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 pregnan