of the purpose of the meeting and the kind of
information they will be asked to provide.  This will allow staff
to prepare by thinking about the topic beforehand and conferring
among themselves.  Also, this will afford participants time to
gather information to illustrate their points of view, if they so
desire.  The ideal size for a group discussion is 5-10 people.
Each group discussion should begin with a brief introduction and
explanation of the purpose of the discussion.  Also, the person
who leads the discussion should explain the ground rules to the
group before the session.  This is especially important if the
group members normally work together.  They should be reminded
that this meeting has a different purpose and structure.  The
ground rules on the next page will help the group stay on course.

Exhibit 6: Example of a completed quality assessment checklist  
Immunization 
 
1. Health Facility       Northwest Centre 
2. Observer              B. Sing 
3. Regular supervisor    B. Sing 
4., Observation number:, 1, 2, 3, 4, 5, 6, 7, 8, 
9, 10, TOT, Problems identified, Actions taken 
5., Date:, 8/28, 8/28, 8/28, 8/28, 8/28, 8/28, 8/28, 8/28, 8/28, 
8/28, YES, ,  
6., Service provider (initials):, KB, KB, KB, LD, LD, LD, SF, SF,
SF, SF,  , ,  

Identification of needed vaccinations, +, +, +, +, +, +, +, +, +,
+, +, +, +, + 
 
7., Review health records to determine which immunizations are
needed today?, N, N, N, N, N, N, N, N, N, N, 0, missed
opportunities to identify needed  immunization, in-service
training session to cover this topic 
8., Review mother's health record or ask whether she has received
Tetanus Toxoid immunization?, N, Y, N, N, Y, N, N, N, N, N, 2,
communication for women and children,  
9., Review vaccination status of other children in the family?,
Y, Y, Y, N, Y, N, N, N, N, N, 4, ,  
10., Recommend vaccination even if the child is sick?, , , , , ,
, , , , , , ,  
Preparation and care of vaccine, +, +, +, +, +, +, +, +, +, +, +,
+, +, + 
11., Check the label for the correct vaccine and be sure the
vaccine has not expired?, Y, Y, Y, Y, Y, Y, Y, Y, Y, Y, 10,
carried out well, 
12., Load the syringe without contamination?, Y, Y, Y, Y, Y, Y,
Y, Y, Y, Y, 10, , reviewed sterilization procedure with LD. 
13., Use a sterile needle for each injection?, Y, Y, Y, N, Y, Y,
Y, Y, Y, Y, 9, in one case LD used,  
14., Use a sterile syringe for each injection?, Y, Y, Y, N, Y, Y,
Y, Y, Y, Y, 9, needle and syringe twice,  
15., Keep the vaccine on ice and covered during the session?, Y,
Y, Y, Y, Y, Y, Y, Y, Y, Y, 10, ,  
Vaccination techniques, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
16., Apply the vaccine at the right level (BCG=dermal
layer,measles=subcutaneous layer,DTP/TT=muscle)?, DK, Y, DK, DK,
Y, Y, DK, DK, Y, Y, 5, ,  17., Dispose of the needle and syringe
properly?, Y, Y, Y, Y, Y, Y, Y, Y, Y, Y, 10, well done,  
18., Was the child given all vaccinations needed today?, Y, Y, Y,
Y, Y, Y, Y, Y, Y, Y, 10, ,  
19., If the mother required TT did the service provider vaccinate
or arrange for vaccination?, N, Y, N, N, Y, N, N, N, N, N, 2,
problem relates to failure to ID mothers.,  
Documentation, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
20., Record the vaccination on the child's health card?, Y, Y, Y,
Y, Y, Y, Y, Y, Y, Y, 10, well done,  
21., Record the vaccination in health centre records?, Y, Y, Y,
Y, Y, Y, Y, Y, Y, Y, 10, ,  
EPI education, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
22., Tell the mother which vaccinations were given during this
visit?, Y, Y, Y, Y, N, Y, Y, N, N, Y, 7, should explain each
time, review educational messages 
23., Inform the mother of possible side effects (i.e. fever and
pain)?, N, N, N, N, N, N, N, N, N, N, 0, side effects were not
discussed,, 
24., For BCG vaccination explain that a scab will form?, Y, Y, Y,
Y, Y, Y, Y, Y, Y, Y, 10, , " 
25., Tell mother where to go if there is a severe reaction to the
vaccination?, N, N, N, N, N, N, N, N, N, N, 0, severe reactions
not discussed,  
Observation number:, +, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, TOT,
Problems identified, Actions taken EPI education (cont'd), +, +,
+, +, +, +, +, +, +, +, +, +, +, + 
26., Explain the importance of completing the vaccination
series?, Y, Y, Y, Y, Y, Y, Y, Y, Y, Y, 10, ok,  
27., If DPT #3 has been administered stress the importance of
returning for measles vaccination., -, -, N, -, -, -, Y, -, -, -,
1, measles reminder needed each time, in-service training session
28., Explain that the child can be immunized even if she/he is
ill?, N, Y, N, N, N, N, N, N, N, N, 1, vaccination in cases of
illness, review educational technique 
29., Tell mother when to come back for next immunization for
herself or one of her children?, Y, Y, Y, Y, Y, Y, Y, Y, Y, Y,
10, ,  , , 
30., Ask mother to encourage other women to be vaccinated and
have their children vaccinated?, N, N, N, N, N, N, N, N, N, N, 0,
missed opportunity to promote vaccinations, assess education for
other services. 
31., Ask mother to repeat key messages?, N, N, N, N, N, N, N, N,
N, N, 0, must be sure that mothers understand,  
32., Ask mother if she has any questions?, Y, Y, Y, Y, Y, Y, Y,
Y, Y, Y, 10, ,  
Maintenance of cold chain and supplies, +, +, +, +, +, +, +, +, 
+, +, +, +, +, + 
33., Is the refrigerator working today?, Y, , , , , , , , , , ,
34., Is there a thermometer or cold chain monitor in the
refrigerator?, Y, , , , , , , , , , , cold chain is operating
well,  
35., Is there a temperature log?, Y, , , , , , , , , , , ,  
36., Is temperature recorded regularly according to the local
schedule?, Y, , , , , , , , , , , ,  
37., Was the registered temperature betwen 0 and 8 degrees (C) at
all times during the last month?, Y, , , , , , , , , , , ,  
38., Are all vials in storage unopened?, , , , , , , , , , , , , 
For outreach session:, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
39., Were vaccines transported in cold boxes with ice packs?, , ,
, , , , , , , , , ,  
40., Were vaccines sufficient?, , , , , , , , , , , , ,  
41., Were needles and syringes sufficient?, , , , , , , , , , , ,
Exit Interview with mother, +, +, +, +, +, +, +, +, +, +, +, +, 
+, + 
42. What immunization(s) did your child receive today?, Y, Y, Y, 
Y, N, Y, Y, N, N, Y, 7, mothers who were told know, remind health
workers to tell mothers what immunizations are given 
43., When should you return to the health centre for your next
immunization?, Y, Y, Y, Y, Y, Y, Y, Y, Y, Y, 10, ,  
Interview with service provider, +, +, +, +, +, +, +, +, +, +, +,
+, +, + 
At what age should a child receive the following vaccines:, KB, 
LD, SE, , , , , , , , , ,  
44., BCG, Y, Y, Y, , , , , , , , , ,  
45., DPT, Y, Y, Y, , , , , , , , , ,  
46., Measles, Y, Y, Y, , , , , , , , , knowledge is adequate,  
47., OPV, Y, Y, Y, , , , , , , , , ,  
48., Should you vaccinate a child if she/he is ill?, Y, Y, Y, , ,
, , , , , , ,  


After the ground rules have been presented, the leader can use
the guidelines to lead the discussion on a given service delivery
topic.  The leader of the group discussion can refer to the key
questions included in the guidelines if there is a need to probe
the issue in more detail. 

Ground rules for group discussion
Everyone's ideas and opinions are important.
There are no right or wrong answers.
Both positive and negative comments are welcome.  
Participants should feel free to disagree with one another so
that all points of view are heard
Don't wait to be called on; it's a group discussion.
Please speak one at a time.   

The group leader should keep track of the time and guide the
group to new topics when it seems that enough information in a
specific area has been shared.  Before moving to a new topic or
question, the leader should ask the group if anyone has any final
comments to add.  At the end of the discussion, the leader should
thank the group for participating and give everyone in the group
one last opportunity to comment on the overall topic. The leader
should write a summary of the discussion, organised by topic,
soon after the discussion so that key issues will not be
forgotten.  This information will be useful for identifying
management problems, their causes, and possible solutions.  

Step 6: Compile and analyse the data 
The rapid data analysis plan outlined here allows managers to
compile, analyse, and interpret results of quality assessment
quickly and easily. Supervisors and managers can hand tabulate
the results depending on the number of observations. The
information gathered during a service quality assessment may be
tabulated using a simple matrix. Data is transferred from
observation checklists to the matrix, and can be summed easily. 
If multiple observation checklists are used, the tabulation can
be done on the checklist, eliminating the need to transfer the
information to the tally sheet. 

Exhibit 7 shows how a tally sheet was used to record and tabulate
30 observations of the quality of the PHC household visit.  The
question numbers  correspond to those of the rapid service
quality checklist in Appendix B.  Note that the results show
inadequate performance in nutrition counselling, recommending
ORT, referral for family planning, and discussing sanitation
(items 18, 20, 31 and 37). 

Exhibit 7:  Example of a rapid quality assessment tally sheet
30 observations


Rapid data analysis plan. The data analysis plan suggested here
provides managers with a model for data analysis that provides
essential service quality information.  We recommend that you do
these basic calculations for all quality assessments.  Additional
calculations can be carried out in accordance with the purposes
of the study.  

Total:  Sum the number of observations for each variable (service
delivery task).  For example, question number 6 in Exhibit 7
resulted in 30 responses.  
Frequency distributions or counts:  Add up the number of "yes"
and "no" responses for each service delivery task.  For example,
question number 6 in Exhibit 7 resulted in 26 "yes" responses and
four "no" responses.  
Percentage distributions:  Take the number of each count ("yes"
and "no") divided by the total number of observations x 100.  The
percentage distribution for question 6 would be yes=87% and
no=13%.  
Threshold analysis:  This procedures allows the manager to set a
minimal acceptable level for each item to spot problems quickly. 
Those which exceed that level are identified as problems.  For
example, if the threshold is set at 80%, then question 6 would be
classified as acceptable, while question 31, with only 67%
correct performance would be a problem.  
Scoring:  In addition to analysing data by specific service 
delivery tasks, a scoring system can be developed to assess
overall quality.  For example, each task that was carried out
could receive a score of one point.  The total "quality score"
would be the total number of points for a set of tasks compared
with the maximum possible score.  If some tasks are much more
important than others, they can be given added weight (e.g., 1.5
or 2 points).  If each question in Exhibit 7 were worth one
point, the maximum possible score would be nine. Variable number
20 (performed by health worker TR) would receive a score of
eight, while variable number 1 (performed by health worker LM)
would receive a score of five.  

Breakdown by site:  Compare one site or session with another. 
Totals, counts and percentages can be calculated for each site. 
This will help managers to identify strengths and weaknesses at
different sites.  For example, assessment of facility A included
11 observations for questions 5 and 6.  Correct performance of
question 5 was 100% while question 6 was 91%.  
Graphs: Results can be plotted on a graph to give a manager or
supervisor a summary of the data.  This is a useful visual aid
for presenting information.  A graph could be made manually by
plotting the variables on the horizontal axis and the percent on
the vertical axis. 

Exhibit 8 shows an example of such a graph, depicting results
from 30 observations for immunization services, broken down into
20 service delivery tasks. 


Step 7:   Report the findings, provide feedback, and take
corrective action  Quality assessment is the first step in
quality improvement.  It should be followed by steps designed to
maintain the quality of those tasks that are done well while
identifying and implementing ways to improve the quality of those
tasks that are not. The following are some guidelines for
providing feedback and taking corrective action.    
Which activities were carried out well?  Supervisors should begin
by reviewing what the service provider did well.  This reinforces
good performance and establishes a constructive rapport between
the service provider and supervisor. Which activities need
improvement?  Supervisors should then review the areas that need
improvement, providing as much specific information as possible
about what was incorrect, and how it should be done correctly.  
Which can be corrected easily?  Some problems are easy to
correct, have obvious solutions, and require little extra effort
to do correctly.  Supervisors should begin with these, exploring
with the health worker and manager ways that corrections can be
made.  Experience has shown that those changes will be more
acceptable and will more likely be implemented if they are
suggested by the providers.  The supervisor should encourage the
health workers to take the initiative to make the corrections.   
Which problems will be more difficult to correct?  These problems
may need to be analysed more formally, either by a
problem-solving group or through a formal study.  The PHC MAP
Problem-solving guide provides some guidelines and experiences
that may be helpful.  Also, the PRICOR Operations Research
manuals describe procedures for setting priorities and designing
and conducting studies to develop and test solutions to
operational problems in PHC 
Blumenfeld, S. PRICOR Monograph series: Methods Paper 1.
Operations research methods: A general approach in primary health
care. Bethesda, MD: Center for Human Services, 1991.
Appendix A: Rapid service quality assessment checklists
Short form 

OTHER HEALTH CARE   
Water supply, hygiene and sanitation
School health
Childhood disabilities 
Accidents and injuries 
Sexually transmitted diseases
HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable 
diseases

CLIENT SATISFACTION
GENERAL        
PHC household visits          
Health education              

MATERNAL CARE       
Antenatal care      
Safe delivery       
Postnatal care      
Family planning                    

CHILD CARE     
Breast feeding      
Growth monitoring   
Nutrition education 
Immunization        
Acute respiratory infection   
Diarrhoeal disease control     
Oral rehydration therapy 
Rapid quality assessment 
1. Community assessment of primary health care (overall) 

This checklist is intended for rapid assessment of service 
quality in the observation of service delivery during primary
care visits in the household or health centre.  To use the
checklist, mark "yes" if the service provider carries out the
task during service delivery.  For interviews, mark "yes" if the
respondent answers correctly.  If you would like to assess this
service in more detail, please refer to the appropriate service
quality checklist.  The checklist item numbers below correspond
to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES  NO Register all children <<5 on the family health card?
6.   YES  NO Register all women over 16 on the family health
card? 
11.  YES  NO   Vaccinate or arrange for vaccination of children
who need to be immunized? 
(If there are malnourished children in the house): 
18.  YES  NO    Check to be sure that nutritional counselling,
food supplementation and/or medical attention are being received?
(If any children have diarrhoea):  
20.  Yes  NO Recommend ORT and help the mother to prepare and
administer it? 
(For each pregnant woman): 
27.  YES  NO     Ask if she is receiving prenatal care and
arrange for a prenatal visit if necessary? 
(For all households): 
31.  YES  NO Refer interested women or couples for family
planning services? 
35-38.    YES  NO  Discuss water, hygiene, and sanitation, if
indicated? 
41.  YES   NO   Establish a good rapport with the mother? 
 
Rapid quality assessment 
2.  Health education 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery of health
education.  To use the checklist, mark "yes" if the service
provider carries out the task during service delivery.  For
interviews, mark "yes" if the respondent answers correctly.  If
you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES   NO Determine participants' knowledge, attitudes,
practices, about topic? 
6.   YES   NO     Determine participants' general level of
knowledge? 
7-9. YES  NO     Explain the topic and focus the discussion? 
10-17.    YES   NO Discuss all relevant aspects of the topic? 
18-41.    YES   NO Use appropriate discussion techniques to
encourage active participation? 
42-43.    YES   NO  Use appropriate educational materials during
the presentation? 
44.  YES       NO    Distribute any available educational
materials? 

 
Rapid quality assessment 
3.  Antenatal care

This checklist is intended for rapid assessment of service
quality in the observation of service delivery of antenatal 
care.  To use the checklist, mark "yes" if the service provider
carries out the task during service delivery.  For interviews,
mark "yes" if the respondent answers correctly.  If you would
like to assess this service in more detail,  please refer to the
appropriate service quality checklist.  The checklist item
numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES       NO   Review and update obstetric record or family
health card? 
6-12.     YES  NO   Ask at least two questions about reproductive
history risk factors? 
13-25.    YES  NO   Ask at least two questions about risk factors
associated with this pregnancy? 
29-34.    YES  NO   Perform at least 1 physical exam activity? 
35.  YES       NO   Immunize or arrange for immunization against
tetanus? 
43.  YES       NO  Do a blood test (glucose, haemoglobin/
haematocrit and malaria) if medically indicated? 
52.  YES     NO      Discuss the importance of having the
delivery attended by a trained health worker? 
54.  Yes      NO  Explain danger signs which require immediate
attention? 
56.  Yes       NO   Tell pregnant woman when and where to go for
next prenatal visit? 
 
Rapid quality assessment 
4. Safe delivery

This checklist is intended for use in rapid assessment of service
quality in the observation of service delivery.  To use the
checklist, mark "yes" if the service provider carries out the
task during service delivery.  For interviews, mark "yes" if the
respondent answers correctly.  If you would like to assess this
service in more detail, please refer to the appropriate service
quality checklist.  The checklist item numbers below correspond
to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
Before birth: 
5.   YES       NO Sterilise needles, syringes, cord ties,
scissors/razor blade? 
6.   YES       NO Prepare a clean birthing place? 
8-16.     YES  NO Take labour history? 
17.  YES       NO Review reproductive history for high-risk
factors if necessary? 

During birth: 
18-31.    YES       NO Conduct physical exam and monitor woman
throughout labour? 
39-43.    YES       NO Assist the progress of labour? 
44-50.    YES       NO Assist with delivery? 
51-59.    YES       NO Seek help for obstetric problems and
emergencies? 
61-62.    YES       NO Tie the umbilical cord with thread in
three places and cut with blade/scissors? 
64.  YES       NO  Determine APGAR score at 1 minute and 5
minutes after birth? 
70-72.    YES       NO Deliver placenta? 

After birth:
73-76.    YES       NO Monitor mother and provide needed care
immediately after birth? 
77-96.    YES       NO Examine infant? 
66.  YES       NO Insert antibiotic eye ointment or silver
nitrate drops into eyes within one hour after birth? 
67.  YES       NO Give BCG vaccination? 
68.  YES       NO  Administer vitamin K? 
97.  YES       NO  Discuss postnatal cleanliness and provide
related instruction? 
104-114.  YES       NO Give advice about breast feeding? 
115-119.  YES       NO Give advice about well-child care? 
 
Rapid quality assessment 
5.  Postnatal care

This checklist is intended for rapid assessment of service
quality in the observation of post- natal care.  To use the
checklist, mark "yes" if the service provider carries out the
task during service delivery.  For interviews, mark "yes" if the
respondent answers correctly.  If you would like to assess this
service in more detail, please refer to the appropriate service
quality checklist.  The checklist item numbers below correspond
to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider:
5-14.     YES       NO  Ask the mother at least two medical
history questions? 
15-21.    YES       NO  Examine the mother? 
22-37.    YES       NO  Examine the new-born child? 
38.  YES       NO       Record findings of history and physical
examination health record? 
43.  YES      NO   Refer mother for special treatment if
necessary? 
47.  YES     NO     Refer infant for all physical conditions
which need medical attention? 
44.  YES       NO  Give BCG or verify that child received
vaccination at birth? 
45.  YES       NO Give first DPT and OPV? 
48.  YES       NO Tell mother to feed the infant with breast milk
only, for the first 4-6 months? 
54.  YES      NO Discuss family planning with the mother and tell
her how she can obtain family planning services? 
55.  YES      NO encourage mother to enrol child in well-child
clinic? 
 
Rapid quality assessment 
6.  Family planning 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for family
planning services.  To use the checklist, mark "yes" if the
service provider carries out the task during service delivery. 
For interviews, mark "yes" if the respondent answers correctly. 
If you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5-16.     YES       NO  
Ask at least three medical and reproductive history questions? 
17.  YES       NO Take blood pressure? 
18.  YES       NO Examine breast for lumps? 
19.  YES       NO Examine patient for signs of anaemia? 
24.  YES       NO Recommend a method that was free of
contra-indications for this client? 
28,31-33  YES  NO   Discuss side effects? 

Ask client:
44.  YES       NO How do you use the contraceptive you received
today? 
45.  YES       NO What are the possible side effects? 
 
Rapid quality assessment 
7.  Breast feeding 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for promotion of
breast feeding.  To use the checklist, mark "yes" if the service
provider carries out the task during service delivery.  For
interviews, mark "yes" if the respondent answers correctly.  If
you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5-10.     YES       NO Ask about mother's knowledge and practice
concerning breast feeding? 
11.  YES       NO Instruct mothers on the health benefits to
mother and child of breast feeding? 
12-19.    YES       NO  Recommend how long to breast 
feed and encourage continued  breast feeding during illness? 
20-23.    YES       NO  Instruct mother on method of breast
feeding? 
24,29.    YES       NO  Explain warning signs that indicate the
mother should seek help? 
25-26     YES       NO  Provide counselling, as appropriate, on
family planning methods and contraceptive benefits of breast
feeding? 
32-35     YES       NO  Provide appropriate counselling on diet
during lactation, nutrition supplements, and important locally
available foods? 
39-41     YES       NO  Advise mother on weaning practices and
food preparation. 
 
Rapid quality assessment 
8.  Growth monitoring/nutrition education 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for growth
monitoring and nutrition education.  To use the checklist, mark
"yes" if the service provider carries out the task during service
delivery.  For interviews, mark "yes" if the respondent answers
correctly.  If you would like to assess this service in more
detail, please refer to the appropriate service quality
checklist.  The checklist item numbers below correspond to that
list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5-7. YES     NO Calculate the age correctly? 
8-12.     YES       NO Weigh the child correctly? 
13-15.    YES       NO Plot the child's weight correctly? 

(If the child is malnourished):  
17.  YES       NO      Refer for nutritional counselling? 
18-28.    YES       NO Make at least 1 appropriate recommendation
about child feeding and care? 

Ask mother:
39.  YES       NO  Did your child gain weight, lose, or stay the
same since the last weighing? 

Ask service provider: 
36.  YES       NO Do you have a working scale? 
43.  YES       NO Do you have a way of tracking malnourished
children? 
 
Rapid quality assessment 
9. Child immunization 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for child
immunization.  To use the checklist, mark "yes" if the service
provider carries out the task during service delivery.  For
interviews, mark "yes" if the respondent answers correctly.  If
you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
13.  YES      NO  Use a sterile needle for each injection? 
14.  YES      NO  Use a sterile syringe for each injection? 
17.  YES      NO  Give the child all vaccinations needed today? 
19.  YES      NO  Record the vaccination on the child's health
card? 

Ask the service provider: 
36.  YES       NO Was the registered temperature between 0 and 8
degrees (C) at all times during the last month? 

(For outreach sessions): 
41.  YES       NO Were vaccines transported in cold boxes with
ice packs? 

Ask mother:
43.  YES       NO When should you return for the next
immunization? 
 
Rapid quality assessment 
10.  Acute respiratory infection 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for acute
respiratory infection.  To use the checklist, mark "yes" if the
service provider carries out the task during service delivery. 
For interviews, mark "yes" if the respondent answers correctly. 
If you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider:
5-12.     YES       NO Ask at least two medical history
questions? 
13.  YES       NO    Ask about any treatment administered? 
15.  YES       NO    Count respiratory rate? 
24.  YES       NO    Classify child by severity of illness? 
25.  YES       NO   Give antibiotics for pneumonia, strep throat
or otitis? 
26.  YES       NO   Refrain from using antibiotics for colds? 
36.  YES       NO   Tell mother about at least three signs of
pneumonia?

Ask mother: 
(If antibiotics were prescribed): 
45-46.    YES       NO How will you administer the medicine (how
much, how often, for how long)? 
 
 
1 Signs include stridor, chest indrawing/rapid breathing, 
inability to drink, cyanosis, anxiety and weakness or lethargy. 


Rapid quality assessment 
11.  Diarrhoeal disease control/oral rehydration 
therapy 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for diarrhoeal
control and oral rehydration therapy.  To use the checklist, mark
"yes" if the service provider carries out the task during service
delivery.  For interviews, mark "yes" if the respondent answers
correctly.  If you would like to assess this service in more
detail, please refer to the appropriate service quality
checklist.  The checklist item numbers below correspond to that
list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5-11.     YES      NO Ask at least two medical history questions?

12-16.    YES      NO Perform at least two physical exam
activities? 
17.  YES      NO  Determine the degree of dehydration (none,
moderate, severe)? 
18.  YES      NO Prescribe safe ORS solution? 
20.  YES      NO Refrain from using antibiotics, except when
stools contain blood or mucus? 
22.  YES      NO 
If the child is dehydrated, administer ORS solution immediately 
or refer the child to a nearby centre? 
31.  YES      NO 
Tell mother how much ORS solution to give and how often 
to give it? 
35.  YES      NO Show mother how to prepare ORS solution? 
 
