Using_Disca - Health Systems Trust

Evaluating the Quality of Care for
Sexually Transmitted Infections
Using DISCA (District STI Clinic Assessment)
A report from three health districts
Prepared by:
Saiqa Mullick (RHRU), David McCoy (ISDS), Mags Beksinska (RHRU),
Anne Moys (RHRU)
The National STI Initiative is a collaboration of:
Reproductive Health Research Unit - University of the Witwatersrand
Initiative for Sub-District Support - Health Systems Trust
Provincial Departments of Health (KwaZulu-Natal, Mpumalanga and the Free State)
This Publication is also available on the Internet
www.hst.org.za
A joint publication of the Reproductive Health Research Unit (RHRU) and
Initiative for Sub-District Support (ISDS)
Health Systems Trust
Reproductive Health Research Unit
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Fax: (031) 304 0775
Email: saiqa@rhru.co.za
Email: hst@healthlink.org.za
ISBN: 1-919-839-12-7
The National STI Initiative is funded by
The Henry J. Kaiser Family Foundation (USA)
The information contained in this publication may be freely distributed and reproduced,
as long as the source is acknowledged, and it is used for non-commercial purposes.
Designed and printed by the Press Gang, Durban - Tel: (031) 307 3240
Using the DISCA Tool

Contributors
The authors would like to acknowledge the support and input of:
• those who assisted with the data collection: Ms Ruth Marumo, Ms Ntsiki Jolingana (Kopano),
Ms Lindiwe Zuma (IPU), Victor Gwebu (Tonga) and Ms Zamandwandwe Nxumalo (Tonga)
• the ISDS site facilitators: Dr Carmen Baez (Kopano), Ms Gcina Radebe (IPU) and Ms
Zamandwandwe Nxumalo (Tonga).
They would also like to acknowledge the Provincial Departments of Health (KwaZulu Natal,
Mpumalanga and Free State) and the District Management Teams of IPU, Tonga and Kopano.
Finally, thanks to Dr Nicol Coetzee and Ms Sphindile Magwaza at UCT for their work in the
development of the District STI Quality of Care Assessment (DISCA) tool.
Using the DISCA Tool

Contents
1. Introduction ..................................................................................... 1
1.1 The DISCA tool .................................................................................................................... 1
1.2 Step by step guide for programme managers to conducting a DISCA assessment ............. 2
The Problem of Sexually Transmitted Infections (STIs) in South Africa ....... 4
2. Report from the Kopano District Clinics ............................................. 5
2.1 Accessibility ........................................................................................................................ 5
2.2 Examination Facilities ......................................................................................................... 5
2.3 Provision of Safe Syndromic Treatment ............................................................................... 5
2.4 STI Drug Supply/Availability ................................................................................................. 6
2.5 Comments from the clinics ................................................................................................. 7
3 Report on the IPU district clinics....................................................... 8
3.1 Accessibility ........................................................................................................................ 8
3.2 Examination facilities .......................................................................................................... 8
3.3 Provision of Safe Syndromic Treatment ............................................................................... 8
3.4 STI Drug Supply/Availability ................................................................................................. 9
3.5 Comments Section .............................................................................................................. 9
4 Report on the Tonga district clinics ................................................. 10
4.1 Accessibility ...................................................................................................................... 10
4.2 Examination facilities ........................................................................................................ 10
4.3 Provision of Safe Syndromic Treatment ............................................................................. 10
4.4 STI Drug Supply/Availability ............................................................................................... 11
4.5 Comments Section ............................................................................................................ 11
5. Comparing the findings between the three health districts ................ 12
5.1 Client load and STIs .......................................................................................................... 12
5.2 Clinicians trained in STI management and counseling....................................................... 13
5.3 Availability of Partner Notification (PN) cards .................................................................... 14
5.4 RPR testing: turnaround times ......................................................................................... 14
5.5 Condom shortages ............................................................................................................ 15
5.6 Syndromic Management ................................................................................................... 15
5.7 STI drug supply: currently out of stock ............................................................................. 17
Using the DISCA Tool

5.8 STI drug supply: out of stock in the month prior to the assessment................................. 18
5.9 Accessibility and client load............................................................................................... 19
5.10 General comments on the findings ................................................................................... 19
5.11 Summary of issues arising from the assessment in the three health districts .................. 20
6. Responding to the DISCA findings ................................................... 21
6.1 Clinic level use of DISCA data ............................................................................................ 21
6.2 District level use of DISCA data ......................................................................................... 24
7. Conclusions .................................................................................... 26
Appendix 1:
DISCA tool: Example of a DISCA completed for a mobile clinic .......... 27
Using the DISCA Tool