Rapid quality assessment 
12.  Water supply, hygiene and sanitation 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for education in
water supply, hygiene and sanitation.  To use the checklist, mark
"yes" if the service provider carries out the task during service
delivery.  For interviews, mark "yes" if the respondent answers
correctly.  If you would like to assess this service in more
detail, please refer to the appropriate service quality
checklist.  The checklist item numbers below correspond to that
list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider:
10.  YES   NO Discuss keeping water in a clean, covered
container? 
13.  YES  NO Discuss the importance of hand washing before
eating, feeding children, and food preparation? 
16.  YES  NO Inspect latrine? 
23.  YES  NO Discuss appropriate latrine use and human waste
disposal  (e.g. baby potty for children under three)? 
28.  YES  NO Recommend burning or burying refuse? 
30.  YES  NO Recommend penning animals away from the house? 
 
Ask mother: 
37.  YES    NO Why is it important to wash your hands? 
 
Rapid quality assessment 
13. Childhood disabilities 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for childhood
disabilities.  To use the checklist, mark "yes" if the service
provider carries out the task during service delivery.  For
interviews, mark "yes" if the respondent answers correctly.  If
you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5-9  YES       NO Ask questions from the mother to identify
factors which may have contributed to a disability? 
10-20.    YES       NO Ask questions from the mother to determine
the type and degree of disability? 
21-32     YES       NO Correctly examine the child for type and
degree of disability? 
33.  YES       NO Administer/prescribe available treatment or
therapy according 
to established treatment guidelines? 
34.  YES       NO Make the appropriate referral according to
established guidelines? 
36-37.    YES       NO  Provide information on available local
services for the disabled? 
42-44.    YES       NO  Discuss what parents, family and
community can do to help children with disabilities? 

Ask client 
53. What is your child's disability? 
55. If applicable, do you know how to prevent a similar
disability from happening again? 
56-59. What information was given to you about treatment and/or
where to go for help? 

Rapid quality assessment 
14.  Accidents and injuries 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for accidents and
injuries.  To use the checklist, mark "yes" if the service
provider carries out the task during service delivery.  For
interviews, mark "yes" if the respondent answers correctly.  If
you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES       NO Correctly identify type of injury? 
6.   YES       NO Obtain a history of the injury, e.g., cause,
time, etc.? 
7.   YES       NO Administer proper treatment according to
established guidelines? 
8.   YES       NO  Make the appropriate referral according to
established guidelines? 
9.   YES       NO  Discuss some common injuries and how they may
be prevented? 
10,11,13  YES  NO  Discuss child safety in and around the home? 
12.  YES  NO  Discuss any occupational safety issues? 
14-15.    YES  NO Explain how to recognise an emergency and where
to go for help? 
 
Rapid quality assessment 
15.  Sexually transmitted diseases 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for sexually
transmitted diseases.  To use the checklist, mark "yes" if the
service provider carries out the task during service delivery. 
For interviews, mark "yes" if the respondent answers correctly. 
If you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES       NO Ask about symptoms of infection? 
6-9. YES       NO Ask about previous exposure to STD and any
treatments administered? 
10-11.    YES       NO Ask about exposure to other potential
sources of infection, e.g., blood, non-sterile instruments, etc.?

15-18.    YES       NO Ask about possible risk behaviours
associated with STD? 
21-30.    YES       NO Examine patient for signs of infection? 
38-41.    YES       NO Diagnose and treat patient according to
established guidelines? 
32-37,42  YES      NO  Refer patients for diagnoses, treatment or
laboratory testing according to established guidelines? 
45-51.    YES       NO Provide health education on the modes of
transmission and prevention of STD? 
47.  YES       NO Instruct the client on the correct and
consistent use of condoms? 
54-67     YES       NO Provide appropriate counselling on testing
procedures, confidentiality and meaning of test results? 
68-75     YES       NO Provide appropriate counselling to STD
cases on available treatments, complications of disease or any
long term effects, and possible risks to partners and/or
children? 
 
Rapid quality assessment 
16.  Malaria

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for malaria.  To
use the checklist, mark "yes" if the service provider carries out
the task during service delivery.  For interviews, mark "yes" if
the respondent answers correctly.  If you would like to assess
this service in more detail, please refer to the appropriate
service quality checklist.  The checklist item numbers below
correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5-10.     YES       NO Ask at least two medical history
questions? 
11.  YES  NO Ask about anti-malarial drugs taken in the last 24
hours? 
12.  YES       NO Ask about other symptoms to rule out other
fever-related illnesses? 
13.  YES  NO Take temperature? 
20.  YES       NO Make blood slide or refer case to a facility
where a blood slide may be examined? 
22.  YES       NO Administer or prescribe appropriate
anti-malarial drug according to local norms? 
25-26.    YES       NO If fever is over 39 degrees C: Administer
antipyretic drug and sponge or bathe with water? 
30.  YES       NO Discuss danger signs that may indicate
unresponsive or complicated malaria? 
31.  YES       NO Tell client to return for consultation if
danger signs develop? 

Ask client:
52.  YES      NO If medicine is prescribed: How will you take the
medicine, how much, how often, and for how long? 
 
Rapid quality assessment 
17.  Tuberculosis 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for tuberculosis. 
To use the checklist, mark "yes" if the service provider carries
out the task during service delivery.  For interviews, mark "yes"
if the respondent answers correctly.  If you would like to assess
this service in more detail, please refer to the appropriate
service quality checklist.  The checklist item numbers below
correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES       NO  Ask about persistent cough, two weeks or more?

6.   YES       NO Ask about persistent fever, one month or more? 
7.   YES  NO Ask about weight loss? 
8.   YES    NO Ask about blood in sputum? 
17.  YES       NO Perform cutaneous TB test? 
19.  YES       NO Refer for sputum examination? 
21.  YES       NO Prescribe medicines or refer for treatment
according to local norms? 
22.  YES       NO For follow-up cases: Verify that client is
taking medicine correctly? 
28.  YES       NO Explain how much and how often to take
medicine? 
29.  YES       NO Stress the importance of completing the
treatment? 

Ask client: 
44.  YES       NO If drugs were prescribed: How will you take
your medication, how much, how often, and for how long? 
47.  YES       NO If further testing is needed: Where will you go
for the test? 
 
Rapid quality assessment 
18.  Treatment of minor ailments 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for minor
ailments.  To use the checklist, mark "yes" if the service
provider carries out the task during service delivery.  For
interviews, mark "yes" if the respondent answers correctly.  If
you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Medical history 
Did the health provider: 
5.   YES       NO Ask about the chief complaint, fever, pain,
cough, etc? 
6.   YES       NO Determine the present history of the illness? 
7.   YES       NO Determine condition-related past and family
history? 

Physical examination 
Did the service provider: 
8.   YES       NO Check vital signs, blood pressure, temperature,
pulse, respiration rate etc. 
9.   YES       NO Conduct a related physical exam? 

Diagnosis 
Did the service provider: 
10.  YES       NO Make differential diagnosis, e.g., cough, TB,
pneumonia, bronchitis, abdominal pain, gastroenteritis, acute
cholestitis, appendicitis, etc.? 

Laboratory diagnosis 
Did the service provider: 
11.  YES       NO Order condition- or preliminary
diagnosis-related diagnostic tests, laboratory tests, x-ray
studies, etc.? 
 
Treatment and follow-up plans 
Did the service provider: 
13.  YES  NO Provide appropriate treatment according to the
condition? 
14.  YES  NO Provide information to the patient about the
condition and treatment plan? 
18.  YES  NO Discuss the importance of compliance with the drug
therapy? 
21.  YES  NO How often will you take this medicine? 
22.  YES  NO What is the dose you will take? 
23.  YES  NO For how long will you continue treatment? 
 
Rapid quality assessment 
19a.  Hypertension

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for hypertension. 
To use the checklist, mark "yes" if the service provider carries
out the task during service delivery.  For interviews, mark "yes"
if the respondent answers correctly.  If you would like to assess
this service in more detail, please refer to the appropriate
service quality checklist.  The checklist item numbers below
correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5-6  YES   NO Take a proper blood pressure reading? 
7-13.     YES  NO Ask about chief complaints, e.g., blurred
vision, severe headache, shortness of breath, chest pain? 
14,16.    YES  NO Ask about prior/current experience and
treatments for hypertension? 
15.  YES       NO Ask about family history of hypertension? 
17.  YES       NO Ask about history of diabetes or stroke? 
21.  YES       NO Ask about current lifestyle, e.g., work,
stresses, home conditions? 
23-24.    YES  NO Ask about previous illness and treatment? 
25-34.    YES  NO Perform a physical exam which included a check
of vital signs, blood pressure, heart, pulse in foot, neck veins
or other as per local policy? 
35-38.    YES  NO Provide patients with health
education/counselling on  hypertension? 
39-43.    YES NO Instruct patients on the use of any prescribed
medication? 
46,48-49.YES  NO Educate patients on appropriate low sodium diet
and exercise? 
44-45.    YES NO Inform patients of the warning signs indicating
when to return to the clinic? 
 
Rapid quality assessment 
20b.  Diabetes mellitus 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery for diabetes
mellitus.  To use the checklist, mark "yes" if the service
provider carries out the task during service delivery.  For
interviews, mark "yes" if the respondent answers correctly.  If
you would like to assess this service in more detail, please
refer to the appropriate service quality checklist.  The
checklist item numbers below correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES       NO Ask about symptoms, e.g., blurred vision,
unusual thirst, urinary tract infection, yeast infection if a
woman, foot problems, numbness, recurrent infection? 
6-15.     YES   NO  Perform a physical exam including a check of
vital signs, general appearance, appearance and pulse in feet,
fast breathing, signs of dehydration, or others as per local
norm? 
16.  YES       NO Conduct lab tests, (e.g., blood sugar, urine)
as appropriate? 
17-19.    YES      NO Provide patients with health
education/counselling on appropriate diet and exercise? 
22.  YES       NO Instruct family members how to handle common
diabetic emergencies? 
25-30.    YES  NO Educate the patient on proper foot care and
protection? 

For women of child bearing age: 
31.  YES       NO Discuss the importance of maintaining blood
sugar levels within a specified range before and during pregnancy
to prevent birth defects? 
32.  YES       NO Refer high risk pregnancies as per local norm? 
 
Rapid quality assessment 
21c.  Anaemia 

This checklist is intended for rapid assessment of service
quality in the observation of service delivery  for anaemia.  To
use the checklist, mark "yes" if the service provider carries out
the task during service delivery.  For interviews, mark "yes" if
the respondent answers correctly.  If you would like to assess
this service in more detail, please refer to the appropriate
service quality checklist.  The checklist item numbers below
correspond to that list.

1. Health facility 
3. Observer/supervisor 
4. Date 

Did the service provider: 
5.   YES  NO Ask about chief complaints, whether pregnant? 
6.   YES  NO Ask if there is any blood in stool? 
7.   YES  NO Determine the occult blood in the stool? 
11.  YES  NO Check colour of conjunctiva? 
9.   YES  NO Discuss some common injuries and how they may be
prevented? 
13.  YES  NO Ask about family history of anaemia? 
15.  YES  NO Give complete physical examination, chest, abdomen,
etc.? 
16.  YES  NO Get complete blood count with reticulocite count? 
18.  YES  NO Determine haemoglobin type, region, race, age or
sex? 
21.  YES  NO Determine the aetiology of the anaemic condition? 
22.  YES  NO Determine appropriate consultation; referral to a
specialist, if needed? 
Ask client: 
24.  YES  NO   Were you provided nutrition counselling? 
Ask the service provider: 
29.  YES  NO Do you know how to administer the drug, how much,
how often and how long? 
30.  YES  NO Do you know where you can get refills for the drug? 
34.  YES  NO How can you care for anaemia? 

Appendix B: Rapid service quality
assessment checklists
Long form 

OTHER HEALTH CARE
Water supply, hygiene and sanitation
School health
Childhood disabilities
Accidents and injuries
Sexually transmitted diseases
HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable 
diseases
CLIENT SATISFACTION
GENERAL
PHC household visits
Health education
MATERNAL CARE
Antenatal care
Safe delivery  
Postnatal care      
Family planning                    
CHILD CARE
Breast  feeding
Growth monitoring
Nutrition education
Immunization       
Acute respiratory infection
Diarrhoeal disease control 
Oral rehydration therapy

PHC service quality checklist
1: Community assessment of primary health care 

This checklist is intended for use in the observation of service 
delivery during primary care visits in the household or health
centre.  Before using it, the national treatment protocol should
be reviewed in order to adapt the tool to the local situation if
necessary.  It is also recommended that you review the checklist
carefully before using it to be sure that you understand the
questions and know how to use the form.  For observation of
service delivery, mark "yes" if the service provider carries out
these activities during service delivery.  For interview
questions, mark "yes" if the respondent answers correctly.


1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 

Registration and documentation 
Did the service provider: 
5.   YES  Register all children under 5 in the family health
card? 
6.   YES  NO Register all women over 16 in the family health
card? 
7.   YES  NO Update information during the visit? 
8.   YES  NO Record this visit in health centre records? 
Under 5 care 
Immunization:  
Did the service provider: 
9.   YES  NO  Discuss the importance of vaccination? 
10.  YES  NO Review immunization status of all children under 5? 
11.  YES  NO Vaccinate or arrange for vaccination of children who
need to be immunized? 
12.  YES  NO Review vaccinations needed  and the appropriate
dates with mother? 
13.  YES  NO Answer mother's questions about vaccination? 
Growth monitoring:  
Did the service provider: 
14.  YES  NO Review the growth cards of all children under 5? 
15.  YES  NO Weigh children or refer them for growth monitoring? 
16.  YES  NO Discuss changes in weight with the mother and give
nutritional advice? 
17.  YES  NO Answer mother's questions about growth monitoring
and nutrition? 
18.  YES  NO  If there are any malnourished children in the
house: 
Did the health worker check to be sure that nutritional
counselling, food supplementation, and/or medical attention are
being received? 
ORT:  
Did the service provider: 
19.  YES  NO Ask if any children in the household had diarrhoea? 
20.  YES  NO If yes, recommend ORT, and help the mother to
prepare and administer it? 
21.  YES  NO If no, review the importance of ORT and encourage
mother to use it in future diarrhoea episodes? 
22.  YES  NO Answer mother's questions about ORT? 
23.  YES  NO Demonstrate how to make ORT, or invite mother to a
demonstration, if necessary? 
Maternal carE 
Antenatal care: 
Did the service provider: 
24.  YES  NO Discuss the importance of prenatal care? 
25.  YES  NO Ask if ay women in the household are pregnant? 
26.  YES  NO Talk with each pregnant woman about her general
well-being? 
27.  YES  NO Ask if each pregnant woman is receiving prenatal
care and arrange for a prenatal visit if necessary? 
28.  YES  NO Give nutritional advice and iron/calcium
supplementation to each pregnant woman? 
29.  YES  NO Answer pregnant woman's questions? 
Family planning:
Did the service provider: 
30.  YES  NO Provide information  about family planning services?
31.  YES  NO Refer interested women or couples for family
planning services? 
32.  YES  NO Ask women who already use contraception if they are
happy with their method? 
33.  YES  NO Refer current users for advice or follow-up, if
necessary? 
34.  YES  NO Answer questions about family planning? 
Water and sanitation: 
Health workers should include water and sanitation if there 
is a current or recent case of diarrhoea in the home or in any
homes where the health worker feels that poor water and
sanitation may constitute a health risk. 
Did the service provider: 
35.  YES  NO Ask about access to water and provide information
about 
community efforts to address problems, if necessary? 
36.  YES  NO
Ask about water storage practices and give appropriate 
advice? 
37.  YES  NO      
Ask about latrine maintenance and use and give appropriate 
advice? 
38.  YES  NO Ask about refuse and excreta disposal and give
appropriate advice? 
General 
Did the service provider: 
39.  YES  NO Ask if anyone in the household is ill and give
appropriate advice? 
40.  YES  NO Follow up on recent illnesses? 
41.  YES  NO Verify that the client(s) understands key 
information from today's visit? 


PHC service quality checklist 
2: Health education 

F Pleiffer, J. (ed.),  Theories and models in applied behavioral
science, vol. II, p. 12, 28, 65-66, 139, 140, 147-149, 189, 227 >
<$FWallerstein, N. & Bernstein, E., 
Empowerment, education: Freire's ideas adapted to Health
education, Health Education Quarterly<D>, vol. 15, No. 4, p.
379-383 (1988) > 

This checklist is intended for use in supervision and 
monitoring of health education services provided by clinic-based
health workers and community-based health workers. The list is
comprehensive and includes some clinical tasks that the
traditional birth attendants and other peripheral workers do not
routinely carry out. The checklist should be modified and
simplified according to the local situation. This checklist is
intended for use in the observation of service delivery.  It is
recommended that you review the checklist carefully before using
it to be sure that you understand the questions and know how to
use the form.  For observation of service delivery, mark "yes" if
the service provider carries out these activities during service
delivery.  For interview questions, mark "yes" if the respondent
answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
Determine educational background
Did the service provider: 
5.   YES  NO
Determine participants' knowledge, attitudes, practices 
(KAP) about topic? 
6.   YES  NO  Determine participants' general level of education?

Discussion of topic 
Did the service provider: 
7.   YES  NO  Clearly define the purpose of the meeting? 
8.   YES  NO Discuss the relevance and purpose of the topic? 
9.   YES  NO  Remain focused on the topic in hand? 
10.  YES  NO Explain risk factors (i.e. biological,
environmental, 
socio-economic, behavioural, health care related)? 
11.  YES  NO Discuss transmission and prevention? 
12.  YES  NO Discuss specific recommended behaviour changes? 
13.  YES  NO Discuss benefits of the proposed behaviour change? 
14.  YES  NO      
Discuss potential obstacles and problems? 
15.  YES  NO Discuss potential complications and danger signs? 
16.  YES  NO Discuss when to go for services/follow up or seek
help, if needed? 
17.  YES  NO Discuss where to go for services or seek help, if
needed? 

Use of appropriate techniques 
Did the service provider 
18.  YES  NO Establish good rapport with the participants? 
19.  YES  NO Demonstrate sensitivity to existing/various levels
of KAP? 
20.  YES  NO Appeal to emotional and intellectual reasons for
behaviour change? 
21.  YES  NO Solicit participants' honest opinions at the outset
of the meeting? 
22.  YES NO Avoid use of technical/medical terminology? 
23.  YES  NO Speak clearly and make eye contact? 
24.  YES  NO Use verbal and non-verbal communication? 
25.  YES  NO Use creative presentations, appealing to all five
senses, to help to mitigate boredom and fatigue? 
26.  YES  NO Focus on observable behaviour that can be relatively
easily changed? 
27.  YES  NO Communicate the desired behaviour change in a
specific, non-threatning and non-judgemental manner? 
28.  YES  NO Display willingness to compromise as needed? 
29.  YES  NO Avoid imposing his/her cultural values and choices? 
30.  YES  NO Use demonstrations or models during the
presentation? 
31.  YES  NO Use role playing during the presentation? 
32.  YES  NO Promote group discussion and participation during
the presentation? 
33.  YES  NO Promote group members' practice/application of their
newly acquired behaviour, to allow them to gain confidence? 
34.  YES  NO Discuss problems and examples that are realistic and
relevant to the participants? 
35.  YES NO Repeat or restate key messages? 
36.  YES  NO Ask participants to repeat key messages or
demonstrate an activity? 
37.  YES  NO Verify that participants understand key information?

38.  YES  NO Ask participants if they have any questions? 
39.  YES  NO Respond thoroughly to questions from the audience? 
40.  YES  NO Ask for feedback on the presentation from the
participants? 
41.  YES  NO Allocate time well? 

Use of materials 
Did the provider: 
42.  YES  NO Use audio-visual materials during the presentation? 
43.  YES  NO Use materials appropriate for illiterate
participants,if necessary? 
44.  YES  NO Distribute any available educational materials? 
Exit interview with participants  
Mark "yes" if the respondent answers correctly: 
45.  YES  NO  What are the main points that you discussed today? 
46.  YES  NO  Do you feel ready/able to begin the behaviour
change? 
47.  YES  NO  When should you return to the health centre (if
needed)? 
48.  YES  NO  Was this helpful/interesting to you? 

Interview with provider
Mark "yes" if the respondent answers correctly: 
49.  YES  NO Did you communicate the points that you had planned
to? 
 
PHC service quality checklist
3: Antenatal care

This checklist is intended for use in supervision and 
monitoring of antenatal services provided by health workers,
community-based health workers, and traditional birth attendants.
The list is comprehensive and includes some clinical tasks that
the traditional birth attendants and other peripheral workers do
not routinely carry out. The checklist should be modified and
simplified according to the local situation. This checklist is
intended for use in the observation of service delivery.  It is
recommended that you review the checklist carefully before using
it to be sure that you understand the questions and know how to
use the form.  For observation of service delivery, mark "yes" if
the service provider carries out these activities during service
delivery.  For interview questions, mark "yes" if the respondent
answers correctly.

1.  Health facility 
2.  Service provider 
3.  Observer/supervisor 
4.  Date 

Reproductive history 
Did the service provider: 
5.   YES  NO   Review obstetric record or family health card? 

Did the service provider update information on the following: 
6.   YES  NO Age? 
7.   YES  NO Date of last menstrual period? 
8.   YES  NO Date of last delivery? 
9.   YES  NO Number of previous pregnancies? 
10.  YES  NO Outcome of each pregnancy? 
11.  YES  NO Complications during previous pregnancies?
Complications include bleeding, toxaemia, infection, prolonged
labour, RH incompatibility, Cesarean section, stillbirth, and
spontaneous abortion. 
12.  YES  NO Current or past breast feeding? 

Did the service provider ask about risk factors: 
13.  YES  NO Spotting/bleeding during current or past
pregnancies? 
14.  YES  NO Burning on urination? 
15.  YES  NO Foul smelling vaginal discharge? 
16.  YES  NO Diabetes? 
17.  YES  NO Cardiovascular problems? 
18.  YES  NO Renal problems? 
19.  YES  NO Female circumcision? 
20.  YES  NO Previous injuries, especially to pelvis? 
21.  YES  NO Medications currently being taken? 
22.  YES  NO Smoking? 
23.  YES  NO Alcoholism? 
24.  YES  NO Drug abuse? 
25.  YES  NO Any other problems associated with current
pregnancy? 
Ask about preventive actions taken: 
26.  YES  NO Immunization against tetanus? 
27.  YES  NO Malaria prophylaxis? 
28.  YES  NO Plans for delivery? 

Physical exam
Did the service provider: 
29.  YES  NO Take pulse? 
30.  YES  NO Take blood pressure? 
31.  YES  NO Correctly measure height and weight? 
32.  YES  NO Correctly examine legs, face, and hands for signs of
oedema? 
33.  YES  NO Calculate expected date of delivery? 
34.  YES  NO Assess adequacy of pelvic outlet? 

Routine preventive services for pregnant women 
Did the service provider: 
35.  YES  NO Immunize or arrange or immunization against tetanus?
36.  YES  NO Administer or prescribe iron supplements? 
37.  YES  NO Administer or prescribe nutrition supplements? 
38.  YES  NO Administer or prescribe anti-malarial drugs if
indicated? 

Referral
Did the service provider: 
39.  YES  NO Encourage mother to attend prenatal sessions at the
local health facility? 
40.  YES  NO Refer high-risk pregnancies for additional medical
attention? 

Referral is indicated if: 1) one or more high-risk factors (see
reproductive history) are present; 2) there is a history of
complications during pregnancy or birth; 3) the woman is older
(per local norms) or has had many pregnancies (number determined
by local norms).  Referral is also indicated for obstetric and
medical problem(s) and emergencies, ectopic pregnancy, infection
or bleeding from abortion, and other prenatal problems and
emergencies, especially haemorrhage, sepsis and eclampsia. 
Guidelines for referral should follow local norms.> 
 
41.  YES  NO Recommend hospital birth for high-risk pregnancies? 
42.  YES  NO Refer for urine examination (sugar and protein) if
medically indicated? 
43.  YES  NO Refer for blood test (glucose, haemoglobin/
haematocrit or malaria diagnosis) if medically indicated? 
44.  YES  NO Refer for blood test for RH factor determination? 
45.  YES  NO Refer for syphilis serology test (per local norms or
if medically indicated)? 
Counselling 
Did the service provider: 
46.  YES  NO  Explain the importance of continuing prenatal care
during pregnancy? 
47.  YES  NO  Explain the benefits of weight gain during
pregnancy? 
48.  YES  NO  Discuss the types of foods to include in diet
during pregnancy? 
49.  YES  NO  Explain how to take iron tablets/nutrition
supplements? 
50.  YES  NO  Warn about dangers of alcohol, smoking, drugs? 
51.  YES  NO  Explain the importance of tetanus toxoid
immunization during pregnancy? 
52.  YES  NO  Explain the importance of having delivery attended
by trained health worker? 
53.  YES  NO  Explain the dangers of abortions performed by
unqualified individuals? 
54.  YES  NO  Explain danger signs which require immediate
attention?   
55.  YES  NO  Tell pregnant woman to have family seek assistance
or transport her to clinic/hospital if danger signs of obstetric
emergencies or complications of labour occur? 
56.  YES  NO  Tell pregnant woman where and when to go for next
prenatal visit? 
57.  YES  NO  Verify that pregnant woman understood key messages?
58.  YES  NO  Ask if she has any questions? 

Supplies 
Ask the service provider about the following supplies: 
59.  YES  NO  Do you have a working scale (to weigh the pregnant
woman)? 
60.  YES  NO  Do you have a measuring tape? 
61.  YES  NO  Do you have a stethoscope and blood pressure cuff? 
62.  YES  NO  Do you have a watch with a second hand to take
pulse? 
63.  YES  NO  Do you have tetanus toxoid vaccine? 
64.  YES  NO  Do you have iron tablets (per local policy)? 
65.  YES  NO  Do you have drugs for malaria prophylaxis (per
local policy)? 
66.  YES  NO  Do you have forms or health cards to record the
antenatal visit? 

Interview with pregnant woman 
Mark "yes" if the respondent answers correctly: 
67.  YES  NO  Do you plan to have a trained health worker attend
your birth? 
68.  YES  NO  What are the danger signs during pregnancy that
require medical attention?
Danger signs include swelling of hands and face, severe or
prolonged dizziness, bleeding from vagina, sharp or constant 
abdominal pain, fever, vaginal odour or discharge. 
69.  YES  NO    When and where is your next prenatal visit? 
If pregnant woman is at high-risk for any reason: 
70.  YES  NO   Do you plan to seek further medical attention? 
71.  YES  NO   Do you plan to have your baby at a hospital? 

Interview with service provider 
Mark "yes" if the respondent answers correctly: 
72.  YES  NO What are the danger signs during pregnancy that
require medical attention?  
73.  YES  NO Do you refer high-risk pregnancies? 
74.  YES  NO Do you have a way of tracking high-risk pregnancies?

75.  YES  NO Do you follow up pregnant women who do not return to
prenatal sessions? 
PHC service quality checklist 
4: Safe delivery 

This checklist is intended for use in supervision and 
monitoring of service quality as provided by clinic-based health
workers, community-based health workers and traditional birth
attendants.  Although it is difficult to schedule observation of
birth(s), performance assessment can be carried out through
interviews after delivery or role play.  This list includes some
clinical tasks that traditional birth attendants and other
peripheral workers do not routinely carry out. The checklist
should be modified and simplified according to the local
situation.  It is recommended that you review the checklist
carefully before using it to be sure that you understand the
questions and know how to use the form.  For observation of
service delivery, mark "yes" if the service provider carries out
these activities during service delivery.  For interview
questions, mark "yes" if the respondent answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 

Prepare for delivery
Did the service provider: 
5.   YES  NO  Sterilise needles, syringes, cord ties,
scissors/razor blade, and gloves? 
6.   YES  NO   Prepare a Clean birthing place? 
7.   YES  NO   Assess potential complications and emergencies? 

Take labour history 
Did the service provider: 
8.   YES  NO   Ask when labour pains began? 
9.   YES  NO   Ask abou frequency of contractions? 
10.  YES  NO   Ask if and when bag of water broke? 
11.  YES  NO   Ask about vaginal bleeding? 
12.  YES  NO   Ask about dark black/green discharge (meconium)? 
13.  YES  NO   Ask when wOman in labour last ate? 
14.  YES  NO   Ask when woman in labour last passed stool? 
15.  YES  NO   Ask when woman in labour last urinated and about
problems urinating? 
16.  YES  NO  Ask about any medication or treatment 
taken? 
17.  YES  NO  Ask about risk factors if no information is
available from prenatal records?<$FHigh-risk factors include: 1)
there is a history of complications during pregnancy or birth; 2)
the woman is over   years or has had more than  pregnancies; or
3) the following conditions are present: spotting/bleeding during
current or past pregnancies; burning on urination; foul smelling
vaginal discharge during pregnancy;diabetes; cardiovascular
problems; renal problems, circumcision; or previous injuries,
especially to pelvis.  Guidelines for defining high-risk and
appropriate action should follow local norms.
Conduct physical examination and monitor woman throughout 
labour 
Did the service provider: 
18.  YES  NO    Regularly take pulse? 
19.  YES  NO    Regularly take blood pressure? 
20.  YES  NO    Determine strength and length of contractions? 
 21. YES  NO   Determine position of foetus? 
22.  YES  NO   Palpate cervix to determine thickness, firmness,
and openness? 
23.  YES  NO   Determine whether bag of water has broken? 
24.  YES  NO   Determine how far into the pelvis the presenting
part has come (Station)? 
25.  YES  NO  Determine the presenting part and its position? 
26.  YES  NO  Feel for prolapsed cord, placenta previa? 
27.  YES  NO  Regularly measure duration and frequency of
contractions? 
28.  YES  NO  Regularly check foetal heart beat? 
29.  YES  NO  Regularly palpate abdomen to determine any changes
in foetal position? 
30.  YES  NO  Observe perineum for crowning, opening of the vulva
and/or rectum to indicate beginning of second stage of labour? 
31.  YES  NO  Regularly moNItor blood loss? 

Diagnose obstetric complications and emergencies 
Did the service provider: 
32.  YES  NO  Diagnose dystocia if present? 
33.  YES  NO  Diagnose haemorrhage and shock if present? 
34.  YES  NO  Diagnose eclampsia if present? 
35.  YES  NO  Diagnose infection if present?  
36.  YES  NO  Diagnose cause of any maternal distress if present?
37.  YES  NO  Diagnose cause of foetal distress if present? 
38.  YES  NO  Diagnose abnormal presentation of foetus if
present? 

Assist progress of labour 
Did the service provider: 
39.  YES  NO  Tell woman not to bear down until fully dilated and
effaced? 
40.  YES  NO  Encourage woman to urinate frequently? 
41.  YES  NO  Reposition woman in labour or increase her
activities (e.g., walking) to help labour progress? 
42.  YES  NO  Administer low enema if bowel is full of stool and
woman in labour cannot pass it (per local policy)? 
43.  YES  NO  Administer anaesthetic or analgesic (per local
policy)? 

Assist with normal delivery 
Did the service provider: 
44.  YES  NO  Wash hands and mother's perineum? 
45.  YES  NO  Deliver head? 
46.  YES  NO  Support perineum to prevent tearing when foetal
head is crowning? 
47.  YES  NO  Support foetus's head as it passes over perineum? 
48.  YES  NO  Feel if umbilical cord is around foetus's neck and
slip it over head? 
49.  YES  NO  Suck mucus and/or meconium from infant's nose and
mouth? 
50.  YES  NO  Deliver shoulders and body? 
Seek help for obstetric problems and emergencies 
Did the service provider: 
51.  YES  NO  For shock and haemorrhage place mother in
trendelenberg position and treat (per local policy)? 
52.  YES  NO  Treat infection with antibiotics? 
53.  YES  NO  For eclamptic convulsions treat with 
anticonvulsants, protect physical safety of mother during
convulsions, and immediately deliver infant? 
54.  YES  NO  Attempt manual manipulation of foetal head in cases
of incomplete internal rotation? 
55.  YES  NO  Use appropriate technique to deliver foetus in
abnormal position, such as footling, buttocks, face, brow, arm,
shoulder presentations? 
56.  YES  NO Provide other emergency care as indicated? 
57.  YES  NO Refer obstetric problems and emergencies? 
58.  YES  NO Perform episiotomy if indicated (per local policy)? 
59.  YES  NO  Assist with forceps, vacuum extraction, or
symphisiotomy (if indicated and according to local policy)? 
Provide immediate care for new-born 
Did the service provider: 
60.  YES  NO Establish Respiration/loud cry? 
61.  YES  NO Tie umbilical cord in three places with sterile
ties? 
62.  YES  NO Cut umbilical cord with sterile scissors or razor
blade; leave two ties on infant's side? 
63.  YES  NO Wrap in clean cloth and cover head to maintain
warmth? 
64.  YES  NO Determine APGAR score at 1 minute and 5 minutes
after birth? 
65.  YES  NO Give the infant to the mother to suckle? 
66.  YES  NO Insert antibiotic eye ointment or silver nitrate
drops into eyes within one hour after birth? 
67.  YES  NO Immunize? 
68.  YES  NO Administer Vitamin K? 
 69. YES  NO Provide emergency care, as indicated? 

Deliver placenta 
Did the service provider: 
70.  YES  NO    Deliver placenta and examine for completeness? 
71.  YES  NO    Manually remove retained (partial or complete)
placenta? 
72.  YES  NO    Establish breast feeding? 

Monitor mother immediately after delivery 
Did the service provider: 
73.  YES  NO    Regularly monitor blood pressure and pulse? 
74.  YES  NO    Massage uterus within 15 minutes after delivery
and regularly thereafter? 
75.  YES  NO   Monitor blood loss? 
76.  YES  NO   Administer ergonovine 1 mg if mother is bleeding
heavily (Per local policy)? 
  
Examine infant 
Did the service provider: 
77.  YES  NO  Assess general appearance, alertness, tone? 
78.  YES  NO  Take temperature? 
79.  YES  NO  Measure respiratory rate? 
80.  YES  NO  Measure heart rate? 
81.  YES  NO  Weigh? 
82.  YES  NO  Examine head and feel for fontanelles and sutures? 
83.  YES  NO  Examine eyes for redness, discharge, jaundice,
pallor? 
84.  YES  NO  Listen to chest to assess respiration and
heartbeat? 
85.  YES  NO  Palpate abdomen and liver? 
86.  YES  NO  Examine genitals for normality, hernias? 
87.  YES  NO  Examine for muscle tone and Moro reflex? 
88.  YES  NO  Examine extremities and skeletal system for
symmetry, movement, and broken or dislocated bones? 
89.  YES  NO  Inspect skin for sores, breaks? 
90.  YES  NO  Examine for birth defects? 
91.  YES  NO  Weigh? 
92.  YES  NO  Take temperature? 
93.  YES  NO  Refer infants with medical emergencies and birth
defects? 
94.  YES  NO  Record labour and delivery information on labour
charts? 
95.  YES  NO  Watch for and record first urination and bowel
movement? 
96.  YES  NO  Give BCG and OPV (per local policy)? 

Education after delivery 
Aftercare:
Did the service provider: 
97.  YES  NO  Tell mother to keep her genital area clean and
demonstrate how to wash her genitals? 
98.  YES  NO  Tell mother to return to clinic if gross bleeding
occurs, or if lochia remains red or has foul smell, or if she
develops fever or other unexpected symptoms? 
99.  YES  NO   Tell mother to refrain from intercourse for 4-6
weeks? 
100. YES  NO   Tell mother to keep area around cord clean and
dry? 
101. YES  NO   Tell mother not to put anything (soil/salve) on
the cord and not to remove the ties? 
102. YES  NO   Demonstrate how to bathe and clean infant,
especially around umbilical cord? 
103. YES  NO   Tell mother to bring infant to clinic if any
redness or discharge from cord occurs? 
Breast feeding:
Did the service provider: 
104. YES  NO  Instruct mothers in the health benefits of breast
feeding? 
105. YES  NO  Tell mother to feed colostrum? 
106. YES  NO  Tell mother that normal milk flow will begin after
2-3 days? 
107. YES  NO  Tell mother to breast feed infant frequently during
the first few days? 
108. YES  NO  Tell mother to use both breasts, feeding from one
until it is empty, then from the other? 
109. YES  NO  Tell mother to start feeding with the breast that
is not the breast she started feeding from last time? 
110. YES  NO  Tell mother to continue breast feeding when she or
infant is ill? 
111. YES  NO  Tell mother to keep nipples clean and dry to
prevent cracking? 
112. YES  NO  Demonstrate how to express breast milk to relieve
congestion and prevent engorgement? 
113. YES  NO  Demonstrate how to position infant's mouth around
areola for breast feeding? 
114. YES  NO  Tell mother to return if the infant has problems
nursing? 
 
Well-child care:
Did the service provider: 
115. YES  NO  Tell mother about child immunization? 
116. YES  NO  Tell mother when to return for first postpartum
visit and for infant's first well-child visit? 
117. YES  NO  Verify that the mother understands warning signs
for her and/or her infant to return to clinic? 
118. YES  NO  Verify that mother knows when to return for first
postpartum visit and for infant's first well-child visit? 
119. YES  NO  Ask mother if she has any questions? 

Supplies 
120. YES  NO   Do you have cord ties? 
121. YES  NO   Do you have a razor or a pair of scissors? 
122. YES  NO   Do you have gloves? 
123. YES  NO   Do you have a watch with a second hand to take
pulse? 
124. YES  NO   Do you have a stethoscope? 
125. YES  NO   Do you have a blood pressure cuff? 
126. YES  NO   Do you have antibiotics? 
127. YES  NO   Do you have anticonvulsants? 
127. YES  NO   Do you have needles? 
128. YES  NO   Do you have syringes? 

PHC service quality checklist 
5: Postnatal care 

This checklist is intended for use in supervision and 
monitoring of postnatal care provided by clinic-based health
workers, community-based health workers, and traditional birth
attendants. This list is comprehensive and includes some clinical
tasks that traditional birth attendants and other peripheral
workers do not routinely carry out. The list should be modified
and simplified according to the local situation.  It is
recommended that you review the checklist carefully before using
it to be sure that you understand the questions and know 
how to use the form.  For observation of service delivery, mark
"yes" if the service provider carries out these activities during
service delivery.  For interview questions, mark "yes" if the
respondent answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Medical history 
Did the service provider: 
5.   YES  NO Ask mother when and where she delivered? 
6.   YES  NO Ask mother the outcome of the delivery? 
7.   YES  NO Ask about problems during delivery? 
8.   YES  NO Ask mother about vaginal bleeding? 
9.   YES  NO Ask mother about foul smelling vaginal discharge? 
10.  YES  NO Ask mother if she feels pain or tenderness in the
abdomen or breasts? 
11.  YES  NO Ask mother if she's had a fever? 
12.  YES  NO Ask mother if she is taking any medications,
including contraceptives? 
13.  YES  NO  Ask mother what she is eating? 
14.  YES  NO Ask mother about the infant's eating habits? 
   
Physical examination 
Mother:
Did the service provider: 
15.  YES  NO Examine the abdomen for swelling, condition of
caesarean incision, and to determine the size and firmness of the
uterus? 
16.  YES  NO Examine the genitals for swelling, discharge,
bleeding, tears, fistula, and episiotomy repair? 
17.  YES  NO Examine the breasts for cracked nipples,
engorgement, abscess? 
18.  YES  NO  Take pulse? 
19.  YES  NO    
Take blood pressure? 
20.  YES  NO  Weigh the mother? 
21.  YES  NO Examine eyes for signs of anaemia? 
 
Child (first postnatal visit): 
Did the service provider: 
22.  YES  NO Assess vital signs? 
23.  YES  NO Measure height and head circumference? 
24.  YES  NO Weigh child? 
25.  YES  NO Monitor child's growth with growth chart? 
26.  YES  NO Examine head and fontanelle? 
27.  YES  NO Assess eyes (for opacities, jaundice, infection)? 
28.  YES  NO Assess respiration (rate, retraction)? 
29.  YES  NO Assess heart (rate, murmur)? 
30.  YES  NO Examine skin (pallor, jaundice, petechiae,
infection)? 
31.  YES  NO Examine extremities and skeletal system for
symmetry, movement, and broken bones? 
32.  YES  NO Examine umbilicus? 
33.  YES  NO Assess general alertness? 
34.  YES  NO Assess suction reflex? 
35.  YES  NO Assess Moro reflex? 
36.  YES  NO Assess response to brightness? 
37.  YES  NO Assess response to sound? 
  
Documentation:
Did the service provider: 
38.  YES  NO  Record findings of history and physical examination
on health record? 
Treatment, routine preventive services, and referral 
Mother: 
Did the service provider: 
39.  YES  NO Provide iron and/or folic acid tablets (per local
policy)? 
40.  YES  NO Provide nutrition supplements (per local policy)? 
41.  YES  NO  Provide malaria chemoprophylaxis (per local
policy)? 
42.  YES  NO Give other therapeutic medications to treat medical
conditions as appropriate? 
43. YES   NO Refer maternal postpartum cases requiring special
treatment? 
  
  
Child: 
Did the service provider: 
44.  YES  NO  Give BCG vaccination or verify that child received
vaccination at birth? 
45.  YES  NO Give first DPT and OPV (per local policy)? 
46.  YES  NO If the child is malnourished, refer for nutritional
counselling? 
47.  YES  NO Refer the child for all physical conditions which
need medical attention? 
Education 
Breast feeding:  
Did the service provider: 
48.  YES  NO Tell mother to feed infant with breast milk only,
for the first 4-6 months? 
49.  YES  NO Tell mother to eat extra food while she is breast
feeding? 
50.  YES  NO  Recommend locally available protein-rich foods? 
51.  YES  NO Tell mother to breast feed even if she and/or infant
is ill? 
 
Child-spacing:  
Did the service provider: 
52.  YES  NO Tell mother to refrain from intercourse for 4-6
weeks after delivery? 
53.  YES  NO  Explain that breast feeding will not prevent her
from getting pregnant even if her periods have not begun? 
54.  YES  NO  Discuss family planning with the mother and tell
her how she can obtain child spacing services? 
Well child care:  
Did the service provider: 
55.  YES  NO  Tell mother about enrolling infant in well-child
clinic? 
56.  YES  NO  Tell mother when and where to enrol child in
clinic? 
57.  YES  NO  Tell mother when and where to take infant for first
or further immunizations? 
58.  YES  NO  Verify that mother understands key messages? 
 
General:  
Did the service provider: 
59.  YES  NO Provide counselling for specific medical problem(s)?

60.  YES  NO Tell mother when to return for next postpartum
visit, if indicated? 
61.  YES  NO  Verify that mother understood key messages? 
 
Supplies 
Ask the service provider about the following supplies: 
62.  YES  NO Do you have a working scale to weigh the mother? 
63.  YES  NO  Do you have a working scale to weigh the child? 
64.  YES  NO Do you have a watch or time piece with second hand
to measure pulse? 
65.  YES  NO  Do you have a stethoscope and blood pressure cuff? 
66.  YES  NO  Do you have BCG, OPV, and DPT vaccines? 
67.  YES  NO  Do you have iron tablets (per local policy)? 
   
Interview with mother 
Mark "yes" if the respondent answers correctly: 
68.  YES  NO When should your baby receive his or her next
vaccination? 
69.  YES  NO For how long will you breast feed? 
70.  YES  NO What will you do to space your births? 
71.  YES  NO Is your child growing normally? 
 
Interview with service provider 
Mark "yes" if the respondent answers correctly: 
72.  YES  NO Do you maintain records that identify recent mothers
and infants for postnatal care? 
73.  YES  NO Do you educate mothers about  postpartum care during
prenatal care and delivery? 
74.  YES  NO Do you discuss family planning during the postpartum
visit? 
 
PHC service quality checklist 
6:  Family planning services 

This checklist is intended for use in the observation of delivery
of family planning services.  Before using it, the national
treatment protocol should be reviewed in order to adapt the tool
to the local situation, if necessary.  It is also recommended
that you review the checklist carefully before using it to be
sure that you understand the questions and know how to use the
form.  For observationof service delivery, mark "yes" if the
service provider carries outthese activities during service
delivery.  For interview questions,mark "yes" if the respondent
answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Medical and reproductive history (new clients) 
Did the service provider: 
5.   YES  NO Ask the client how old she is? 
6.   YES  NO Ask about number, spacing, and outcome of
pregnancies? 
7.   YES  NO Ask about previous use of family planning methods? 
8.   YES  NO Ask about reasons for stopping or switching previous
methods? 
9.   YES  NO Ask about heart disease? 
10.  YES  NO Ask about liver disease? 
11.  YES  NO Ask about high blood pressure? 
12.  YES  NO Ask about history of Pelvic Inflammatory Disease? 
13.  YES  NO Ask about history of suspected or confirmed venereal
disease? 
14.  YES  NO Ask about history of blood clots or thromboembolism?
15.  YES  NO Ask if she is breast feeding? 
16.  YES  NO Ask about date of last menstrual period? 
  
Physical examination 
Did the service provider: 
17.  YES  NO Take blood pressure? 
18.  YES  NO Examine breast for lumps? 
19.  YES  NO Examine patient for signs of anaemia? 
  
Determine method 
Did the service provider: 
20.  YES  NO Ask if and when the client and her spouse would like
to have children? 
21.  YES  NO Describe contraceptive options to the client? 
22.  YES  NO Ask about the client's preference? 
23.  YES  NO Offer to discuss child spacing and methods with
spouse or family? 
24.  YES  NO Recommend a method that was free of
contra-indications for this client? 
25.  YES  NO Verify that the client is comfortable with the
recommended method? 
26.  YES  NO If necessary, refer the client to a doctor or
midwife? 
  
For follow-up cases 
Did the service provider: 
27.  YES  NO Verify correct usage? 
28.  YES  NO Ask about side effects? 
29.  YES  NO Give advice about managing side effects? 
  
Counselling (for all) 
Did the service provider: 
30.  YES  NO Explain the correct usage of the selected method? 
31.  YES  NO Explain possible minor side effects of the selected
method?   
32.  YES  NO Explain how to manage side effects at home? 
33.  YES  NO Explain major side effects which require medical
attention? 
34.  YES  NO Explain where and when to go for resupplies? 
35.  YES  NO Explain where and when to go for routine follow-up? 
36.  YES  NO Explain how to discontinue the method when pregnancy
is desired? 
37.  YES  NO Verify that the client understands key messages? 
38.  YES  NO Ask the client if she has any questions? 
  
Supplies 
Ask the service provider about the following supplies: 
39.  YES  NO Do you have a blood pressure cuff and stethoscope? 
40.  YES  NO Do you have a supply of oral contraceptives? 
41.  YES  NO Do you have a supply of IUDs? 
42.  YES  NO Do you have a supply of injectable contraceptives? 
43.  YES  NO Do you have a supply of implants? 
  
Exit interview with client 
Mark "yes" if the respondent answers correctly: 
44.  YES  NO How do you use the contraceptive you received today?

45.  YES  NO What are the possible side effects? 
46.  YES  NO Where can you get more supplies? 
47.  YES  NO When will you come back for a check up? 
  
Service provider interview 
Mark "yes" if the respondent answers correctly: 
48.  YES  NO Under what conditions should you refrain from
prescribing oral contraceptives? 
49.  YES  NO Under what conditions should you refrain from
prescribing the IUD? 
50.  YES  NO Under what conditions should you refrain from
prescribing injectable? 
51.  YES  NO Under what conditions should you refrain from
prescribing implants? 
   
PHC service quality checklist 
7:  Breast feeding

PHC Management Advancement Programme, Module 5, User's guide p.
58> <$FPRICOR Thesaurus, vol. II, p. 232, 253> WHO, Indicators
for assessing breast feeding practices, p. 4> Mothercare:
Interventions to improve maternal and neonatal nutrition, Working
Paper # 4, November 1990 (John Snow, Inc)> <$FUSAID, Maternal and
child health in Bolivia: Report on the in-depth DHS Survey in
Bolivia 1989, p. 49> USAID, 
Media promotion of breast feeding: A decade's experience,
Nutrition Communication Project, p. 45> Breast feeding for child
survival strategy, USAID, May 1990 p. 29-30, 38> 

This checklist is intended for use in the observation of service
delivery for promotion of breast feeding..  Before using it, the
national treatment protocol should be reviewed in order toadapt
the tool to the local situation, if necessary.  It is also
recommendedthat you review the checklist carefully before using
it to be surethat you understand the questions and know how to
use the form.  Forobservation of service delivery, mark "yes" if
the service providercarries out these activities during service
delivery.  For interviewquestions, mark "yes" if the respondent
answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Medical history 
Did the service provider: 
5.   YES  NO Ask about the mother's knowledge, attitudes and
beliefs about breast feeding? 
6.   YES  NO Ask about previous use of breast feeding with each
child born in the last five years? 
7.   YES  NO Ask about duration of previous breast feeding and
reasons for stopping? 
8.   YES  NO Ask about use of medications and alcohol? 
9.   YES  NO Ask about any current illnesses that might affect
breast feeding? 
10.  YES  NO Ask about socio-economic status and dietary habits
and intake? 
  
Breast feeding education and counselling 
Skills Training:  
Did the service provider: 
11.  YES  NO Instruct mothers on the health benefits to mother
and child of breast feeding? 
12.  YES  NO Instruct mothers on the financial benefits of breast
feeding? 
13.  YES  NO Tell mother to feed colostrum (begin breast feeding
as soon as possible)? 
14.  YES  NO Tell mother that normal milk flow will begin after
2-3 days? 
15.  YES  NO Tell mother to breast feed infant frequently during
the first few days? 
16.  YES  NO Explain the importance of feeding breast milk only,
for the first 4-6 months? 
17.  YES  NO Tell mother to use both breasts, feeding from one
until it is empty, then from the other? 
18.  YES  NO Tell mother to start feeding with the breast that is
not the breast she started feeding from the last time? 
19.  YES  NO Tell mother to continue breast feeding when she or
infant is ill (diarrhoea, infection)? 
20.  YES  NO Tell mother to keep nipples clean and dry to prevent
cracking? 
21.  YES  NO Tell mother to avoid using soap on nipples and to
air breasts? 
22.  YES  NO Demonstrate how to express breast milk to relieve
congestion and prevent engorgement?  
23.  YES  NO Demonstrate how to position infant's mouth around
areola for breast feeding? 
24.  YES  NO Tell mother to return if the infant has problems
nursing? 
25.  YES  NO Counsel on family planning methods with least effect
on quantity and quality of breast milk (spermicides, barrier
methods, progesterone only pills or injections, IUDs or
abstinence)? 
26.  YES  NO Teach ways to increase contraceptive benefits of
breast feeding (e.g., exclusive and frequent demand feeding for
the first six months)? 
27.  YES  NO Use appropriate health education techniques and
materials? 
28.  YES  NO Encourage breast feeding among HIV positive women,
if appropriate? 
29.  YES  NO Explain that frequent bowel movements in the
new-born indicate good milk intake and infrequent stools in the
first few weeks could be a warning sign? 
30.  YES  NO Ask the mother to repeat key messages? 
31.  YES  NO Ask the mother if she has any questions? 
  
Nutritional messages:  
Did the service provider: 
32.  YES  NO Tell mother to increase her total food and liquid
intake or to balance her food intake and activities during
lactation? 
33.  YES  NO        
Explain to mother the administration schedule for nutrition 
supplements, iron and/or folic acid tablets prescribed or
distributed for home administration? 
34.  YES  NO Warn mothers of dangers of alcohol and drugs? 
35.  YES  NO Tell mother about specific, nutritious, appropriate
local foods (protein rich)? 
36.  YES  NO Discourage dietary taboos that restrict important
foods/food groups for lactating women? 
37.  YES  NO Encourage those cultural practices that promote
consumption of important foods for lactating women? 
38.  YES  NO Discuss other feeding options with the mother? 
  
Weaning:   
Did the service provider: 
39.  YES  NO Explain the importance of introducing complementary
foods during a two-month transitional period (i.e., months five
and six)? 
40.  YES  NO Explain that children should be breastfed (not
exclusively) for at least one year and preferably for up to 2
years of age or beyond. 
41.  YES  NO Demonstrate preparation of weaning foods? 
 
Exit interview with mother 
Mark "yes" if the respondent answers correctly. 
42.  YES  NO For how long will you breast feed? 
43.  YES  NO Do you know the proper position to breast feed your
child? 
44.  YES  NO Do you know how to care for your breasts? 
45.  YES  NO Do you know what/how much you should be eating
during the lactation period? 
 
Interview with service provider 
Mark "yes" if the respondent answers correctly. 
46.  YES  NO Explain the length of time that mothers should
breast feed? 
47.  YES  NO        
Explain the health and economic benefits of breast feeding? 


PHC MAP service quality 
Checklist 8: Growth monitoring/nutrition education 

This checklist is intended for use in the observationof service
delivery for growth monitoring and nutrition education.Before
using it, the national treatment protocol should be reviewedin
order to adapt the tool to the local situation if necessary. 
Itis also recommended that you review the checklist carefully
beforeusing it to be sure that you understand the questions and
know howto use the form.  For observation of service delivery,
mark "yes"if the service provider carries out these activities
during servicedelivery.  For interview questions, mark "yes" if
the respondent answerscorrectly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Age calculation 
Did the service provider: 
5.   YES  NO Base calculation on a reliable date of birth?
Reliable sources for date of birth: growth chart, health record,
or birth certificate. Rely on mother's memory only when these are
not available.
6.   YES  NO Correctly calculate date of birth?<$FThe accuracy of
age calculation and weight reading should be determined by
comparing the health worker's reading with the supervisor's
reading.
7.   YES  NO Correctly record age? 
  
Weighing 
Did the service provider: 
8.   YES  NO Set scale to 0? 
9.   YES  NO Remove child's clothing? 
10.  YES  NO Place child correctly on scale? 
11.  YES  NO Correctly read scale?<$FThe accuracy of age
calculation and weight reading should be determined by comparing
the health worker's reading with the supervisor's reading.> 
12.  YES  NO Correctly record weight? 
Locating the child's growth on chart 
Did the service provider: 
13.  YES  NO Plot or locate the child's weight at correct age? 
14.  YES  NO Plot or locate the child's weight at correct weight?
15.  YES  NO Connect to previous growth point? 
  
Referral and follow-up 
16.  YES  NO Refer sick/malnourished child for medical attention?
17.  YES  NO Refer malnourished child for nutritional
rehabilitation? 
  
Growth monitoring and nutrition education 
Did the service provider do the following for all children 
weighed: 
18.  YES  NO Tell mother whether child has gained, lost, stayed
the same since last weighing? 
19.  YES  NO Tell mother the nutritional status of the child? 
20.  YES  NO Use growth card to explain to mother how her child
is growing? 
 
Did the service provider do the following for malnourished 
children and for children who have not gained weight since the
last session: 
21.  YES  NO Ask if the child has had any health problems since
last weighing? 
22.  YES  NO Make recommendations regarding child feeding and
care? 
23.  YES  NO Explain importance of good breast feeding and
weaning practices? 
24.  YES  NO Explain which locally available foods constitute a
balanced diet for children? 
25.  YES  NO Explain how to feed children during illness? 
26.  YES  NO Tell mother when to take child for next weighing? 
27.  YES  NO Verify that mother understands key messages? 
28.  YES  NO Ask mother if she has any questions? 
For outreach education sessions: 
Did the service provider: 
29.  YES  NO Explain the importance of gaining weight for health?

30.  YES  NO Explain the purpose of growth monitoring? 
31.  YES  NO Explain when and where to go for growth monitoring
services? 
32.  YES  NO Use appropriate health education techniques and
materials? 
33.  YES  NO Demonstrate preparation of weaning foods? 
34.  YES  NO Verify that attendees understand key messages? 
35.  YES  NO Use visual aids in transmitting key messages? 
  
Supplies 
Ask the service provider about the following supplies: 
36.  YES  NO Working scale 
37.  YES  NO Growth charts 
  
Exit interview with mother 
Mark "yes" if the respondent answers correctly: 
38.  YES  NO How much does your child weigh? 
39.  YES  NO Did your child gain weight, lose, or stay the same
since the last weighing? 
40.  YES  NO When will you return for growth monitoring? 
  
If the child is malnourished: 
41.  YES  NO Where will you take your child for nutritional
rehabilitation? 
42.  YES  NO What will you do to improve your child's condition? 
  
Interview with service provider 
43.  YES  NO Do you have a way of tracking malnourished children?
44.  YES  NO Do you refer malnourished children for nutritional
rehabilitation or medical care? 
45.  YES  NO Do you follow up malnourished children who do not
come back for growth monitoring? 
 
PHC service quality checklist 
9:  Immunization 

This checklist is intended for use in the observationof service
delivery for immunization.  Before using it, the national
treatment protocol should be reviewed in order to adapt the tool
tothe local situation if necessary.  It is also recommended that
you review the checklist carefully before using it to be sure
that you understand the questions and know how to use the form. 
For observation of service delivery, mark "yes" if the service
provider carries out these activities during service delivery. 
For interview questions,mark "yes" if the respondent answers
correctly.

1.  Health facility 
2.  Service provider 
3.  Observer/supervisor 
4.  Date 
 
Identification of needed vaccinations 
Did the service provider: 
5.   YES  NO Review health records to determine which
immunizations are needed today? 
6.   YES  NO Review mother's health record or ask mother whether
she has received tetanus toxoid immunization? 
7.   YES  NO Review vaccination status of other children in the
family? 
8.   YES  NO Recommend vaccination even if the child is sick? 
  
Preparation and care of vaccine 
Did the service provider: 
9.   YES  NO Check the label for the correct vaccine and to be
sure the vaccine has not expired? 
10.  YES  NO Load the syringe without contamination? 
11.  YES  NO Keep the vaccine on ice and covered during the
session? 
  
Vaccination technique 
Did the service provider: 
12.  YES  NO Prepare the area of injection? 
13.  YES  NO Use a sterile needle for each injection? 
14.  YES  NO Use a sterile syringe for each injection? 
15.  YES  NO Apply the vaccine at the right level?  (BCG = dermal
layer, measles = subcutaneous layer, DPT/TT = muscle) 
16.  YES  NO Properly dispose of the needle and syringe? 
17.  YES  NO Was the child given all vaccinations needed today? 
18.  YES  NO If the mother required TT, did the service provider
vaccinate her or arrange for vaccination? 
  
Documentation 
Did the service provider: 
19.  YES  NO Record the vaccination on the child's health card? 
20.  YES  NO Record the vaccination in the appropriate health
centre record(s)? 
 
EPI education 
Did the service provider: 
21.  YES  NO Tell the mother which vaccinations were given during
this visit? 
22.  YES  NO Inform the mother that side effects, such as fever
and pain, are possible? 
23.  YES  NO For BCG vaccination, explain that a scab will form? 
24.  YES  NO Tell mother where to go if she or the child should
have a severe reaction to the vaccination? 
25.  YES  NO Explain the importance of completing the vaccination
series? 
26.  YES  NO If DPT #3 has been administered, stress the
importance of returning for measles vaccination? 
27.  YES  NO Explain that the child can be immunized even if
she/he is ill? 
28.  YES  NO Tell when to come back for the next immunization for
mother or child? 
29.  YES  NO Ask mother to encourage other women and their
children to be vaccinated? 
30.  YES  NO Verify that mother understands key messages? 
31.  YES  NO Ask mother if she has any questions? 
  
Maintenance of cold chain and supplies  
Observe the facility or ask health worker to determine the 
following: 
32.  YES  NO Is the refrigerator working today? 
33.  YES  NO Is there a thermometer or cold chain monitor in the
refrigerator? 
34.  YES  NO Is there a temperature log? 
35.  YES  NO Is temperature recorded regularly according to the
local schedule? 
36.  YES  NO Was the registered temperature between 0 and 8
degrees (C) at all times during the last month? 
37.  YES  NO Are all vials in storage unopened? 
38.  YES  NO Were vaccines sufficient during the last month? 
39.  YES  NO Were needles and syringes sufficient during the last
month? 
40.  YES  NO Were vaccination cards sufficient during the last
month? 
41.  YES  NO For outreach sessions, were vaccines transported in
cold boxes with ice packs? 
  
Exit interview with mother or caretaker 
Mark "yes" if the respondent answers correctly: 
42.  YES  NO What immunization(s) did you or your child receive
today? 
43.  YES  NO When should you return to the health centre for your
next immunization? 
  
Interview with service provider 
Mark "yes" if the service provider answers correctly: 
44.  YES  NO At what age should a child receive BCG vaccine? 
45.  YES  NO At what age should a child receive DPT vaccine? 
46.  YES  NO At what age should a child receive Measles vaccine? 
47.  YES  NO At what age should a child receive OPV vaccine? 
48.  YES  NO Should you vaccinate a child if she/he is ill? 
 
 
PHC service quality checklist 
10:  Acute respiratory infection 

This checklist is intended for use in the observation of service
delivery for acute respiratory infection.  Before using it, the
national treatment protocol should be reviewed in order to adapt
the tool to the local situation if necessary.  It is also
recommendedthat you review the checklist carefully before using
it to be surethat you understand the questions and know how to
use the form.  Forobservation of service delivery, mark "yes" if
the service providercarries out these activities during service
delivery.  For interviewquestions, mark "yes" if the respondent
answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Medical history 
Did the service provider: 
5.   YES  NO Ask about presence/level of fever? 
6.   YES  NO Ask about duration of cough? 
7.   YES  NO Ask about activity level? 
8.   YES  NO Ask about ability to drink? 
9.   YES  NO Ask about presence of sore throat? 
10.  YES  NO Ask about presence of earache? 
 
11.  YES  NO Ask about any past history of respiratory problems
(e.g. asthma)? 
12.  YES  NO Ask about family history of TB or other respiratory
illness? 
13.  YES  NO Ask about any treatment administered? 
  
Physical examination 
Did the service provider: 
14.  YES  NO Assess general status (alertness, muscle tone)? 
15.  YES  NO Count respiratory rate? 
16.  YES  NO Take temperature? 
17.  YES  NO Observe breathing for chest indrawing? 
18.  YES  NO Listen for stridor, wheeze, and/or hoarseness? 
19.  YES  NO Auscltate chest? 
20.  YES  NO Examine throat for discharge, enlarged tonsils, or
inflamed pharynx? 
21.  YES  NO Examine neck for tender glands? 
22.  YES  NO Examine ears? 
23.  YES  NO Observe colour of lips, ears, face, and nail beds? 
  
Classification, treatment and referral 
Did the service provider: 
24.  YES  NO Classify child by severity of illness (cold,
pneumonia, severe pneumonia)? 
25.  YES  NO Administer/prescribe antibiotics for pneumonia,
strep throat, or otitis (per local policy)? 
26.  YES  NO Refrain from using antibiotics for colds? 
27.  YES  NO Administer or prescribe drug for fever (per local
policy)? 
28.  YES  NO Administer or prescribe cough mixture (per local
policy)? 
29.  YES  NO Refer children with severe pneumonia or cough
lasting more than 30 days? 
  
ARI education 
Did the service provider: 
30.  YES  NO Explain how to administer antibiotics? 
31.  YES  NO Explain the importance of completing entire
treatment course? 
32.  YES  NO Explain how to administer cough mixture (how much,
how often, how long)? 
33.  YES  NO Explain how to drain child's nose (especially if
mother is breast feeding)? 
34.  YES  NO Tell mother to give extra fluids, continue
feeding/breast feeding during illness? 
35.  YES  NO Tell mother to maintain a neutral temperature for
the child? 
36.  YES  NO Tell mother about at least three of the
signs/symptoms of moderate/severe ARI?<$FDanger signs include
stridor, chest indrawing/rapid breathing, inability to drink,
cyanosis, anxiety, and weakness or lethargy. 
37.  YES  NO Tell mother to return for further consultation if
the child's condition worsens or does not improve? 
38.  YES  NO Verify that mother understands key messages? 
39.  YES  NO Ask mother if she has any questions? 
  
Essential supplies for ARI treatment 
Ask the service provider about the following supplies: 
40.  YES  NO Do you have a watch with a second hand or other
timepiece to assess respiratory rate? 
41.  YES  NO Were antibiotic supplies adequate during the last
month? 
42.  YES  NO Do you have a thermometer to measure the patient's
temperature? 
  
Interview with mother 
Mark "yes" if the respondent answers correctly: 
43.  YES  NO How will you treat your child at home?<$FSupportive
home treatment includes extra fluids, continued feeding,
maintaining a neutral temperature, clearing the nose, and using
cough medicine or antihistamine (per local policy).>  
44.  YES  NO What danger signs indicate that you should bring
child to the health centre?1  
45.  YES  NO If antibiotics were prescribed:  How will you
administer the medicine? 
46.  YES  NO If antibiotics were prescribed:  When will you stop
giving the medicine to your child? 
Interview with health worker 
Mark "yes" if the respondent answers correctly: 
47.  YES  NO What are the signs and symptoms of pneumonia?1 
48.  YES  NO How can you differentiate a cold from pneumonia? 
49.  YES  NO How can you differentiate pneumonia from severe
pneumonia? pneumonia is defined as cases with respiratory rates
over 50 for children from 2 months to 5 years old (over 60 for
children under 2 months), and with danger signs such as severe
chest indrawing, inability to drink, or stridor.> 
50.  YES  NO When do you prescribe antibiotics? 
51.  YES  NO What home treatments do you recommend for colds and
pneumonia? Supportive home treatment includes extra fluids,
continued feeding, maintaining a neutral temperature, clearning
the nose, and using cough medicine or antihistamine (per local
policy).> 
52.  YES  NO When should you refer a child to the health
centre/hospital? 
  
PHC service quality checklist 
11: Diarrhoeal disease control/oral rehydration 
therapy 

This checklist is intended for use in the observationof service
delivery for oral rehydration therapy.  Before using it,the
national treatment protocol should be reviewed in order to
adaptthe tool to the local situation if necessary.  It is also
recommendedthat you review the checklist carefully before using
it to be surethat you understand the questions and know how to
use the form.  Forobservation of service delivery, mark "yes" if
the service providercarries out these activities during service
delivery.  For interviewquestions, mark "yes" if the respondent
answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Medical history 
Did the service provider check for: 
5.   YES  NO Duration of diarrhoea? 
6.   YES  NO Consistency of stools? 
7.   YES  NO Frequency of stools? 
8.   YES  NO Presence of blood and/or mucus in stools? 
9.   YES  NO Presence of vomiting? 
10.  YES  NO Fever? 
11.  YES  NO Home treatments? 
  
Physical examination 
Did the service provider: 
12.  YES  NO Assess general status (alert or lethargic)? 
13.  YES  NO Pinch skin?<$FHealth workers should also look for
sunken fontanelle and examine the mucus membrane. These are
omitted here because they cannot be observed, however they could
be included if the health worker is asked to describe what he or
she  is doing. 
14.  YES  NO Weigh child? 
15.  YES  NO Determine nutritional status to be sure the child is
not severely malnourished? 
16.  YES  NO Take temperature? 
  
Classification and treatment 
Did the service provider: 
17.  YES  NO Determine the degree of dehydration (none, moderate,
severe)? 
18.  YES  NO Prescribe safe ORS or cereal-based ORT? 
19.  YES  NO Recommend safe home treatment with ORS, or
cereal-based ORT? 
20.  YES  NO Refrain from using antibiotics, except when stools
contain blood or mucus? 
21.  YES  NO Refrain from using anti-diarrhoeals? 
22.  YES  NO If the child is dehydrated, administer ORS or
cereal-based ORT immediately or refer the child to a nearby
centre? 
23.  YES  NO Give sufficient amount of ORS solution? 
24.  YES  NO Plan to reassess child's hydration status after an
appropriate interval? 
25.  YES  NO Rehydrate with intravenous fluid or naso-gastric
tube if dehydration is severe? 
26.  YES  NO Try ORS solution, if IV or NG tube are not available
within 30 minutes of facility? 
28.  YES  NO NG treatment, if child cannot drink, refer/evacuate
for IV? 
  
ORT education 
Did the service provider: 
29.  YES  NO Tell mother to give extra fluids during diarrhoea? 
30.  YES  NO Tell mother how to prepare ORS solution? 
31.  YES  NO Tell mother how much ORS solution to give and how
often to give it? 
32.  YES  NO Tell mother about appropriate feeding practices
during and after diarrhoea? 
33.  YES  NO Tell mother about at least three signs of
dehydration? Signs for dehydration; 1) lethargy; 2) absence of
tears while crying; 3) pinched skin retracts slow> 
34.  YES  NO Tell mother about at least two danger signs that
indicate that she should bring the child to health centre? Danger
signs : 1) many watery stools; 2) repeated vomiting; 3) very
thirsty; 4) eating or drinking poorly; 5) fever; 6) blood in
stool; 7) child shows signs of dehydration.
35.  YES  NO Show mother how to prepare ORS solution? 
36.  YES  NO Show mother how to administer ORS solution? 
37.  YES  NO Verify that  mother understands key information? 
38. YES   NO Ask mother if she has any questions? 
  
Essential supplies for ORT 
39.  YES  NO Was the supply of ORS packets adequate for the past
month? 
40.  YES  NO Do you have the materials necessary (cup, spoon,
water) to prepare and administer ORS solution? 
Exit interview with the child's mother/caretaker 
Mark "yes" if the respondent answers correctly: 
41.  YES  NO How do you make ORS solution? 
42.  YES  NO How much ORS solution will you give your child? 
43.  YES  NO How often will you give ORS solution? 
44.  YES  NO What danger signs indicate that you should bring
your child back to the health centre? 
  
Interview with service provider 
Mark "yes" if the respondent answers correctly: 
45.  YES  NO When you examined the child for dehydration, what
physical signs did you look for?1 
46.  YES  NO What was the child's degree of dehydration? 
 
PHC service quality checklist 
12:  Water supply, hygiene, and sanitation 


This checklist is intended for use in the observation of service
delivery for education in water supply, hygiene, and sanitation. 
Beforeusing it, the national treatment protocol should be
reviewed in orderto adapt the tool to the local situation if
necessary.  It is alsorecommended that you review the checklist
carefully before using itto be sure that you understand the
questions and know how to use theform.  For observation of
service delivery, mark "yes" if the serviceprovider carries out
these activities during service delivery.  For interview
questions, mark "yes" if the respondent answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Observation of health education sessions or individual
counselling Individual counselling should be carried out in cases
of diarrhoea, or in any cases where the health worker feels that
poor water and sanitation may constitute a health risk. 
Did the service provider: 
5.   YES  NO Explain that dirty water, human and animal waste,
and refuse can cause disease? 
6.   YES  NO Explain the link between water and sanitation and
diarrhoea? 
7.   YES  NO Explain that cleanliness can prevent disease? 
8.   YES  NO Discuss whether the woman has adequate access to
water (i.e. located within 15 minutes of a water source)? 
9.   YES  NO If there is a problem with access, discuss current
or potential community efforts to address water supply problems
and tell the woman how she can be involved? 
Water storage and use: 
Did the service provider: 
10.  YES  NO Discuss keeping water in a clean, covered container?
11.  YES  NO Recommend use of a long-handled dipper to remove
water from container? 
12.  YES  NO Recommend keeping soap near the water storage
container? 
13.  YES  NO Discuss the importance of hand washing before
eating, feeding children, and food preparation? 
14.  YES  NO Discuss the importance of washing hands with soap
after using the latrine, cleaning children, or handling refuse or
excreta? 
15.  YES  NO Encourage use of safe water for drinking, cooking,
and washing vegetables or fruit?  
Latrine maintenance and use: 
Did the service provider: 
16.  YES  NO Inspect latrine? 
17.  YES  NO Recommend cleaning latrine daily with brush or
broom? 
18.  YES  NO Recommend making sure that latrine is absent of
faeces? 
19.  YES  NO Recommend making sure that latrine is absent of
puddles? 
20.  YES  NO Recommend making sure that latrine is absent of
flies? 
21.  YES  NO Recommend making water or paper available in
latrine? 
22.  YES  NO Advise not to use latrine for storage? 
23.  YES  NO Advise to keep animals out of the latrine? 
24.  YES  NO Discuss appropriate latrine use and human waste
disposal (e.g. baby potty for children under three)? 
Refuse and excreta disposal: 
Did the service provider: 
25.  YES  NO Recommend sweeping house and courtyard daily? 
26.  YES  NO Recommend keeping animals away from cooking and
eating areas? 
27.  YES  NO Recommend collecting and drying animal excreta for
fertiliser, fuel, or as a construction material? 
28.  YES  NO Recommend burning or burying refuse? 
29.  YES  NO Recommend collecting used water and channel it into
the garden? 
30.  YES  NO Recommend penning animals away from the house? 
  
Interview with health workers 
Mark "yes" if the respondent answers correctly: 
31.  YES  NO Do you talk to individuals or groups about water and
sanitation? 
32.  YES  NO Do you keep a list of neighbourhoods or households
that do not have adequate access to water? 
33.  YES  NO What do you tell mothers about how to keep the
drinking water at her home safe? 
34.  YES  NO What do you tell mothers about how to keep the
latrine clean? 
35.  YES  NO What do you tell mothers about refuse disposal? 
  
Interview with mothers 
Mark "yes" if the respondent answers correctly: 
36.  YES  NO Has a health worker ever talked to you, individually
or in a group, about water and sanitation? 
37.  YES  NO Why is it important to wash your hands? 
38.  YES  NO What do you do to keep the drinking water at your
home safe? 
39.  YES  NO What do you do to keep your latrine clean? 
40.  YES  NO How do you dispose of refuse? 
PHC service quality checklist 
13: Childhood disabilities 

This checklist is intended for use in the observation  of
services provided by clinic-based and community-based service
providers  to clients with Childhood Disabilities.  In this
instance, the  term "disabilities" will refer to clients who are
crippled, who have  trouble moving, speaking, seeing, hearing, or
learning, and  who have  physical, mental, or emotional 
handicaps.1 It is expected  that providers will have different
levels of training and expertise  and have varied access to
resources such as diagnostic, treatment,  rehabilitation, and
special education services. Therefore, national  management and
treatment protocols should be reviewed in order to  adapt the
tool to the local situation. PHC managers can use the checklist 
as a supervision tool to determine whether services are delivered 
according to established norms. 

NOTE: Questions included in this checklist were constructed  from
existing manuals and references on disabilities,2, 3, 4,  5 and
from the reported field experiences of relevant clinicians  and
researchers.6

1 This is the working definition used by the following 
contributors: Dr. David Marsh, Aga Khan University, with Drs.
Salma  Alam, Ghaxala Parveen, Shafiq-ur-Rab, and Mohammed Zahid.

2 Helander, E., et al., Training in the Community  for People
with Disabilities, Geneva, WHO, 1989.

3 Thorburn, M.J., & Marfo, K., Practical approaches  to childhood
disability in developing countries: Insights from  experience and
research, 3D Projects, Spanish Town, Jamaica, 1990.

4 Wallace, H., "Health care of women and children in developing 
countries", Chapter 38, Handicapped children and youth  in
developing countries, Third party publishing company, Oakland, 
CA, 1990.

5 Werner, D. Disabled Village Children, Hesperian  Foundation,
Palo Alto, CA, 1987.

6 See footnote 3. Also Dr. Pasquale Accardo, Chair, Section  on
children with disabilities, American Academy of Pediatrics,
provided  some meaningful comments.

1.  Health facility 
2.  Service provider 
3.  Observer/supervisor 
4.  Date 
 
Medical history 
Did the service provider: 
5.   YES  NO Ask the mother if she received prenatal care? 
6.   YES  NO Ask the mother if her deliveries were attended by a
health worker or TBA? 
7.   YES  NO Ask the mother about the health/size of the newborn?
8.   YES  NO Ask the mother if the child's growth was monitored? 
9.   YES  NO Ask the mother if the child is fully immunized? 
10.  YES  NO Ask the mother whether the child had any serious
delay in sitting, standing, or walking? 
11.  YES  NO Ask the mother whether the child has difficulty
learning to do things like other children his/her age? 
12.  YES  NO For children 3 - 9 yrs. old, ask the mother whether
the child's speech is in any way different from normal, e.g., not
clear enough to be understood by people outside the immediate
family? 
13.  YES  NO For 2-year-old children, ask whether he/she can
identify and say the name of at least one object? 
14.  YES  NO Ask whether the child has difficulty in walking,
moving his/her arms, or has weakness or stiffness in the arms or
legs? 
15.  YES  NO Ask whether the child has had trouble seeing, either
in the daytime or evening? 
16.  YES  NO Ask whether the child has had trouble hearing? 
17.  YES  NO  Ask the mother whether the child has had fits
(e.g., lost consciousness, blank stares, twitching or other
uncontrolled movements)? 
18.  YES  NO Ask the mother whether the child has had any
behavioural or emotional problems? 
19.  YES  NO Ask when the disability began? 
20.  YES  NO Ask whether any family members or relatives have had
a similar problem? 
21.  YES  NO Ask whether medical care was sought for the
disability? 
 Physical exam 
Did the service provider: 
22.  YES  NO                Note the presence of any deformities
or defects? 
23.  YES       NO Check for normal range of motion in legs,
knees, feet, hips? 
24.  YES       NO Check for differences in leg length? 
25.  YES       NO Check muscle strength in legs, knees, feet,
hips, shoulders, back, arms or hands? 
26.  YES       NO Check sense of balance and coordination? 
27.  YES       NO Check reflexes in knee? 
28.  YES       NO Check ability to touch or feel pain? 
29.  YES       NO Check for abnormal curve of the spine? 
30.  YES       NO Examine ears and test hearing? 
31.  YES       NO Examine and test eyes? 
32.  YES       NO Examine oral cavity? 
 
Case identification/referral 
Did the service provider: 
33.  YES       NO Administer/prescribe appropriate treatment or
therapy according to established treatment guidelines?  
34.  YES       NO Make the appropriate referral according to
established guidelines?  
35.  YES       NO Record the case according to established
guidelines? 
 
Counselling client on childhood disabilities 
Did the service provider: 
36.  YES          NO Provide adequate information about local or
regional 
referral services for people with disabilities (e.g., NGOs,
special schools, therapy, and treatment centres)? 
37.  YES          NO Provide adequate information on local or
regional medical specialists? 
38.  YES       NO Discuss with the client what may have caused
the disability? 
39.  YES       NO Discuss available medicine or treatment, if
any? 
40.  YES       NO Discuss any possible long-term outcomes
associated with the condition and, if applicable, the need for
ongoing treatment? 

41.  YES       NO If applicable, discuss the possible risk of
having another child if more than one child is known to have been
born with a genetic condition? 
42.  YES       NO Discuss what parents and families can do to
help the disabled child? 
43.  YES       NO Discuss what community or schools can do to
help children with disabilities? 
44.  YES       NO Discuss how a child with a disability can still
do many things normally and can continue to be a productive
member of the community? 
 
Interview with service provider  
Mark "yes" if the respondent answers correctly: 
45.  YES       NO What are some signs and symptoms associated
with disabilities? 
46.  YES       NO What are the local treatment guidelines and
available treatments? 
47.  YES       NO What are some ways that disabilities can be
prevented? 
48.  YES       NO When should you refer cases for further
diagnosis, testing, or treatment? 
49.  YES       NO What are the local or regional referral
services, e.g. NGOs, special schools, therapy and treatment
centres, or specialists available to clients with disabilities? 
50.  YES       NO Who is the individual in the community
responsible for supervising or organising disability-related
activities, such as rehabilitation, special education,
recreational activities? 
51.  YES       NO What are the committees or support groups in
the community which are responsible for the above
disability-related activities? 
52.  YES       NO What is the process of recording or following
up the progress of individuals? 
 
Exit interview with client 
Mark "yes" if the client responds correctly: 
53.  YES       NO What is your child's disability? 
54.  YES       NO Do you know how he/she got it? 
55.  YES       NO If applicable, do you know how to prevent a
similar disability from happening again? 
56.  YES       NO What treatment did you receive?  
57.  YES       NO How do you administer it? 
58.  YES       NO Where do you go for treatment or follow-up? 
59.  YES       NO What are some of the available therapy and
treatment 
centres and/or community groups which can help your child? 
60.  YES       NO What kinds of things can your child still do
normally despite his/her disability? 
61.  YES       NO Do you have some questions or concerns that
were not addressed by the provider? 
 
PHC service quality checklist 
14:  Accidents and injuries<$FKirsch, T. and Kiess, L.<MI> 

Thesaurus of injury care skills. Draft. Baltimore, MD, The 
Johns Hopkins University, 1992.><P8M^> 

This checklist is intended for use in the observation  of service
delivery for accidents and injuries.  Before using it,  the
national treatment protocol should be reviewed in order to adapt 
the tool to the local situation if necessary.  It is also
recommended  that you review the checklist carefully before using
it to be sure  that you understand the questions and know how to
use the form.  For  observation of service delivery, mark "yes"
if the service provider  carries out these activities during
service delivery.  For interview  questions, mark "yes" if the
respondent answers correctly.

1.  Health facility 
2.  Service provider 
3.  Observer/supervisor 
4.  Date 
 
Medical history 
Did the service provider: 
5.   YES       NO Correctly identify type of injury? 
6.   YES       NO Obtain history of the injury (cause, time of
injury, determine type of poisoning, etc.)? 
 
Physical examination 
Did the service provider: 
7.   YES       NO Administer proper treatment according to
established guidelines? 
8.   YES       NO Make the appropriate referral according to
established guidelines? 
 
Education on injury prevention 
Did the service provider: 
9.   YES       NO Discuss some common injuries and how they may
be prevented? 
10.  YES       NO Discuss the use of alcohol and dangers related
to alcohol consumption? 
11.  YES       NO Discuss the importance of proper storage of
dangerous substances? 
12.  YES       NO Discuss occupational safety issues? 
13.  YES       NO Discuss child safety in and around the home? 
14.  YES       NO Explain how to recognise an emergency? 
15.  YES       NO Discuss location of emergency facilities in the
area? 
16.  YES       NO Explain the importance of determining the cause
of the injury, particularly in the case of poisonings? 
 
Interview with service provider  
This section can be used to assess the knowledge of the service 
provider depending on his or her training.  A response should be
judged correct if it is in agreement with local guidelines. 
Mark "yes" if the respondent answers correctly: 
17.  YES  NO What are some common injuries 
18.  YES  NO How can these injuries be prevented? 
19.  YES       NO How can you recognise an emergency? 
20.  YES       NO Where can treatment be obtained? 
21.  YES       NO                              
When should a patient be referred? 
22.  YES       NO How should a patient with an injury be
transported? 
23.  YES       NO What important information do you need to
obtain from a patient regarding their injury? 
 
Exit interview with client 
Mark "yes" if the respondent answers correctly: 
24.  YES       NO What is your injury? 
25.  YES       NO Do you understand how to care for the injury? 
26.  YES       NO What medication were you given? 
27.  YES       NO Do you understand how to take this medication? 
28.  YES       NO What are the danger signs that warn you to
return to the health care facility for help? 
29.  YES       NO Whatkind of follow-up or rehabilitative care
does your injury require? 
30.  YES       NO How can this kind of injury be prevented or
avoided in the future? 
 
 
PHC service quality checklist 
15: Sexually transmitted diseases and HIV/AIDS 

This checklist is intended for use in the observation  of
STD-related services which are delivered by health care service 
providers in STD clinics, PHC centres, MCH facilities or FP
clinics.  It is expected that providers will have different
levels of training  and expertise, and have varied access to
resources such as clinical,  diagnostic, and treatment services.
Therefore, national management  and treatment protocols should be
reviewed in order to adapt the tool  to the local situation. PHC
managers can use the checklist as a supervision  tool to
determine whether services are delivered according to established 
norms.  Because of the confidential nature of the questions,
supervisors  may want to observe simulated visits rather than
actual visits, or  to use an interview with the health worker
rather than observation.

1 World Health Organization: Management of patients  with
sexually transmitted diseases. WHO Technical report series  810,
Geneva, World Health Organization, 1991.

2 Lamptey, P, Piot, P,. The handbook for AIDS prevention  in
Africa. Durham, NC, Family Health International, 1990.

3 World Health Organization, AIDS prevention: guidelines  for
MCH/FP Programme managers. Global Programme on AIDS, Geneva, 
World Health Organization, 1990.

4 Andrist, L., Taking a sexual history and educating  clients
about safe sex. Nursing Clinics of North America,
Dec.,23(4):959-73  (1988).

5 Stone, D. & Kaleeba, N., Counselling and AIDS. The  handbook
for AIDS prevention in Africa, 181-190, Durham, NC, Family 
Health International, 1990.

6  World Health Organization: Management of patients  with
sexually transmitted diseases. WHO technical report series  810,
61-7, Geneva, World Health Organization, 1991.

7 Bernham, G., Department of International Health, Johns  Hopkins
School of Public Health; Brady, W., PA-C, MPH Division of 
STD/HIV prevention, Centers for Disease Control; Millar, M,
University  Resesarch Corporation, Training programme as part of
WHO Global Programme  on AIDS; Neill, M., Training and Materials
Development Specialist,  CDC; Alwood, C., NP, AIDS Clinic, Johns
Hopkins Hospital.

NOTE: Questions included in this checklist were constructed 
from existing STD/HIV/AIDS medical and management protocols
developed by WHO1 from AIDS prevention programme
materials2 3 and from related studies on counselling and
education,4 5 6and drawn  from the reported field experiences
of relevant clinicians and researchers.7 
1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Medical history 
This section can be used to assess the service provider who 
takes the medical history. The purpose of taking the medical
history is to alert the provider to possible types of infection
associated with STDs.  
Did the service provider: 
5.   YES       NO Ask about symptoms of infection such as
prolonged fever? 
     YES       NO unexplained weight loss? 
     YES       NO chronic diarrhoea? 
     YES       NO persistent cough? 
     YES       NO visual symptoms? 
     YES       NO genital ulcers? 
     YES       NO urethral/vaginal discharge? 
     YES       NO painful or difficult urination? 
     YES       NO mouth sores? 
     YES       NO night sweats? 
6.   YES       NO Ask about previous exposure to STDs? 
7.   YES       NO Ask about treatments administered? 
8.   YES       NO Ask about follow-up and compliance with
treatment? 
9.   YES       NO Ask about treatment of partner(s)? 
10.  YES       NO Ask whether client has ever had transfusion of
blood or blood products? 
11.  YES       NO Ask whether client has ever been exposed to
non-sterile instruments such as needles or knives? 
12.  YES       NO If applicable, take the medical history in
private? 
 
Sexual history   
The purpose of taking a sexual history is to alert the service 
provider to possible risk behaviours associated with STDs. Due to
the sensitive nature of the subject matter, the provider should
be careful to explain the reason for obtaining this information
and to assure the client of the confidentiality of his/her
responses.  
Did the service provider: 
13.  YES       NO Explain why taking a sexual history is useful
in identifying a condition? 
14.  YES       NO Assure the client that all responses will
remain confidential? 
15.  YES       NO Ask whether client is currently sexually
active? 
16.  YES       NO Ask whether client is active with more than one
partner? 
17.  YES       NO Ask about types of sexual practice? 
18.  YES       NO Ask whether condoms are used during sexual
activity? 
19.  YES       NO Ask client for questions or concerns regarding
his/her sexual activity? 
20.  YES       NO Take the sexual history in private? 
 
Physical examination 
This section can be used to assess how the physical examination 
is conducted given that proper equipment such as an examination
table, gloves, and speculum, may not be available. 
Did the service provider: 
21.  YES       NO If client felt feverish, take temperature? 
22.  YES       NO Weigh client? 
23.  YES       NO Examine oral cavity for signs of infection
e.g., thrush? 
24.  YES       NO Examine eyes (infant) for conjunctiva? 
25.  YES       NO Check for swollen glands in the neck, armpit,
or groin? 
26.  YES       NO For women, check for lower abdominal
pain/tenderness? 
27.  YES       NO For women, examine cervix, vagina, and labia? 
28.  YES       NO For men, examine penis base, and scrotum, and
retract foreskin? 
29.  YES       NO                        
Examine anus for ulcers or warts? 
30.  YES       NO Check for possible skin infection?  
31.  YES       NO Take the necessary precautions to minimise
exposure to blood and body fluids during the examination? 
 
 
Case identification/treatment/referral 
Guidelines for diagnosis, testing, treatment and referral 
of priority diseases or syndromes will need to be reviewed in
order to correctly identify and treat cases.  
 
With appropriate laboratory support: 
Did the service provider: 
32.  YES       NO            
Practise universal precautions before and after drawing 
a sample, e.g., blood, urethral/vaginal discharge? 
33.  YES       NO Draw the sample according to protocol? 
34.  YES       NO Take the recommended amount of specimen? 
35.  YES       NO Seal and label container of specimen? 
36.  YES       NO Compete record of transfer to laboratory? 
37.  YES       NO Transfer specimen to laboratory within
prescribed time limit? 
After testing is complete or in the absence of laboratory
support: When laboratory support is unavailable, the
identification of STD cases may be based on the client's
medical/sexual history and physical examination alone. > 
Did the service provider: 
38.  YES       NO Identify disease according to established
guidelines? 
39.  YES       NO Inform the client of the diagnosis? 
40.  YES       NO Administer/prescribe appropriate treatment
according to established treatment guidelines?  
41.  YES       NO Instruct client on treatment compliance and
when to return? 
42.  YES       NO Make the appropriate referral according to
established guidelines?  
43.  YES       NO Record the case according to established
guidelines? 
44.  YES       NO Ask for questions from the client? 
  
Counselling client on prevention of STD and HIV/AIDS 
Counselling the client about STDs is intended to prevent
behaviours that lead to infection and to provide support to those
who are infected or are caring for someone who is infected. This
section can be used if the medical/sexual history indicates that
the client may be at risk for STD. 
Did the service provider: 
45.  YES       NO Inform the client about the ways in which STDs
can be transmitted within that community? 
46.  YES       NO Discuss some basic ways to prevent sexual
transmission of STDs? 
47.  YES       NO Instruct the client on the correct and
consistent use of condoms?  
48.  YES       NO Teach client how to recognise some common
symptoms of STDs and understand the importance of getting correct
treatment? 
49.  YES       NO Explain that some STDs are not curable (HIV
infection; human papillomavirus)? 
50.  YES       NO Explain that behaviours that may lead to STD
also put client at risk of HIV infection? 
51.  YES       NO Provide the client with any available brochures
or handouts? 52.    YES       NO Use available educational
materials to instruct the client? 
53.  YES       NO Ask for questions from the client? 
  
Pre- and post- test counselling for HIV antibody testing or STD
laboratory testing This section is applicable only if laboratory
testing is indicated for the client and adequate laboratory
protocols and facilities are available. 
Did the service provider: 
54.  YES       NO Explain the testing procedure to the client? 
55.  YES       NO Assure the client of the confidentiality of
his/her test results? 
56.  YES       NO Discuss the meaning of a negative test result? 
57.  YES       NO Discuss the meaning of a positive test result? 
58.  YES       NO Discuss available treatment of conditions, if
any? 
59.  YES       NO Discuss the importance of notifying a partner? 
60.  YES       NO Discuss the possibility that the infected
client or partner may not yet have symptoms or show signs of
being infected? 61.      YES       NO Explain about some common
symptoms which may occur as a result of infection and should be
reported to the provider? 
 
For HIV-positive women:  
Did the service provider: 
62.  YES       NO Advise client of the risks to a foetus/infant? 
63.  YES       NO Give contraceptive advice or, if desired,
direct the client to family planning services? 
64.  YES       NO Suggest any prenatal or postnatal care that may
be needed?  
For mothers of HIV-infected newborns: 
Did the service provider: 
65.  YES       NO                      Explain that the child
could have many years of normal life? 
66.  YES       NO Encourage breast feeding and growth monitoring
of the child? 
67.  YES       NO Recommend complete immunizations except BCG if
the child shows clinical signs of HIV infection? 
 
Counselling client with diagnosed STD 
In this section, counselling is intended to provide support 
to clients whose laboratory testing, if available, and clinical
findings indicate STD infection. 
Did the service provider: 
68.  YES       NO Explain how the infection may have been
transmitted? 
69.  YES       NO Discuss available treatments, if any? 
70.  YES       NO Explain if the infection is curable, and if
not, the long term effects? 
71.  YES       NO Discuss complications, if any, of disease or
treatment? 
72.  YES       NO Discuss the possibility that infected partners
may not yet have symptoms or show signs of being infected? 
73.  YES       NO Explain the risk of reinfection if sex is
resumed with an untreated partner? 
74.  YES       NO Explain that STDs may increase the transmission
of HIV? 75.    YES       NO Counsel client in private? 
 
Interview with service provider  This section can be used to
assess a service provider depending on his/her level of training,
education, and skill in the delivery of STD-related services. A
response should be judged as correct if it is in agreement with
local guidelines and his/her level in these areas. 
Mark "yes" if the respondent answers correctly. 
76.  YES       NO What are some common examples of STDs?  
77.  YES       NO How are HIV infection and AIDS defined? 
78.  YES       NO How are they transmitted? 
79.  YES       NO What are some signs or symptoms of a sexually
transmitted disease? of HIV infection? of AIDS? 
80.  YES       NO What are some risk factors for STDs? 
81.  YES       NO What are some preventive measures against
infection? 
82.  YES       NO Which STDs may increase the transmission of
HIV? 
83.  YES       NO What treatments are available? 
84.  YES       NO What tests should be carried out if you suspect
infection? 
85.  YES       NO Who are the people at greatest risk of being
infected in your area?  
86.  YES       NO When and to whom should you refer cases for
further diagnoses, testing, or treatment?   
 
Exit interview of client with STD 
Mark "yes" if the client responds correctly 
87.  YES       NO What is your illness? 
88.  YES       NO How do you think you got it? 
89.  YES       NO How do you prevent giving what you have to
someone else and how do you prevent becoming infected again? 
90.  YES       NO What treatment/medicine did you receive or will
receive? 
 
91.  YES       NO How much and how often will you take it? 
92.  YES       NO When and where will you return for test
results, treatment, or follow-up? 
93.  YES       NO Were you asked to encourage your sexual partner
to come for an examination? 
94.  YES       NO Do you have questions or concerns that were not
addressed by the provider? 
 
Exit interview of client without STD 
Mark "yes" if the client responds correctly 
95.  YES       NO How are STDs transmitted in your community? 
96.  YES       NO How can you protect yourself from getting an
STD? 
97.  YES       NO How would you know if you got an STD? 
98.  YES       NO What would you do if you thought you had an
STD? 
99.  YES       NO Did you receive any educational brochures or
handouts? 
100. YES       NO Do you have questions or concerns that were not
addressed by the provider? 
 
 
PHC service quality checklist 
16: Malaria 

This checklist is intended for use in the observation  of service
delivery for malaria.  Before using it, the national treatment 
protocol should be reviewed in order to adapt the tool to the
local  situation if necessary.  It is also recommended that you
review the  checklist carefully before using it to be sure that
you understand  the questions and know how to use the form.  For
observation of service  delivery, mark "yes" if the service
provider carries out these activities  during service delivery. 
For interview questions, mark "yes" if the  respondent answers 
correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
 
Medical history 
Did the service provider: 
5.   YES       NO Ask about level of fever? 
6.   YES       NO Ask about pattern of fever? 
7.   YES       NO Ask about chills/sweats? 
8.   YES       NO Ask about headache? 
9.   YES       NO Ask about vomiting? 
10.  YES       NO Ask about convulsions? 
11.  YES       NO Ask about anti-malarial drugs taken in last 24
hours? 
12.  YES       NO Ask about other symptoms to rule out other
fever-related illnesses? Other symptoms that might indicate a
cause other than malaria are diarrhoea, cough, runny nose, sore
throat, ear pain, urinary symptoms (dysuria, frequency), and
joint pain or swelling.
Physical examination 
Did the service provider: 
13.  YES       NO                       
Take temperature? 
14.  YES       NO Examine neck for stiffness? 
15.  YES       NO Palpate abdomen/stomach? 
16.  YES       NO Ascultate lungs? 
17.  YES       NO Examine ears, nose, throat? 
18.  YES       NO Examine skin? 
19.  YES       NO Weigh patient? 
20.  YES       NO Make blood slide or refer case to a facility
where a blood slide may be examined? 
21.  YES       NO Examine blood slide? 
 
Treatment and Referral 
Did the service provider: 
22.  YES       NO Administer or prescribe appropriate
Anti-malarial drug according to local norms? 
23.  YES       NO Refer case of cerebral or other
serious/complicated or 
unresponsive malaria? 
24. YES        NO Refer for further diagnosis/treatment if other
serious fever-related illness is suspected? 
 
If fever is over 39 degrees centigrade: 
25.  YES       NO Administer anti-pyretic drug? 
26.  YES       NO Sponge or bathe with water? 
 
Malaria education and counselling 
Did the service provider: 
27.  YES       NO Tell how to administer anti-malarial drug?  
28.  YES       NO Provide drugs or verify that client has access
to drugs? 
29.  YES       NO Discuss the importance of completing entire
treatment course? 
30.  YES       NO Discuss danger signs that may indicate
unresponsive or complicated malaria? Danger signs include:
unconsciousness, severe drowsiness, fever continuing for more
than two days after initiation of treatment, relapse of fever
within three weeks. 
31.  YES       NO Tell client to return for consultation if
danger signs develop? 
32.  YES       NO Discuss prevention? Preventive measure include
chemoprophylaxis, the use of mosquito nets, household spraying,
and eliminating standing water. 
33.  YES       NO Verify that client understands key messages? 
34.  YES       NO Ask client if he or she has any questions? 
 
Outreach education (household visits or group sessions): 
 
Case identification and treatment: 
Did the service provider: 
35.  YES       NO Ask if anyone in the household has fever? 
36.  YES       NO Explain malaria signs and symptoms, especially
fever? 
37.  YES       NO Explain importance of immediate treatment of
malaria (fever) in the home? 
38.  YES       NO Explain which drug(s) should be used to treat
fever in the home? 
39.  YES       NO Explain recommended treatment schedule for
anti-malarial drugs? 
40.  YES       NO Explain where drugs can be obtained? 
41.  YES       NO Explain indications for seeking medical care?  
 
Prevention: 
Did the service provider: 
42.  YES       NO Explain the use of mosquito nets? 
43.  YES       NO Explain the use of household spraying? 
44.  YES       NO Tell where nets and sprays are available? 
45.  YES       NO Explain how to eliminate standing water? 
 
Chemoprophylaxis for pregnant women: 
Did the service provider: 
46.  YES       NO Explain which drug(s) can be used for malaria
prevention? 

47.  YES       NO Explain recommended anti-malarial drug
administration schedule for prevention? 
48.  YES       NO Discuss possible side effects?  
49.  YES       NO Explain when and where to go to obtain
chemoprophylaxis services? 
Supplies 
Ask the service provider about the following supplies: 
50.  YES       NO Do you have a thermometer? 
51.  YES       NO Do you have a stethoscope? 
52.  YES       NO Do you have a scale? 
53.  YES       NO Do you have a working microscope and slides? 
54.  YES       NO Do you have chloroquine? 
55.  YES       NO Do you have other anti-malarial drugs? 
 
PHC service quality checklist 
17: Tuberculosis 

This checklist is intended for use in the observation  of service
delivery tuberculosis.  Before using it, the national treatment 
protocol should be reviewed in order to adapt the tool to the
local  situation if necessary.  It is also recommended that you
review the  checklist carefully before using it to be sure that
you understand  the questions and know how to use the form.  For
observation of service  delivery, mark "yes" if the service
provider carries out these activities  during service delivery. 
For interview questions, mark "yes" if the  respondent answers
correctly.

1.  Health facility 
2.  Serviceprovider 
3.  Observer/supervisor 
4.  Date 
 
Medical History 
Did the service provider: 
5.   YES       NO Ask about persistent cough (2 weeks or more)? 
6.   YES       NO Ask about persistent fever (1 month or more)? 
7.   YES       NO Ask about weight loss? 
8.   YES       NO Ask about blood in sputum? 
9.   YES       NO Ask about persistent chest or back pain (1
month or more)? 
10.  YES       NO Ask if household members or neighbours have had
similar symptoms? 
  
Physical examination 
Did the service provider: 
11.  YES       NO Take temperature? 
12.  YES       NO Take respiratory rate? 
13.  YES       NO Take pulse? 
14.  YES       NO Weigh patient? 
15.  YES       NO Lymph node examination? 
16.  YES       NO Auscultate lungs? 
 
Treatment and referral 
Did the service provider: 
17.  YES       NO Perform cutaneous TB test (per local policy)? 
18.  YES       NO Tell the patient that he has (or may have ) TB?

19.  YES       NO Refer for sputum examination? 
20.  YES       NO Refer for chest X-ray? 
21.  YES       NO Prescribe medicines or refer for treatment
according to local norms? 
For follow-up cases 
Did the service provider: 
22.  YES       NO Correctly verify that client is taking
medicine? 
23.  YES       NO Assess client's progress? 
24.  YES       NO Ask about side effects or adverse reactions? 
25.  YES       NO If side effects are present: give advice about
managing side effects? 
26.  YES       NO Change treatment procedure if necessary? 
 
Health education 
Did the service provider: 
27.  YES       NO Explain where to go for examinations/lab tests?

28.  YES       NO Explain how much and how often to take
medicine? 
29.  YES       NO Stress the importance of completing the
treatment? 
30.  YES       NO Inform the patient if he or she is contagious? 
31.  YES       NO Discuss how to prevent spread of the disease? 
32.  YES       NO Discuss danger signs and adverse reactions that
require further care? 
33.  YES       NO Tell when to return for a follow-up visit? 
34.  YES       NO Discuss the importance of testing and treating
family members with similar symptoms? 
35.  YES       NO Verify that the patient understood key
messages? 
36.  YES       NO Ask if the patient has any questions? 
 
Supplies 
Ask the service provider if he or she has the following supplies:

37.  YES       NO Thermometer? 
38.  YES       NO Watch? 
39.  YES       NO Stethoscope? 
40.  YES       NO Scale? 
41.  YES       NO Cutaneous TB test? 
 
Interview with patient 
Mark "yes" if the respondent answers correctly: 
42.  YES       NO What is your illness? 
43.  YES       NO Did you receive medicine or a prescription? 
44.  YES       NO If prescription: do you know where you can get
the needed medicine? 
45.  YES       NO How much and how often will you take the
medicine? 
46.  YES       NO Did the health worker give you a sputum test or
arrange for you to have a sputum test? 
47.  YES       NO If test was arranged: Where will you go for the
test? 
48.  YES       NO What can you do to prevent the spread of the
disease? 
49.  YES       NO What are the danger signs that indicate that
you should come back to the health centre? 
50.  YES       NO When will you come back for test
results/follow-up?  
 
Interview with service provider 
Mark "yes" if the respondent answers correctly: 
51.  YES       NO What are the signs and symptoms of TB? 
52.  YES       NO What tests should be carried out if TB is
suspected? 
53.  YES       NO What medicines do you use to treat TB? 
54.  YES       NO How much and how often should that patient take
the medicines? 
55.  YES       NO What are the danger signs that indicate that
the patient requires further care? 
 
PHC service quality checklist 
18.  Treatment of minor ailments 

This checklist is intended for use in the observation  of
treatment of minor ailments.  Before using it, the local
treatment  protocol should be reviewed in order to adapt the tool
to the local  situation if necessary.  It is also recommended
that you review the  checklist carefully before using  it to be
sure that you understand  the questions and know how to use the
form.  For observation of service  delivery, mark "yes" if the
service provider carries out these activities  during service
delivery.  For interview questions, mark "yes" if the  respondent
answers correctly.

1.   Health facility 
2.   Serviceprovider 
3.   Observer/supervisor 
4.   Date 
 
Medical history 
Did the service provider: 
5.   YES       NO Ask about the chief complaint (fever, pain,
cough, etc)? 
6.   YES       NO Determine the present history of the illness? 
7.   YES       NO Determine condition-related past and family
history? 
 
Physical examination 
Did the service provider: 
8.   YES       NO Check vital signs (blood pressure, temperature,
pulse, respiration rate etc.) 
9.   YES       NO Conduct a related physical exam? 
 
Diagnosis 
Did the service provider: 
10.  YES       NO Make differential diagnosis (e.g., cough, TB,
pneumonia, bronchitis, abdominal pain, gastroenteritis, acute
cholestitis, appendicitis, etc.)? 
Laboratory diagnosis 
Did the service provider: 
11.  YES       NO Order condition- or preliminary
diagnosis-related diagnostic tests (laboratory tests, x-ray
studies, etc) 
 
Treatment and follow-up plans 
Did the service provider: 
13.  YES       NO Provide appropriate treatment according to the
condition? 
14.  YES       NO Provide information to the patient about the
condition and treatment plan? 
18.  YES       NO Discuss the importance of compliance with the
drug therapy? 
21.  YES       NO How often will you take this medicine? 
22.  YES       NO What is the dose you will take? 
23.  YES       NO For how long will you continue treatment? 

PHC service quality checklist 
19a:  Hypertension 

This checklist is intended for use in the observation  of service
delivery for hypertension.  Before using it, the national 
treatment protocol should be reviewed in order to adapt the tool
to  the local situation if necessary.  It is also recommended
that you  review the checklist carefully before using it to be
sure that you  understand the questions and know how to use the
form.  For observation  of service delivery, mark "yes" if the
service provider carries out  these activities during service
delivery.  For interview questions,  mark "yes" if the respondent
answers correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
  
Initial reading 
Did the service provider: 
5.   YES       NO Take a blood pressure reading? 
6.   YES       NO Make sure proper cuff size was utilised in
taking blood pressure? 
If diastolic blood pressure is 115 or more: Did provider ask 
patient about: 
7.   YES       NO Blurry vision? 
8.   YES       NO Severe headache that is getting worse? 
9.   YES       NO Change in mental status (sleepy, confused)? 
10.  YES       NO Seizure? 
 
If diastolic blood pressure is over 90: Did provider ask the 
patient about: 
11.  YES       NO Chest pain? 
12.  YES       NO Shortness of breath? 
 
Medical history 
Did the service provider: 
13.  YES       NO Ask about chief complaints? 
14.  YES       NO Ask about duration of hypertension? 
15.  YES       NO Ask about family history of hypertension? 
16.  YES       NO Ask about previous or current treatment and
response? 
17.  YES       NO Ask about history of diabetes, stroke? 
18.  YES       NO Ask about previous heart trouble, chest pain? 
19.  YES       NO Ask if patient has had excessive thirst? 
20.  YES       NO Ask about swelling, varicose veins and blood
clots? 
21.  YES       NO Ask about current lifestyle (work, stresses,
home conditions)? 
22.  YES       NO Ask about eating habits, smoking, alcohol and
drug consumption? 
23.  YES       NO Ask about previous serious illness? 
24.  YES       NO Ask about medications patient is taking now? 
 
Physical examination 
Did the service provider: 
25.  YES       NO Check vital signs? 
26.  YES       NO Check and record blood pressure in both arms? 
27.  YES       NO Check neck veins? 
28.  YES       NO Feel for thyroid? 
29.  YES       NO Listen to lungs? 
30.  YES       NO Listen to heart? 
31.  YES       NO Check for oedema in lower legs? 
32.  YES       NO Check for pulse in top of foot? 
33.  YES       NO Examine abdomen? 
34.  YES       NO Conduct urinalysis? 
 
Hypertension education and counselling 
Did the service provider: 
35.  YES       NO Explain hypertension? 
36.  YES       NO Explain the prognosis? 
37.  YES       NO Inform patient of blood pressure level? 
38.  YES       NO Explain lack of symptoms? 
39.  YES       NO Explain treatment goal? 
40.  YES       NO Provide patient with regimen sheet for
systematic antihypertensive 
therapy? 
41.  YES       NO Explain how to take medication? 
42.  YES       NO Discuss importance of taking medication daily? 
43.  YES       NO Discuss the possible side effects of
medication? 
44.  YES       NO Discuss possible warning signs of high blood
Pressure? 
45.  YES       NO Tell patient to return if warning signs appear?
46.  YES       NO Advise patient to restrict sodium and fat
intake? 
47.  YES       NO Advise patient to avoid nicotine? 
48.  YES       NO Advise patient to lose weight if overweight? 
49.  YES       NO Discuss the importance of following the
prescribed diet? 
50.  YES       NO Verify that patient understands key points? 
51.  YES       NO Ask if the patient has any questions? 
 
Supplies 
Does the service provider have the following supplies: 
52.  YES       NO A stethoscope? 
53.  YES       NO Blood pressure cuffs (different sizes)? 
54.  YES       NO Medications available to treat emergencies? 
55.  YES       NO Medications used in treatment of hypertension? 
 
Exit interview with client or caretaker 
Mark "yes" if the respondent answers correctly. 
56.  YES       NO Why is it important to have your blood pressure
checked at least once a year? 
57.  YES       NO Where can you have your blood pressure checked?
58.  YES       NO Where can you receive treatment? 
59.  YES       NO How should you take medication? 
60.  YES       NO Why is it important to follow treatment
instructions daily? 
61.  YES       NO How often should you have your blood pressure
checked? 
62.  YES       NO What danger signs indicate you should return to
clinic? 
63.  YES       NO What can you do to prevent hypertension? 
 
Interview with service provider 
Mark "yes" if the respondent answers correctly. 
64.  YES       NO What blood pressure measurement is considered
high blood pressure? 
65.  YES       NO When should patient be referred to a physician
for an emergency? 
66.  YES       NO At what point entreatment should a patient be
referred to a physician? 
67.  YES       NO What drugs should be prescribed for the
treatment of hypertension? 
68.  YES       NO What kind of diet should be prescribed for
hypertension? 
69.  YES       NO How can hypertension be prevented? 
 
PHC service quality checklist 
19b: Diabetes mellitus 

This checklist is intended for use in the observation  of service
delivery for diabetes mellitus.  Before using it, the national 
treatment protocol should be reviewed in order to adapt the tool
to  the local situation if necessary.  It is also recommended
that you  review the checklist carefully before using it to be
sure that you  understand the questions and know how to use the
form.  For observation  of service delivery, mark "yes" if the
service provider carries out  these activities during service
delivery.  For interview questions,  mark "yes" if the respondent
answers correctly.

Burgess, R., Community health aide/practitioner manual<MIU>,
55-58, Washington, DC, United States Department of Health and
Human Services, 1987. Hoole, 
A., Greenber, R., & Pickard, G., Patient care guidelines for
family nurse practitioners, p. 265-272, Boston, MA, Little Brown
and Company, 
1976. 

1. Health       
2. Service provider 
3. Observer/supervisor 
4. Date 
  
Medical history 
Did the service provider: 
5.   YES       NO Ask about early symptoms such as frequent
urination, unusual thirstiness (dry mouth), loss of appetite,
nausea, vomiting and weight loss? 
     YES       NO blurry vision that comes and goes? 
     YES       NO vaginal itching or yeast infections (if patient
is a woman)? 
     YES       NO gum swelling or soreness? 
     YES       NO chest pain, especially when exercising? 
     YES       NO symptoms of urinary tract infection, such as
pain or burning when urinating? 
     YES       NO foot problems such as a sore or injury that
does not heal, a change in the skin or toe nails, or numbness? 
     YES       NO numbness, tingling, weakness or pain in any
part of the body? 
     YES       NO other infections that don't clear up (skin,
gums, urine)? 
 
Physical examination 
Did the service provider: 
6.   YES       NO Check the patient's general appearance, vital
signs and weight? 
7.   YES       NO Check for fast, deep breathing, or acetone
breath? 
8.   YES       NO Check for signs of dehydration such as weight
loss and dry mouth? 
9.   YES       NO Observe mental changes (confusion, sleepiness,
unconsciousness)? 
10.  YES       NO Do Snellen test, if patient complains of change
in vision? 
11.  YES       NO Check gums for inflammation, tenderness,
redness, swelling? 
12.  YES       NO Check the general appearance of the feet, their
size and shape? 
13.  YES       NO Check for pitting oedema by pressing thumb over
shin bone? 
14.  YES       NO Check for strength of pulse in each foot (top
of foot)and behind medial ankle bone? 
15.  YES       NO Check for poor blood supply, if pulse in foot
is weak? 
16.  YES       NO Conduct lab tests for blood sugar and urine
dipstick for protein, glucose and ketones? 
 
Diabetes education and counselling 
Did the service provider: 
17.  YES       NO Discuss diet guidelines, such as avoidance of
sugars and fats, and eating more fibre? 
18.  YES       NO Discuss weight control and diet, if the patient
is overweight? 
19.  YES       NO Recommend regular exercise, after consultation
with doctor? 
20.  YES       NO Demonstrate how to do blood and urine tests? 
21.  YES       NO Discuss the importance of avoiding/stopping
smoking? 
22.  YES       NO Discuss how to teach the family about handling
common diabetic emergencies? 
23.  YES       NO Ask the patient to repeat key messages? 
24.  YES       NO Ask the patient if he/she has any questions? 
 
Foot Care: 
Did the service provider: 
25.  YES       NO Discuss the importance of proper foot care
(i.e. daily, gentle cleansing)? 
26.  YES       NO Discuss foot protection? 
27.  YES       NO Recommend not walking barefoot and wearing
proper fitting shoes? 
28.  YES       NO Discuss avoiding injury from heat or cold? 
29.  YES       NO                
Discuss cutting toe nails straight across with proper 
instruments, and not cutting calluses? 
30.  YES       NO Recommend wearing soft, dry socks without tight
elastic, 
and using foot powder to keep feet dry? 
 
Women of child bearing age: 
Did the service provider: 
31.  YES       NO Discuss the importance of maintaining  blood
sugar levels 
within a specified range before and during pregnancy to prevent
birth 
defects? 
32.  YES       NO Refer high risk pregnancies (per local policy)?

Exit interview with the patient 
Mark "yes" if the respondent answers correctly? 
33.  YES       NO Do you know what medications to take, and when?

34.  YES       NO Where will you get the needed medicine? 
35.  YES       NO How will you administer the drug (how much, how
often, 
for How long)? 
36.  YES       NO                    
What danger signs indicate that you should come back 
to the health facility? 
37.  YES       NO What will you do to care for your diabetes? 
 
Interview with service provider 
Mark "yes" if the respondent answers correctly. 
38.  YES       NO What are the signs and symptoms of diabetes
that require further medical attention? 
39.  YES       NO When should you refer a case for further
diagnosis? 
40.  YES       NO What measures can be taken to prevent or care
for diabetes? 
 
PHC service quality checklist 
19c:  Anaemia 

This checklist is intended for use in the observation  of service
delivery for anaemia.  Before using it, the national treatment 
protocol should be reviewed in order to adapt the tool to the
local  situation if necessary.  It is also recommended that you
review the  checklist carefully before using it to be sure that
you understand  the questions and know how to use the form.  For
observation of service  delivery, mark "yes" if the service
provider carries out these activities  during service delivery. 
For interview questions, mark "yes" if the  respondent answers
correctly.

1. Health facility 
2. Service provider 
3. Observer/supervisor 
4. Date 
  
Medical history 
Did the service provider: 
5. YES         NO Ask about chief complaints: whether pregnant? 
6. YES         NO Ask if there is any blood in stool? 
7. YES         NO Determine the occult blood in the stool? 
8. YES         NO Ask about menstrual history? 
9. YES         NO Ask whether vomit with blood? 
 
Physical examination 
Did the service provider: 
10.  YES       NO Take pulse and blood pressure? 
11.  YES       NO Check colour of conjuctiva? 
12.  YES       NO Check occult blood in stool? 
13.  YES       NO Ask about family anaemia history? 
14.  YES       NO Ask about previous or current treatment and
response? 
15.  YES       NO Give complete physical examination (chest,
abdomen, etc.)? 
 
Laboratory test 
Did the service provider: 
16.  YES       NO Get complete blood count with reticulocite
count? 
17.  YES       NO Get sedimentation rate? 
18.  YES       NO Determine haemoglobin type (region, race, age
or sex)? 
19.  YES       NO Determine iron binding capacity? 
20.  YES       NO Get full chemical analysis (calcium, potassium
etc., ) (optional)? 
 
Diagnosis treatment, nutrition education 
Did the service provider: 
21.  YES       NO Determine the aetiology of the anaemic
condition? 
22.  YES       NO Determine appropriate consultation (referral to
a specialist, if needed)? 
23.  YES       NO Provide appropriate treatment according to
condition? 
24.  YES       NO Provide nutrition counselling? 
 
Women of child bearing age 
Did the service provider: 
25.  YES       NO Discuss the importance of proper nutrition
(high in iron) 
and iron supplementation during pregnancy? 
26.  YES       NO Scheule a return/follow-up appointment after 46
weeks of treatment to evaluate treatment response? 
27.  YES       NO Provide a referral to a specialist if anaemia
is due to a malignant condition? 
 
Exit interview with client 
Mark "yes" if the respondent answers correctly: 
28.  YES       NO Do you know about what diet is good for you? 
29.  YES       NO Do you know how to administer the drug (how
much, how often and how long)? 
30.  YES       NO Do you know where you can get refills for the
drug? 
31.  YES       NO Do you know why you need to comply with the
drug/nutrition therapy? 
 
Interview with service provider 
Mark "yes" for correct answers: 
32.  YES       NO What are the  signs and symptoms of anaemia? 
33.  YES       NO Under what conditions should you refer a client
to a specialist? 
34.  YES       NO How can you care for anaemia? 
 
PHC MAP Service quality checklist 
20: Client satisfaction 
 
In addition to using service quality checklists to assess 
the clinical performance of providers, it is useful to assess
provider performance from the patient or client perspective. This
checklist will thus enable managers to 1) examine the degree to
which services and providers meet the expectations of the client,
and 2) identify opportunities to improve the quality of care
based on the client's perspective. 

The dimensions of client satisfaction
Client satisfaction consists of a number of dimensions,  each of
which should be addressed in a client satisfaction survey.  These 
dimensions include:
Accessibility of services:  Do clients feel they  can easily take
advantage of services?  How convenient are services  for clients?
Facilities, equipment and supplies:  Do clients  feel that the
health facility (hospital, clinic, health centre, outreach 
service), equipment and supplies are acceptable to them?
Availability of services:  Do clients believe that  the 
providers and services they need are available? 
Continuity of care:  Do clients feel that the same  level of care
is provided from visit to visit or from provider to provider? 
Interpersonal qualities of service provider:  Do  clients feel
that the provider possesses adequate interpersonal skills?
Professional competence:  Do clients feel that the  provider's
technical skills and knowledge are adequate?
Cost:    Are clients satisfied with the cost of  the service?
Resulting health status/Efficacy of treatment: Are  clients
satisfied with their health outcome after service is provided  to
them?

How to use the checklist 
This checklist can be used: 
as part of an exit interview at the health facility, as a guide
for discussion in a focus group setting, as part of a
comprehensive household interview survey, or as a questionnaire
distributed to clients. This checklist is designed to be used as
a client interview at the time of the clinic encounter. Depending
on how you choose to use the instrument, the wording and tense of
questions can be changed to reflect the client's experience
during the last clinic visit, or to assess a more general level
of satisfaction with services regardless of what visit.  When
modifying the checklist consider all the dimensions and adapt, or
add questions  or delete those you feel are not relevant for your
situation.  
A pre-test of the checklist may allow you to identify the issues
of concern for the facility. In a pre-test, you should be able to
identify the major issues which clients believe should be
addressed and then modify the instrument to collect that
information. 
You may also wish to change the order in which the questions are
asked. One way is to structure questions so that they follow the
flow of activities in the health facility, e.g., registration,
examination by the provider, referral, etc.  However you modify
the instrument, keep in mind that questions should be organised
to facilitate response by the client, not just to make it easier
for the interviewer. 
You may find that a YES/NO format limits the range of responses
to a given question, in which case a rating scale may be
substituted.  Some of the more common ones include a five-point
response scale ranging from "excellent" to "poor," or a six-point
scale ranging from "very satisfied" to "very dissatisfied." 

1 Ware, J. E. & Hays, R. "Methods for measuring patient
satisfaction with specific medical encounters." Medical Care
1988;26:393-402. 
2 Osterweis, M. & Howell, J. "Administering patient satisfaction
questionnaires at diverse ambulatory care sites." Journal of
Ambulatory Care Management 1979;67-88.

You may also wish to substitute any other scale that you feel
clients would more easily recognise and understand.  Throughout
the checklists, the term "health facility" has been used.  This
term can be replaced with other, more specific terms such as
hospital, clinic, outreach centre or any other facility.  Also
"provider" can be substituted with the terms doctor, nurse,
midwife, community health worker or any other local provider.
Finally, this checklist can be made more specific to assess the
quality of a specific clinic encounter or to evaluate certain
providers or services.  However, be careful not to
over-generalise.  Do not assume that dissatisfaction within one
dimension or with one service or provider will reflect
dissatisfaction in other areas.  
 
Client satisfaction checklist 

If you wish to assess whether socio-economic factors  such as
clients' background, education levels, etc., are affecting  their
satisfaction, you could begin by asking questions similar to  the
ones below. Otherwise, proceed to the next page.

Health facility/location                           
Supervisor/observer                               
Date of interview                                   

1.   Age of client?            years Sex(M/F)               
2.   a.  What is the last year of school completed? (modify 
according to local education system)
     b. What is the last year of school completed by your spouse?
3.   What is the main source of drinking water for your
household? (check one) 
        Piped water               Surface water
(spring/river/lake, etc.) 
4.   Does your household have: 
Electricity     YES     NO    
Radio            YES     NO    
Television        YES     NO    
5.   What is the main material of the floor of your home? 
(check one) 
         Earth/sand               Finished surface
(wood/cement/tile) 
         Wood planks/palm/bamboo       Other                     

6.   Does any member of your family own 
Bicycle   YES    NO   Donkey, horse, 
camel     YES    NO  
Motorbike YES    NO    Other          YES    NO         
Car       YES    NO  
 
7.   What is the main economic activity of your household? 
(check one) 
    Agriculture                   Manufacturing 
    Fishing                       Other                    
    Trading/marketing 
8.   Where is the principle place you receive health care? 
(check one) 
    Public hospital               Private hospital/clinic 
    Public health centre/clinic             Local TBA/healer 
9.   Ask a country/region-specific question on type of religion. 
10.  Ask a country/region-specific question on ethnicity, 
if applicable. 
11.  Ask any additional questions you feel are appropriate. 
Please circle a response or fill in blanks where indicated  for
each question. (Y = Yes, N = No, DK = Don't Know, NA = Not
Applicable)

1. Did you feel that the schedule (clinic hours) at the 
health facility was adequate for your needs?   
Y     N     DK     NA 
2. Were you able to get to the health facility easily? 
Y     N     DK     NA 
a.   How long (minutes/hours) does it normally take you to get 
to the health facility? 
b.  By what means do you normally get to the health facility, 
e.g., walking, motorcyle, etc.?                                   
       _________ 
4. After arriving at the clinic, did you feel that the time 
spent waiting to be seen by a provider was reasonable?      
Y     N     DK     NA 
a.  About how long (no. of minutes/hours) did you have to wait?   
   _________ 
 
5. For follow-up or referral visits, did you feel that you 
were able to see a provider within a reasonable period of time?  
Y    N     DK    NA 

a.   About how long (no. of days) did you have to wait?           
           _________ 
                                    
6. Do you feel that the provider spent enough time with 
you during the visit?     
Y    N     DK     NA 
 
Facilities, equipment, and supplies 
Were you satisfied with: 
7. The overall cleanliness and comfort of the waiting area? 
Y    N     DK     NA 

8. The overall cleanliness and comfort of the examination 
room or place where you received service?    
Y     N     DK     NA 

9. The condition of any instruments or equipment used by 
the provider to treat or examine you?   
Y     N     DK     NA 

Availability of services 
10. Were all the services you needed to treat your problem 
available at the health facility during your visit?    
Y     N     DK     NA 
a. If not, please list any services which are not available at 
the health facility but are important to meet your needs.         
                                       __________ 
Continuity of care 
11. Did you see the same provider during this visit as on 
the last visit?     Y     N     DK     NA 

12. Were the same services available during this visit as 
on your last visit? Y     N     DK     NA 
 
Interpersonal qualities of service provider   
13. Were you treated with courtesy and respect by the provider 
during your visit?   
Y     N     DK     NA 
14. Did the provider allow you to ask questions?  
Y     N     DK     NA 
 
Professional competence and skill of the service provider 
15. Were you satisfied overall with the services you received 
from the provider? 
Y     N     DK     NA 
a.   If not, what are some reasons why?                           
               ___________ 
16. Did you feel comfortable discussing your problem with 
the provider?  Y     N     DK     NA 
 
17. Were you satisfied with the provider's skills and ability 
in treating your problem?       
Y     N     DK     NA 
18. Were you satisfied with the completeness of the information 
given to you about your problem?    
a. Were you given any information which you did not
understand?    Y     N     DK     NA 
 
       If "Yes," what information did you not understand?         
              ___________ 
 
 
Cost 
19. Did you feel that the cost for services you received 
at the health facility was reasonable? 
Y     N     DK     NA 
Satisfaction with resulting health status/Efficacy of treatment 
20. Do you feel that services you received at the health 
centre were effective in solving your problem?    
Y     N     DK     NA 
 
Other 
21. Were you satisfied with the measures taken to assure 
privacy during your examination e.g., a private room, curtained
or screened area, etc.?  Y     N     DK     NA 
22. Were you satisfied with the measures taken to assure 
confidentiality about your health problem?   
Y     N     DK     NA 
23. Would you recommend the services at this health facility 
to someone else?     
Y    N     DK     NA 
24. What do you think should be done to improve the quality 
of the services in this health facility?                          
                                                           
___________ 
References 
1. Dovlo, D., et al. What does the public want from 
us? A study of user satisfaction with services in government
health facilities in the eastern region, Ghana. April, 1992. 
2. Ware, J. E. & Hays, R. "Methods for measuring patient 
satisfaction with specific medical encounters." Medical Care
1988;26:393-402. 
3. Osterweis, M. & Howell, J. "Administering patient 
satisfaction questionnaires at diverse ambulatory care sites."
Journal of Ambulatory Care Management 1979;67-88.
Appendix C: Service quality assessment
Discussion guidelines  

OTHER HEALTH CARE   
Water supply, hygiene and
   sanitation
School health
Childhood disabilities 
Accidents and injuries 
Sexually transmitted diseases

HIV/AIDS
Malaria
Tuberculosis
Treatment of minor ailments
Chronic, non-communicable
  diseases

GENERAL        
PHC household visits          
Health education              
MATERNAL CARE       
Antenatal care      
Safe delivery       
Postnatal care      
Family planning                    

CHILD CARE     
Breast feeding      
Growth monitoring   
Nutrition education 
Immunization        
Acute respiratory infection   
Diarrhoeal disease control     
Oral rehydration therapy


PHC service quality assessment
Discussion guidelines: 1.  PHC household visit 

Introduction: Welcome the group and briefly give the purpose of
the discussion 
Ground rules: Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.

These discussion guidelines are provided to help you to lead a
group discussion about the quality of  services provided during a
household visit.  You may also refer to the detailed version of
the PHC service quality checklists, Appendix B, as a resource for
the discussion. 
 
Discussion 
What works well in the way we provide services during a household
visit? 
 
Guidelines  
What does not work well in the way we provide services during a
household visit? 
What standards, guidelines or protocols are used for providing
services during a household visit? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information is registered on family health cards or other
records during a household visit? 
What information do you ask from clients who have malnourished
children? 
What information do you ask from clients who have children with
diarrhoea? 
What information do you ask from clients who are pregnant? 
What information do you ask from all households you visit? 
 
Key questions 
Do service providers register all children under five on a health
card? 
Do service providers register  all women over 16 on a family
health card? 
Do service providers make arrangements for vaccination of
children requiring immunization? 
Are nutritional counselling, food supplementation and/or medical
attention being received? 
Has ORS solution been recommended to the client and is help in
preparing to administer it available? 
Has the client received prenatal care ?  
If necessary, has a prenatal visit been arranged? 
Are interested women or couples referred for family planning
services ? 
Has water, hygiene and sanitation been discussed? 
Has a good rapport been established with the mother? 
 
PHC service quality assessment
Discussion guidelines: 2.  Health education 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules: Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.

These discussion guidelines are provided to help you 
to lead a group discussion about the quality of your health
education services.  You may also refer to the detailed version
of the PHC service quality checklists, Appendix B, as a resource
for the discussion. 
 
Discussion 
What works well in the way we provide health education? 
 
Guidelines 
What does not work well in the way we provide health education? 
What standards, guidelines or protocols are used for providing
health education? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their
educational background? 
What techniques do you use when presenting and discussing health
topics? 
What educational materials do you use? 
What key messages related to your health topic do you emphasise
to clients during health education sessions? 
 
Key questions 
Are participants' knowledge, attitudes, and practices of health
education determined? 
Is participants' general level of knowledge determined? 
Do service providers explain the topic and focus the discussion? 
Are all relevant aspects of the topic discussed? 
Are appropriate discussion techniques used to encourage active
participation? 
Do service providers use appropriate educational materials during
the presentation? 
Are any available educational materials distributed? 
 
PHC service quality assessment
Discussion guidelines: 3.  Antenatal care 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your antenatal services. 
You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion.

 
Discussion  
What works well in the way we provide antenatal services? 

Guidelines  
What aspects do not work well in the way we provide antenatal
services? 
What standards, guidelines or protocols are used for providing
antenatal services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you review on the clinic record during the
antenatal visit? 
What do you ask  your clients about their reproductive history? 
What  do you ask your clients about risk factors associated with
their current pregnancy?  
What do you ask your clients about preventive actions taken? 
What activities do you carry out during a physical exam? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Are obstetric  records or family health cards reviewed and
updated? 
Are at least two questions about reproductive history risk
factors asked? 
Are at least two questions about risk factors associated with
this pregnancy asked? 
Is at least one physical exam activity performed? 
Are clients immunized against tetanus or have arrangements for
immunization  been made? 
Are clients referred for blood test, glucose,
haemoglobin/haematocrit and malaria, if medically indicated? 
Do service providers discuss with clients the importance of
having the delivery attended by a trained health worker? 
Do service providers explain the danger signs which require
immediate attention? 
Do service providers tell pregnant  woman when and where to go
for next antenatal visit? 
 
PHC service quality assessment
Discussion guidelines: 4.  Safe delivery 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group:

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time. 

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your safe delivery
services.  You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the
discussion. 
 
Discussion 
What works well in the way we provide safe delivery services? 
 
Guidelines  
What aspects do not work well in the way we provide safe delivery
services? 
What standards, guidelines or protocols are used for providing
safe delivery services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What activities do you perform before the labour begins? 
What information do you review with your clients or ask from your
clients before labour begins? 
What activities do you perform during the progress of labour and
delivery? 
For what reasons might you seek help during the progress of
labour and delivery? 
What activities do you perform immediately after birth? 
What messages do you emphasise when educating or counselling your
clients after birth? 
 
Key questions 
Do service providers sterilise needles, syringes, cord ties,
scissors/razor blades before the birth? 
Is a clean birthing place prepared? 
Do service providers take labour history? 
If necessary, is the reproductive history for high-risk factors
reviewed? 
Is  the woman monitored throughout labour and is a physical exam
conducted? 
Is  the progress of labour assisted? 
Is the delivery assisted? 
Is help sought for obstetric problems and emergencies? 
Do service providers tie the umbilical cord with thread in three
places and cut with blade/scissors? 
Do service providers determine APGAR score at one minute and five
minutes after birth? 
 
PHC service quality assessment
Discussion guidelines: 5.  Postnatal care 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time. 

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your postnatal services. 
You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion. 


Discussion  
What works well in the way we provide postnatal services? 
 
Guidelines     
What does not work well in the way we provide postnatal services?

What standards, guidelines or protocols are used for providing
postnatal services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you review on the clinic record during the
antenatal visit? 
What do you ask your clients about their medical history? 
What activities do you carry out during a physical exam? 
What treatment or routine preventive services do you provide? 
 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Did the service provider ask the client at least two medical
history questions? 
Was the client examined? 
Were findings of history and physical examinations recorded on
the clients health record? 
Did the service provider refer the client for special treatment
if necessary? 
Was the infant referred for all physical conditions requiring
medical attention? 
Was a BCG given or verification received that the child received
vaccination at birth? 
Did the service provider give first DPT and OPV? 
Was the client told to feed the infant with breast milk only, for
the first 4-6 months? 
Was family planning and how to obtain its services discussed with
the client? 
Are clients encouraged to enrol their child in the well-child
clinic? 
 
PHC service quality assessment
Discussion guidelines: 6.  Family planning 
 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your family planning
services.  You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the
discussion. 
 
Discussion 
 What works well in the way we provide family planning services? 
 
Guidelines 
 What does not work well in the way we provide family planning
services? 
What standards, guidelines or protocols are used for providing
family planning services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What do you ask from your clients about their medical and
reproductive history? 
What activities do you carry out during a physical exam? 
What do you ask from your clients in order to determine which
method to recommend? 
What messages do you emphasise to all clients when educating or
counselling them? 
What information do you ask from clients during follow-up visits?

 
Key questions 
Are clients asked at least three medical and reproductive history
questions? 
Did the service provider take the clients blood pressure? 
Are clients breast examined for lumps? 
Did the service provider examine the patient for signs of
anaemia? 
Did the service provider recommend to the client a method that
was free of contraindications? 
Are side effects discussed? 
Is the client asked about use of the contraceptive received? 
Was the client asked about the possible side effects? 
 
PHC service quality assessment
Discussion guidelines: 7.  Breast feeding 
 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.   

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your breast feeding
activities. You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the
discussion. 
 
Discussion 
 What works well in the way we perform our breast feeding
activities? 
 
Guidelines     
 What does not work well in the way we perform our breast feeding
activities? 
What standards, guidelines or protocols are used for carrying out
breast feeding activities? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What messages do you emphasise when educating or counselling your
clients on breast feeding practices? 
What messages do you emphasise when educating or counselling your
clients on weaning practices? 
What additional messages do you emphasise when educating or
counselling your clients on nutrition?  
Key questions 
Do service providers ask about the mother's knowledge and
practice concerning breast feeding? Are mothers instructed on the
health benefits to mother and child of breast feeding? 
Do service providers recommend how long to breast feed and
encourage continued breast feeding during illness? 
Is the client instructed on the method of breast feeding? 
Are warning signs that indicate the mother should seek help
explained? 
Do service providers provide counselling, as appropriate, on
family planning methods and contraceptive benefits of breast
feeding? 
Is appropriate counselling provided on diet during lactation,
nutrition supplements, and important locally available foods? 
Is the client advised on weaning practices and food preparation? 
 
PHC service quality assessment
Discussion guidelines: 8. Growth monitoring/nutrition education 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.   

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your growth monitoring 
services.  You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the
discussion. 
 
Discussion     
 
What works well in the way we provide growth monitoring services?

 
Guidelines     
 
What aspects do not work well in the way we provide growth
monitoring services? 
What standards, guidelines or protocols are used for providing
growth monitoring services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What growth monitoring activities do you perform? How do you
determine the child's age? 
What do you do to prepare the child for weighing? 
What information do you record?  
What information do you ask from your clients about the child's
growth and nutrition? 
What are some reasons you would refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients on growth monitoring and nutrition? 
 
Key questions 
Was the clients age calculated correctly? 
Is the child weighed correctly? 
Is the child's weight plotted correctly? 
Are clients referred for nutritional counselling? 
Is at least 1 appropriate recommendation about child feeding and
care made? 
Are clients asked if their child gained weight, lost, or stayed
the same since the last weighing? 
Do service providers have a working scale? 
Do service providers have a method of tracking malnourished
children? 
 
PHC service quality assessment
Discussion guidelines: 9. Immunization 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.   

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your immunization services. 
You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion. 
Discussion 
 What works well in the way we provide immunization services? 
 
Guidelines     
 What aspects do not work well in the way we provide immunization
services? 
What standards, guidelines or protocols are used for providing
immunization services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you review on the clinic record and/or ask
from your clients during the immunization visit? 
What activities do you perform during an immunization visit? 
What is your technique for providing vaccinations? 
What sterilisation procedures do you follow? 
How are supplies stored and how is the cold chain maintained, for
clinic and outreach services? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Is a sterile needle used for each injection? 
Is a sterile syringe used for each injection? 
Do service providers give the child all vaccinations needed
today? 
Are vaccinations recorded on the child's health card? 
During the last month was the registered temperature between zero
and eight degrees (C) at all times? 
Are vaccines transported in cold boxes with ice packs? 
Is the return for the next immunization discussed with the
client? 
 
PHC service quality assessment
Discussion guidelines: 10.  Acute respiratory infection 
 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your services for 
acute respiratory infection.  You may also refer to the detailed
version of the PHC service quality checklists, Appendix B, as a
resource for the discussion. 
 
Discussion     
 What works well in the way we provide ARI services? 
 
Guidelines     
 What does not work well in the way we provide ARI services? 
What standards, guidelines or protocols are used for providing
ARI services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
What treatments do you prescribe for what types of ARI? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Are at least two medical history questions asked? 
Do service providers ask about any treatment administered? 
Is the respiratory rate counted? 
Is the child classified by severity of illness? 
Are antibiotics for pneumonia, strep throat or otitis given? 
Do service providers refrain from using antibiotics for colds? 
Are clients told about at  least three signs of pneumonia?1 
If antibiotics are prescribed, is the client asked, "How will you
administer the medicine; how much, how often, for how long?" 
 
PHC service quality assessment
Discussion guidelines: 11.  Diarrhoeal disease control/oral
rehydration therapy 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your services for
diarrhoeal disease control/ORT services.  You may also refer to
the detailed version of the PHC service quality checklists,
Appendix B, as a resource for the discussion. 
 
Discussion 
 What works well in the way we provide diarrhoeal disease
control/ORT services?  
 
Guidelines 
What aspects do not work well in the way we provide diarrhoeal
disease control/ORT services? 
What standards, guidelines or protocols are used for providing
diarrhoeal disease control/ORT services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
What treatments do you prescribe and when would you normally
prescribe them? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Are at least two medical history questions asked? 
Are at least two physical exam activities performed? 
Was the degree of dehydration determined (none, moderate,
severe)? 
Is safe ORS prescribed? 
Do service providers refrain from using antibiotics, except when
stools contain blood or mucus? 
Do service providers administer ORS solution immediately or refer
the client to a nearby centre, if the child is dehydrated? 
Are clients informed how much ORS solution to give and how often
to give it? 
Are clients shown how to prepare ORS solution? PHC service
quality assessment
<%-2>Discussion guidelines: 12.  Water supply, hygiene and
sanitation<M%0> 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your services related to
water supply, hygiene and sanitation. You may also refer to the
detailed version of the PHC service quality checklists, Appendix
B, as a resource for the discussion. 
 
Discussion     
 What works well in the way we provide services related to water
supply, hygiene and sanitation? 
 
Guidelines     
What aspects do not work well in the way we provide services
related to water supply, hygiene and sanitation? 
What standards, guidelines or protocols are used for providing
services related to water supply, hygiene and sanitation? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What messages do you emphasise when educating or counselling your
clients about contaminated water and disease? 
What messages do you emphasise when educating or counselling your
clients about water storage and use? 
What messages do you emphasise when educating or counselling your
clients about latrine maintenance and use? 
What messages do you emphasise when educating or counselling your
clients about refuse and animal excreta disposal? 
 
Key questions 
Is keeping water in a clean, covered container discussed? 
Is the importance of hand washing before eating, feeding
children, and food preparation discussed? 
Do service providers discuss appropriate latrine use and human
waste disposal, e.g. baby potty for children under three? 
Is burning or burying refuse recommended? 
Do service providers recommend penning animals away from the
house? 
Is the importance of washing hands discussed with the client? 
PHC service quality assessment 
Discussion guidelines: 13.  Childhood disabilities 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your services for 
childhood disabilities.  You may also refer to the detailed
version of the PHC service quality checklists, Appendix B, as a
resource for the discussion. 
 
Discussion     
What works well in the way we provide services for childhood
disabilities?  
 
Guidelines  
What does not work well in the way we provide services for
childhood disabilities? 
What standards, guidelines or protocols are used for providing
services for childhood disabilities? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their child's
medical history? 
What activities do you carry out during a physical exam? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients on childhood disabilities? 
 
Key questions 
Are clients asked about the prenatal and antenatal care of the
child? 
Do service providers ask the client whether the child's speech,
development, mobility, strength, sight, hearing, behaviour is in
any way different from normal? 
Is an examination conducted for the presence of any deformities
or defects? 
Is appropriate treatment or therapy administered/prescribed
according to established treatment guidelines? 
Do service providers discuss available medicine or treatment, if
any? 
If applicable, is the possible risk of having another child
discussed, if more than one child is known to have been born with
a genetic condition? 
Do service providers discuss what parents and families can do to
help the disabled child? 
Is the client questioned about their child's disability? 
If applicable, is the client questioned about their knowledge of
how to prevent a similar disability form happening again? 
Is the client aware of where to go for treatment or follow-up? 
Is the client questioned about the treatment they received? 
PHC service quality assessment
Discussion guidelines: 14.   Accidents and injuries 
 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your services for accidents
and injuries.  You may also refer to the detailed version of the
PHC service quality checklists, Appendix B, as a resource for the
discussion. 
 
Discussion     
What works well in the way we provide services for accidents and
injuries? 
 
Guidelines     
What does not work well in the way we provide services for
accidents and injuries? 
What standards, guidelines or protocols are used for providing
services for accidents and injuries? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients on injury prevention? 
 
Key questions 
Is the type of injury correctly identified? 
Do service providers obtain a history of the injury, e.g. cause,
time, etc.? 
Is proper treatment administered according to established
guidelines? 
Is appropriate referral made according to established guidelines?

Do service providers discuss some common injuries and how they
may be prevented? 
Is child safety in and around the home discussed? 
Are occupational safety issues discussed? 
Do service providers explain how to recognise an emergency and
where to go for help? 
 
PHC service quality assessment
<B%-5>Discussion guidelines: 15.  Sexually transmitted diseases
and 
HIV/AIDS<M%0> 
 Introduction: Welcome the group and briefly give 
the purpose of the discussion. 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your STD-related services. 
You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion.

 
Discussion    
What works well in the way we provide STD services? 
 
Guidelines     
What does not work well in the way we provide STD services? 
What standards, guidelines or protocols are used for providing
STD services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What information do you ask from your clients about their sexual
history? 
What activities do you carry out during a physical exam? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling
clients on prevention of STD? 
What messages do you emphasise when educating or counselling
clients on laboratory testing? 
What messages do you emphasise when educating or counselling
clients with diagnosed STD? 
 
Key questions 
Are at least two symptoms of infection asked? 
Do service providers ask about current sexual practices? 
Is a complete physical examination as required for male, female
or infant conducted? 
Is the illness correctly identified and appropriate treatment
prescribed? 
Do service providers discuss some basic ways to prevent sexual
transmission of STDs? 
Is the client assured of confidentiality of test results? 
Is the importance of notifying a partner discussed? 
Do service providers explain the risk to a foetus/infant 
and the avoidance of pregnancy through the use of appropriate
contraception? 
Do service providers suggest any prenatal or postnatal care, if
any, that is needed? 
Are the risks of re-infection and/or transmission explained if
sex is resumed with an untreated partner? 
Is the client asked about their illness? 
Are clients asked about their knowledge on how to prevent giving
it to someone else and how to prevent becoming infected again? 
Is the client aware of when and where to return for test results,
treatment, or follow-up? 
 
PHC service quality assessment
Discussion guidelines: 16.  Malaria 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your malaria services.  You
may also refer to the detailed version of the PHC service quality
checklists, Appendix B, as a resource for the discussion. 
 
Discussion     
What works well in the way we provide malaria services? 
 
Guidelines     
What does not work well in the way we provide malaria services? 
What standards, guidelines or protocols are used for providing
malaria services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
What treatments do you prescribe for malaria? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Are at least two medical history questions asked? 
Do service providers ask about anti-malarial drugs taken in the
last 24 hours? 
Do service providers ask about other symptoms to rule out other
fever-related illnesses? 
Is the clients temperature taken? 
Is a blood slide made or the client referred to a facility where
a blood slide may be examined? 
Are appropriate anti-malarial drugs administered or prescribed
according to local norms? 
Do service providers administer antipyretic drug and sponge or
bathe the client with water if fever is over 39 degrees C. 
Do service providers discuss danger signs that may indicate
unresponsive or complicated malaria? 
Are clients told to return for consultation if danger signs
develop? 
Is the client questioned about the prescribed medicine, e.g. how
will you take the medicine (how much, how often, and for how
long)? 
 
PHC service quality assessment
Discussion guidelines: 17.  Tuberculosis 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your tuberculosis services. 
You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion.

 
Discussion    
What works well in the way we provide tuberculosis services? 
 
Guidelines     
What does not work well in the way we provide tuberculosis
services? 
What standards, guidelines or protocols are used for providing
tuberculosis services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
What treatments do you prescribe for tuberculosis? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Are clients questioned about persistent coughs; two weeks or
more? 
Are clients questioned about persistent fever; one 
month or more? 
Do service providers ask clients about weight loss? 
Do service providers ask clients about blood in sputum? 
Is cutaneous TB test performed? 
Is client referred for sputum examination? 
Do service providers prescribe medicines or refer for treatment
according to local norms? 
Is verification made that follow-up cases have taken medicine
correctly? 
Do service providers explain how much and how often to take
medicine? 
Is the importance of completing the treatment stressed? 
Is the client questioned about prescribed drugs, e.g., how will
they take their medicine (how much, how often, and for how long)?

Is the client questioned about the need for further testing,
e.g., where will they go for the test? 
 
PHC service quality assessment
Discussion guidelines: 18. Treatment of minor ailments 
 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules: Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time.  

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your treatment of minor
ailment services.  You may also refer to the detailed version of
the PHC service quality checklists, Appendix B, as a resource for
the discussion. 
 
Discussion     
What works well in the way we provide treatment of minor ailment
services? 
 
Guidelines     
What does not work well in the way we provide for treatment of
minor ailments? 
What standards, guidelines or protocols are used for providing
services for the treatment of minor ailments? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What activities do you perform for the treatment of minor
ailments? 
What messages do you emphasise when educating or counselling your
clients? 
 
Key questions 
Do you ask patients about their chief complaint? 
Do you determine medical history and past drug allergies? 
How do you check vital signs? 
How do you conduct a related physical exam? 
How do you make an appropriate diagnosis? 
How do you schedule diagnostic testing? 
Do you provide appropriate treatment and discuss compliance with
drug therapy? 
Do you provide information to the patient about the condition and
treatment plan? 
Do you explain to the patient how often to take this medicine? 
Do you explain what dose to take? 
Do you tell the patient how long to continue treatment? 
 
PHC service quality assessment
Discussion guidelines: 19a.  Hypertension 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time. 

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your hypertension 
services.  You may also refer to the detailed version of the PHC
service quality checklists, Appendix B, as a resource for the
discussion. 
 
Discussion     
What works well in the way we provide hypertension services? 
 
Guidelines     
What does not work well in the way we provide hypertension
services? 
What standards, guidelines or protocols are used for providing
hypertension services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients on hypertension? 
 Key questions 
Is a proper blood pressure reading taken? 
Do service providers ask about chief complaints, e.g. blurred
vision, severe headache, shortness of breath, chest pain? 
Do service providers ask about prior/current experience and
treatments for hypertension? 
Do service providers ask about family history of hypertension? 
Do service providers ask about history of diabetes or stroke? 
Do service providers ask about current lifestyle, e.g. work,
stresses, home conditions? 
Do service providers ask about previous illness or treatment? 
Is a physical exam performed, which includes a check of vital
signs, blood pressure, heart, pulse in foot, neck veins or other
as per local policy? 
Are patients provided with health education/counselling on
hypertension? 
Are patients instructed on the use of any prescribed medication? 
Are patients informed of the warning signs indicating when to
return to the clinic? 
 
PHC service quality assessment
Discussion guidelines: 19b. Diabetes mellitus 
 
Introduction:  Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time. 

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your diabetes services. 
You may also refer to the detailed version of the PHC service
quality checklists, Appendix B, as a resource for the discussion.

 
Discussion     
What works well in the way we provide diabetes services? 
 
Guidelines     
What does not work well in the way we provide diabetes services? 
What standards, guidelines or protocols are used for providing
diabetes services? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from your clients about their medical
history? 
What activities do you carry out during a physical exam? 
For what reasons would you refer a client to another service
provider? 
What messages do you emphasise when educating or counselling your
clients on treatment of diabetes? 
What messages do you emphasise to women of child bearing age when
providing education or counselling on diabetes? 
 
Key questions 
Do service providers ask about symptoms, e.g. blurred vision,
unusual thirst, urinary tract infection, yeast infection if a
woman, foot problems, numbness, recurrent infection? 
Is a physical exam performed, including a check of vital signs,
general appearance,  and pulse in feet, fast breathing, signs of
dehydration, or others as per local policy? 
Are lab tests (e.g.,sugar, urine) conducted, as appropriate? 
Are patients provided with health education/counselling on
appropriate diet and exercise? 
Do service providers instruct family members how to handle common
diabetic emergencies? 
Is the patient educated in proper foot care and protection? 
Is the importance of maintaining blood sugar levels within a
specified range before and during pregnancy to prevent birth
defects discussed with women of child bearing age? 
Are high-risk pregnancies referred as per local policy? 
 
PHC service quality assessment
Discussion guidelines: 19c. Anaemia 
 
Introduction: Welcome the group and briefly give the purpose of
the discussion. 
Ground rules:  Explain the following ground rules to the group: 

Ground rules for group discussion
Everyone's ideas and opinions are important. 
There are no right or wrong answers.
Both positive and negative comments are welcome. 
Participants should feel free to disagree with one another so all
points of view are heard.
Don't wait to be called on; it's a group discussion. 
Please speak one at a time. 

These discussion guidelines are provided to help you to lead a
group discussion about the quality of your anaemia services.  You
may also refer to the detailed version of the PHC service quality
checklists, Appendix B, as a resource for the discussion. 
 
Discussion    
What works well in the way we provide services during a visit for
anaemia? 
 
Guidelines     
What does not work well in the way we provide services for
anaemia? 
What standards, guidelines or protocols are used for providing
services for anaemia? 
To whom would you go if you had questions about a standard or how
to perform an activity? 
What information do you ask from clients about their medical
history? 
What activities do you carry during a physical exam? 
For what reasons would you refer a client to another provider? 
What messages do you emphasise when educating or counselling your
clients on treatment for anaemia? 
 
Key questions 
Do service providers ask about chief complaints, whether
pregnant? 
Is occult blood in the stool determined? 
Is the client asked if blood is in the stool? 
Do service providers check colour of conjuctiva? 
Are clients asked about family history of anaemia? 
Is the client given a complete physical examination; chest,
abdomen, etc.? 
Do service providers get a complete blood count with reticulocite
count? 
Is the haemoglobin type; region, race, age or sex determined? 
Do service providers determine the aetiology of the anaemic
condition? 
Is appropriate consultation determined; referral to a specialist,
if needed? 
Are clients provided with nutrition counselling? 
Are clients asked about their knowledge in how to administer the
drug; how much, how often and how long? 
Is the client aware how to get refills for drugs? 
Appendix D: Multiple observation checklists
PHC household visit
Growth monitoring
Immunization
Oral rehydration therapy
Family planning
Rapid service quality assessment checklist
PHC household visitRapid quality assessment checklist 
Growth monitoring 
 
1. Health facility                                        
2. Observer                                               
3. Observer/supervisor                                    
4. Date                                              
 
Observation number/registration and documentation, +, 1, 2, 3, 
4, 5, 6, 7, 8, 9, 10, TOT, Problems identified, 
Actions taken 
Age calculation, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
5., Base calculation on a reliable date of birth ?, , , , , , , ,
, , , , ,  
6., Correctly calculate date of birth ?, , , , , , , , , , , , , 
7., Record age?, , , , , , , , , , , , ,  
Weighing , +, +, +, +, +, +, +, +, +, +, +, +, +, + 
8., Set scale to 0?, , , , , , , , , , , , ,  
9., Remove the child's clothing?, , , , , , , , , , , , ,  
10., Place child correctly on scale?, , , , , , , , , , , , ,  
11., Correctly read scale? , , , , , , , , , , , , ,  
12., Record weight?, , , , , , , , , , , , ,  
Plotting the child's growth on chart  , +, +, +, +, +, +, +, +, 
+, +, +, +, +, + 
13., Plot or locate the child's weight at correct age?, , , , , ,
, , , , , , ,  
14., Plot or locate the child's weight at correct weight?, , , ,
, , , , , , , , ,  
15., Connect to previous growth point? , , , , , , , , , , , , , 
Referral and follow-up , +, +, +, +, +, +, +, +, +, +, +, +, +, 
+ 
17., Refer malnourished child for nutritional rehabilitation?, ,
, , , , , , , , , , ,  
18., Tell mother whether child has gained,, lost,, stayed  the
same 
since last weighing?, , , , , , , , , , , , ,  
19., Tell mother the nutritional status of the child?, , , , , ,
, , , , , , ,  
20., Use growth card to explain to mother how her child is
growing?, , , , , , , , , , , , ,  
21., Ask if the child has had any health problems since last
weighing?, , , , , , , , , , , , ,  
22., Make recommendations regarding child feeding and care?, , ,
, , , , , , , , , ,  
23., Explain importance of good breastfeeding and weaning
practices?, , , , , , , , , , , , ,  
24., Explain which locally available foods constitute a balanced
diet for children?, , , , , , , , , , , , ,  
25., Explain how to feed children during illness?, , , , , , , ,
, , , , ,  
26., Tell mother when to take child for next weighing?, , , , , ,
, , , , , , ,  
27., Verify that mother understands key messages?, , , , , , , ,
, , , , ,  
28., Ask mother if she has any questions?, , , , , , , , , , , ,
, 
 Rapid quality assessment checklist 
Immunization 
  
1.   Health facility                                           
2.   Observer                                                  
3.   Observer/supervisor                                       
4.   Date                                            
 
Observation number:, +, 1, 2, 3, 4, 5, 6, 7, 8, 9, 
10, TOT, Problems identified, Actions taken 
13., Use a sterile needle for each injection?, , , , , , , , , ,
, , ,  
14., Use a sterile syringe for each injection?, , , , , , , , , ,
, , ,  
Vaccination technique, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
17. , Was the child given all vaccinations needed today?, , , , ,
, , , , , , , ,  
Documentation, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
19., Record the vaccination on the child's health card?, , , , ,
, , , , , , , ,  
36., Was the registered temperature between 0 and 8 degrees (C)
at all times during the last month?, , , , , , , , , , , , ,  
41., Were all vaccines transported in cold boxes with ice packs?,
, , , , , , , , , , , ,  
Exit Interview with mother, +, +, +, +, +, +, +, +, +, +, +, +, 
+, + 
43., When should you return to the health center for your next
immunization?, 
, , , , , , , , , , , ,  
Rapid quality assessment checklist 
Oral rehydration therapy 
 
1.   Health facility                                           
2.   Observer                                                  
3.   Observer/supervisor                                      
4.   Date                                            
Observation number/registration and documentation, +, 1, 2, 3, 
4, 5, 6, 7, 8, 9, 10, TOT, Problems identified, 
Actions taken 
, , , , , , , , , , , , , ,  
Medical history, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
5., Duration of diarrhea?, , , , , , , , , , , , ,  
6., Consistency of stools?, , , , , , , , , , , , ,  
7., Frequency of stools?, , , , , , , , , , , , ,  
8., Presence of blood and/or mucus in stools?, , , , , , , , , ,
, , ,  
9., Presence of vomiting?, , , , , , , , , , , , ,  
10., Fever?, , , , , , , , , , , , ,  
11. , Home treatments?, , , , , , , , , , , , ,  
Physical examination , +, +, +, +, +, +, +, +, +, +, +, +, +, + 
12., Assess general status (alert or lethargic)?1, , , , , ,
, , , , , , ,  
13., Pinch skin?, , , , , , , , , , , , ,  
14., Weigh child?, , , , , , , , , , , , ,  
15., Determine nutritional status to be sure the child is not
severely malnourished?, , , , , , , , , , , , ,  
16., Take temperature?, , , , , , , , , , , , ,  
17., Determine the degree of dehydration (none,, moderate,,
severe)?, , , , , , , , , , , , ,  
18., Prescribe ORS or cereal-based ORT?, , , , , , , , , , , , , 
20., Refrain from using antibiotics except when stools contain
blood or mucus?, , , , , , , , , , , , ,  
22., If the child is dehydrated administer ORS solution or
cereal-based ORT immediately or refer the child to a nearby
centre?, , , , , , , , , , , , ,  
31., Tell mother about appropriate feeding practices during and
after dehydration?, , , , , , , , , , , , ,  
35., Show mother how to administer ORS solution or cereal-based
ORT?, , , , , , , , , , , , ,  
1 Signs of dehydration: 1. lethargy; 2. absence of tears 
while crying; 3. pinched skin retracts slowly; 4. dry mouth; 5.
sunken yeys.
2 Danger signs: 1. many watery stools; 2. repeated vomiting; 
3. very thirsty; 4. eating or drinking poorly; 5. fever; 6. lood
in stool; 7. dehydration persists. 
Rapid quality assessment checklist 
Clinical family planning services 
 
1. Health facility                                        
2. Observer                                               
3. Observer/supervisor                                    
4. Date                                              

Observation number:, +, 1, 2, 3, 4, 5, 6, 7, 8, 9, 
10, TOT, Problems identified, Actions taken 
Medical and reproductive history* (new clients), +, +, +, +, +, 
+, +, +, +, +, +, +, +, + 
5., Ask the client how old she is?, , , , , , , , , , , , ,  
6., Ask about number,, spacing and outcome of pregnancies?, , , ,
, , , , , , , , ,  
7., Ask about previous use of family planning methods?, , , , , ,
, , , , , , ,  
8., Ask about reasons for stopping or switching previous
methods?, , , , , , , , , , , , ,  
9., Ask about heart disease?, , , , , , , , , , , , ,  
10., Ask about liver disease?, , , , , , , , , , , , ,  
11., Ask about high blood pressure?, , , , , , , , , , , , ,  
12., Ask about history of pelvic inflamatory disease?, , , , , ,
, , , , , , ,  
13., Ask about history of suspected or confirmed venereal
disease?, , , , , , , , , , , , ,  
14., Ask about history of blood clots or thromboemboli?, , , , ,
, , , , , , , ,  
15., Ask if she is breast feeding?, , , , , , , , , , , , ,  
16., Ask about date of last menstrual period?, , , , , , , , , ,
, , ,  
Physical examination *, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
17., Take blood pressure?, , , , , , , , , , , , ,  
18., Examine breast for lumps?, , , , , , , , , , , , ,  
19., Examine patient for signs of anaemia?, , , , , , , , , , , ,
Selection of a method , +, +, +, +, , , , , , , , , ,  
24., Choose a method that was free of contra-indications for this
client?, , , , , , , , , , , , ,  
28., Ask about side effects?, , , , , , , , , , , , ,  
Counselling (for all)*, +, +, +, +, +, +, +, +, +, +, +, +, +, + 
31., Describe possible minor side effects of the selected
method?, , , , , , , , , , , , ,  
32., Explain how to manage side effects at home?, , , , , , , , ,
, , , ,  
33., Describe major side effects which require medical
attention?, , , , , , , , , , , , ,  
Exit interview with client **, +, +, +, +, +, +, +, +, +, +, +, 
+, +, + 
44., How do you use the contraceptive you received today?, , , ,
, , , , , , , , ,  
45., What are the possible side effects?, , , , , , , , ,

Appendix E: Other PHC MAP tools
Worksheets for planning quality assessment activities
Form for making your own checklist
Form for manual tabulation
Table for selection of an LQAS sample

WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 1.  Specify the scope and objectives
A.  What is the purpose of the assessment? 
B.  What services will be included?  
C.  Who will use the information gathered? 
D.  How will the information be used?  
E.  What geographic area will be covered?   
F.  Over what period of time will the activities take 
place?
G.  What additional resources, if any, are available? 

WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 2:   Select unit of observation and data sources
Unit of observation:
Client/patient
Service elements
Health worker
Clinic session
Health centre



Data sources: 

Direct observation   
by supervisor    
by peer     
self-assessment  
Interview
structured interviews 
open-ended interviews 
discussion  
Record review   
routine records  
records kept especially for the assessment   

WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES

Step 4. Determine sampling procedures and select 
sample (optional)

Number of units in sampling frame:                      
Sample size (%)  =
Sampling method:
Census (100 percent sample)
Random sample
Systematic sample                             
LQAS sample                    
Convenience sample                

Purposive sample                  
Quota sample              
What is the minimum number of observations that 
should be made for each unit? <MU>                       

WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES<M>
Step 3:   Select and adapt the appropriate 
PHC MAP checklist(s)

Will the checklist require adaptation?  _________

Who will adapt the checklist? 
_____________________________________


WORKSHEET FOR PLANNING QUALITY ASSESSMENT ACTIVITIES
Step 4. Determine sampling procedures and select 
sample (optional)
Number of units in sampling frame:  
Sample size  (%)  =    (N)
Sampling method:
Census (100 percent sample)   
Random sample         
Systematic sample           
LQAS sample    
Convenience sample 
Purposive sample   
Quota sample 
What is the minimum number of observations that should be made
for each unit? 
Quality assessment checklist 
1.   Health facility                                           
2.   Observer                                                  
3.        Regular supervisor                                   
4, Observation number:, 1, 2, 3, 4, 5, 6, 7, 8, 9, 
10, TOT, Problems identified, Actions taken 
5, Date, , , , , , , , , , , , ,  
6, Service provider (initials), , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
, , , , , , , , , , , , , ,  
Manual tabulation exhibit
PHC MAP tally sheet 
Observation,  Facility ID, Worker ID, Observer ID, Date,
Questions, 
, , , , , , , , , , , , , , , , , , , , ,  
1, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
2, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
3, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
4, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
5, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
6, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
7, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
8, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
9, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
10, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
11, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
12, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
13, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
14, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
15, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
16, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
17, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
18, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
19, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
20, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
21, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
22, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
23, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
24, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
25, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
26, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
27, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
28, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
29, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
30, , , , , , , , , , , , , , , , , , , , , , , , , , ,  
Selection of LQAS sample 
Determination of minimum level, sample size, and acceptable size 
based on differences between clinics.  Need to focus on worst
clinics and pre-established goals 

1) Big difference, +, YES, +, YES or NO, +, +, NO, +, +,  
2) Focus on worst, +, YES, +, NO, YES, +, NO, +, +,  
, M1, S1, A1, M2, S2, A2, M3, S3, A3,  
Goal, Minimum level, Sample size, Acceptable size, Minimum 
level, Sample size, Acceptable size, Minimum level, Sample 
size, Acceptable size, Goal 
95%, 70%, 13, 12, 75%, 18, 16, 80%, 28, 26, 95% 
98%, 65%, 16, 13, 70%, 24, 20, 75%, 40, 34, 90% 
85%, 60%, 19, 15, 65%, 29, 23, 70%, 49, 39, 85% 
80%, 55%, 22, 16, 60%, 33, 24, 65%, 57, 42, 80% 
75%, 50%, 23, 15, 55%, 36, 24, 60%, 63, 43, 75% 
70%, 45%, 25, 15, 50%, 38, 23, 55%, 66, 43, 70% 
65%, 40%, 25, 14, 45%, 40, 23, 50%, 70, 41, 65% 
60%, 35%, 25, 12, 40%, 40, 20, 45%, 72, 38, 60% 
55%, 35%, 40, 18, 38%, 55, 26, 40%, 72, 35, 55% 
50%, 30%, 38, 16, 33%, 54, 23, 35%, 70, 31, 50% 
45%, 25%, 36, 13, 28%, 51, 19, 30%, 67, 25, 45% 
40%, 20%, 33, 10, 23%, 48, 15, 25%, 63, 21, 40% 
35%, 15%, 29, 7, 18%, 43, 11, 20%, 57, 16, 35% 
30%, 10%, 24, 5, 13%, 36, 8, 15%, 49, 11, 30% 
25%, 5%, 28, 3, 8%, 29, 5, 10%, 40, 7, 25% Appendix E: Other PHC MAP tools 
References and bibliography 
Andrist, L. "Taking a sexual history and educating clients 
about safe sex."Nursing Clinics of North America, 23(4), Dec.,
1988. pp. 959-73.  
 
Blumenfeld, S. PRICOR Monograph series: Methods 
paper 1. Operations research methods: A General approach in
primary health care. Center for Human Services, Bethesda, MD,
1986. 
 
Brown, L.D., et al. Quality assurance of health care in
developing countries. Center for Human Services, Bethesda, MD,
1992. 
 
Burgess, R. Community health aide/practitioner manual. 
United States Department of Health and Human Services,
Washington, DC, 1987.  pp. 55-58. 
 
Dovlo, D., et al. What does the public want from us? 
A study of user satisfaction with services in government health 
facilities in the eastern region, Ghana. April, 1992. 
 
Helander, E., et al. Training in the community for people 
with disabilities, Geneva, WHO, 1989. 
 
Hoole, A., R. Greenber and G. Pickard. Patient care 
guidelines for family nurse practitioners, Little Brown and
Company, Boston, MA, 1976. pp. 265-272. 
 
Kirsch, T. and L. Kiess. Thesaurus of injury care skills. 
Draft. The Johns Hopkins University, Baltimore, MD, 1992. 
 
Lamptey, P.  and P.  Piot. The handbook for AIDS prevention 
in Africa. Family Health International, Durham, NC, 1990. 
 
Lemeshow, S. and G. Stroh.  Sampling techniques for 
evaluating health parameters in developing countries. National 
Academy Press, Washington, D.C., 1988. 
 
McMahon, R., et al.  On being in charge: A guide to 
management in primary health care. World Health Organization, 
Geneva, Switzerland, 1992. 
 
Nicholas, D., et al. "The quality assurance project:  Introducing
quality improvement to primary health care in less developed
countries, Quality assurance in health care. Vol.3. No. 3, 1991. 
pp. 147-165. 
 
Osterweis, M. and  J. Howell. "Administering patient satisfaction
questionnaires at diverse ambulatory care sites," Journal of
ambulatory care management,  1979.  pp. 67-88. 
 
Pleiffer, J. (Ed.). Theories and models in applied behavioral 
science, vol. II, pp. 12, 28, 65-66, 139-140, 147-149, 189, 227 
 
PRICOR Project, Center for Human Services, Primary health 
care thesaurus, volumes I and II, Bethesda, Maryland, 1992. 
 
Stone, D. and N. Kaleeba. "Counselling and AIDS," The 
handbook for AIDS prevention in Africa, Family Health
International, Durham, NC, 1990. pp. 181-190.  
 
Thorburn, M.J. and K. Marfo. Practical approaches to 
childhood disability in developing countries: Insights from
experience and research, 3D Projects, Spanish Town, Jamaica,
1990. 
 
USAID. Media promotion of breast feeding: A decade's 
experience. p. 45. 
 
USAID. Breast feeding for child survival strategy, 
May, 1990, pp. 29-30, 38. 
 
Wallace, H. "Health care of women and children in developing 
countries," (Chapter 38), Handicapped children and youth 
in developing countries, Third Party Publishing Company, Oakland,
CA, 1990. 
 
Wallerstein, N. and E. Bernstein. "Empowerment, education: 
Freire's ideas adapted to health education," Health Education 
Quarterly, vol. 15, No. 4, pp. 379-383, 1988. 
 
Ware, J. E. and R. Hays. "Methods for measuring patient 
satisfaction with specific medical encounters," Medical Care, 
1988. pp. 26, 383-402. 
 
Werner, D. Disabled Village Children. Hesperian Foundation, 
Palo Alto, CA, 1987. 
 
Wolff, M. and R. Black.  Manual for Conducting Lot Quality 
Assessments in Oral Rehydration Therapy Clinics. The Johns
Hopkins University School of Hygiene and Public Health, Institute
for International Programs, Baltimore, MD, 1989. 
 
World Health Organization. AIDS prevention: guidelines 
for MCH/FP Programme managers. Global Programme on AIDS, World 
Health Organization, Geneva, 1990. 
 
World Health Organization: Management of patients with 
sexually transmitted diesases. WHO Technical report series 810, 
Geneva, World Health Organization, 1991. 

Acronyms and abbreviations 
AIDS Acquired immune deficiency syndrome 
AKF  Aga Khan Foundation 
ANC  Antenatal care 
ARI  Acute respiratory infection 
BCG  Bacillus of Calmette and Guerin (tuberculosis vaccine) 
CHW  Community health worker 
DK   Don't know 
DPT  Diptheria, pertussis and tetanus vaccines 
EPI  Expanded Programme for Immunization 
FP   Family planning 
GM   Growth monitoring 
HIV  Human Imunodeficiency Virus 
IEC  Information, education, communication 
IV   Intravenous 
KAP  Knowledge, attitudes, practice (behaviour) 
LQAS Lot quality assurance sampling 
MCH  Maternal and child health 
MIS  Management information system 
NA   No answer 
NG   Nasal Gastric 
NGO  Non-governmental organisation 
OPV  Oral poliovirus vaccine 
ORS  Oral rehydration salts 
ORT  Oral rehydration therapy 
PHC  Primary health care 
PHC MAP   Primary Health Care Management Advancement Programme 
PRICOR    Primary Health Care Operations Research 
RH   Rhesus 
STD  Sexually transmitted diseases 
TB   Tuberculosis 
TBA  Traditional birth attendant 
TT   Tetanus toxoid 
WHO  World Health Organization 
PHC MAP MANAGEMENT COMMITTEE 
Dr. Ronald Wilson 
Aga Khan Foundation, Switzerland (Co-Chair) 
Dr. Jack Bryant 
Aga Khan University, Pakistan (Co-Chair) 
Dr. William Steeler 
Secretariat of His Highness the Aga Khan, France (Co-Chair) 
Dr. Jack Reynolds 
Center for Human Services, USA (PHC MAP Director) 
Dr. David Nicholas 
Center for Human Services, USA 
Dr. Duane Smith 
Aga Khan Foundation, Switzerland 
Dr. Pierre Claquin 
Aga Khan Foundation, Switzerland 
Mr. Aziz Currimbhoy 
Aga Khan Health Service, Pakistan 
Mr. Kabir Mitha 
Aga Khan Health Service, India 
Dr. Nizar Verjee 
Aga Khan Health Service, Kenya 
Ms. Khatidja Husein 
Aga Khan University, Pakistan 
Dr. Sadia Chowdhury 
Aga Khan Community Health Programme, Bangladesh 
Dr. Mizan Siddiqi 
Aga Khan Community Health Programme, Bangladesh 
Dr. Krasae Chanawongse 
ASEAN Institute for Health Development, Thailand 
Dr. Yawarat Porapakkham 
ASEAN Institute for Health Development, Thailand 
Dr. Jumroon Mikhanorn 
Somboon Vacharotai Foundation, Thailand 
Dr. Nirmala Murthy 
Foundation for Research in Health Systems, India 

PHC MAP TECHNICAL ADVISORY COMMITTEE 
Dr. Nirmala Murthy 
Foundation for Research in Health Systems, India (Chair) 
Dr. Krasae Chanawongse 
ASEAN Institute for Health Development, Thailand 
Dr. Al Henn 
African Medical and Research Foundation (AMREF), formerly 
of the Harvard Institute for International Development 
Dr. Siraj-ul Haque Mahmud 
Ministry of Planning, Pakistan
Dr. Peter Tugwell 
Faculty of Medicine, University of Ottawa, Canada
Dr. Dan Kaseje 
Christian Medical Commission, Switzerland, formerly of the 
University of Nairobi, Kenya 

KEY PHC MAP STAFF AT THE CENTER FOR HUMAN SERVICES 
Dr. Jack Reynolds (PHC MAP Director)     Dr. Neeraj Kak
Dr. Paul Richardson           Ms. Lori DiPrete Brown
Dr. David Nicholas            Ms. Pam Homan 
Dr. Wayne Stinson             Dr. Lynne Miller-Franco
Ms. Maria Francisco           Ms. Mary Millar