1. Introduction
1.1 The DISCA tool
The district STI Clinic Assessment tool or DISCA is a quality improvement instrument for use in
Primary Health Care clinics (Appendix 1). It was developed after extensive consultation with nurses,
public health professionals and health service managers; and measures key input, process and output indicators
related to care for Sexually Transmitted Infections (STI).
The DISCA tool is a short questionnaire divided into several sections covering a number of key areas
of STI care. The broad areas covered in the DISCA tool are:
✧ Access to STI services
✧ Infrastructure
✧ Routine data
✧ Staffing and training
✧ Management of STI syndromes
The DISCA is filled in using a combination of methods, including the use of routine clinic data,
interviewing health care providers at the clinic and conducting a record review. Completion of the form
takes less than an hour for each clinic.
The DISCA tool should ideally be completed at clinic level by a clinic supervisor, preferably in
conjunction with the facility manager and interpreted with the STI/HIV programme manager, the health
informatics officer, the district medical officer and other relevant members of the District Management
Team.
The purpose of this report
As part of the National STI Initiative’s baseline assessments of three health districts 1 , a DISCA evaluation
was carried out in each of three health districts. Results from these districts showed that the instrument was
acceptable and easy to use with some training. The objectives of the training were to motivate supervisors
to discover the value of the DISCA tool in assessing quality of care and to stress the importance of accurate
information. Of the 53 DISCA assessment forms distributed to clinics, 48 were completed and returned.
The data was entered and analyzed both manually and using a statistical software programme called Epi-
Info 6.04 (Centres for Disease Control Atlanta).
This information can be used by District Management Teams to outline an action plan to address
shortcomings and improve the quality of care.
By comparing the three health districts with each other, we show how the DISCA tool can be useful
to a province or to a regional manager who can compare and contrast the quality of care provided by
different health districts. This allows managers and supervisors at higher levels of the health system to
target health districts that provide poor standards of care.
This report first presents the individual findings from each district one by one, and this is then followed
by a comparison of the three health districts. This format has been chosen in order to highlight both the
use of the tool for individual districts and to illustrate how comparisons across districts can be made.
This report has been written for the purpose of sharing, the process, results and interpretation of the
DISCA assessment with a view to using it as an ongoing tool for monitoring and evaluation.
1 Kopano district, Free State; Impendle/Pholela/Underberg district, KwaZulu Natal; Tonga district, Mpumalanga.
Using the DISCA Tool
1

1.2 Step by step guide for programme managers to conducting a
DISCA assessment
1. Identify the appropriate and relevant people concerned with the quality of STI care in the clinics.
At the district level these would include the District HIV/STI programme co-ordinator, the
clinic supervisors, the Maternal and Child Health (MCH) programme manager, the district PHC
nurse trainer and the district medical officer.
2. Bring this team together to discuss the issue of the quality of care in the clinics, and examine the
DISCA tool as a method for improving quality.
3. Discuss how the DISCA can be used in the district, including suggestions on additional data to be
collected, how the data would be collected, analyzed and used.
4. Discuss the importance of the quality and completeness of data
5. Compile a complete list of clinics in the district and allocate each clinic to a supervisor and/or
STI co-ordinator.
6. Inform all clinics about the DISCA evaluation. Ensure that everyone using the DISCA understands
how to fill in the information.
7. Follow up any outstanding DISCA forms after the agreed upon deadline.
8. Analyze the information, either manually or using a computer programme like EPI-INFO.
9. Prepare report with graphs (see those prepared in this report)
10. Discuss the findings within the district teams and arrange individual feedback to each clinic.
11. Develop an action plan to address problems and shortcomings
12. Disseminate the report and action plans to other stakeholders.
How often should the DISCA be used?
The DISCA should be adopted as an on-going monitoring system, and so it is recommended to
conduct a district assessment twice a year.
2 Using the DISCA Tool

Figure 1: Schematic diagram for conducting a DISCA assessment
Discuss with district team
Use of DISCA
Train and motivate clinic supervisor/
facility manager in the use of the DIS
Apply to clinics to assess and
monitor STI quality of care
DISCA
Form
Clinic Supervisor/
Facility Manager
Discuss with district team
Collate data from individual
clinics, analyse and interpret
Discuss with district team
Bi-Annual Report on
STI Quality of care
Regional/
Provincial
STI co-ordinator
Feedback to clinics,
regional, provincial office
Action Plans to address
deficiencies
Inter-district
comparison
district health
training
information system
contact tracing
drug supply
condom supply
Repeat Assessment
6 monthly
Using the DISCA Tool
3

The Problem of Sexually Transmitted
Infections (STIs) in South Africa
It is estimated that 333 million new cases of treatable STIs (excluding AIDS and other viral STIs)
occur every year, globally, and that approximately 11 million of these occur in South Africa.
Not only do STIs themselves represent a huge disease burden on society, they also lead to serious
complications in both adults and infants, and can facilitate the transmission of HIV by up to 10 times or
more. 2 In South Africa, the Department of Health guidelines on STI management follow the 1990 WHO
recommendation to use the “syndromic management” approach in treating STI clients and their contacts.
This approach classifies and treats the main causal pathogens according to the syndromes they commonly
produce. The advantage of this approach is that it can be done by the use of simplified flow charts, does not
require any form of laboratory testing and has been found to be more effective than clinical diagnosis.
The role of effective STI syndromic treatment in reducing transmission of HIV has been documented
in a community randomized controlled trial conducted in the Mwanza region of Tanzania. This trial
showed that improved clinical services for STIs, using the syndromic approach, reduced the incidence of
HIV infection by approximately 40% over a two year period. 3
Despite the effectiveness of syndromic treatment, other challenges that need to be considered and
addressed in the control of STIs include:
✧ overcoming the stigma associated with STIs;
✧ delays in seeking health care;
✧ the need for improving strategies of detecting asymptomatic STIs, particularly in women;
✧ identifying STIs in clients who present at clinics for other reasons;
✧ difficulties in notifying partners.
The few assessments of quality of care for STIs in South Africa show that management of STIs is poor.
A study by the Centre for Health Policy, University of Witwatersrand showed that only a third to as few
as 3% of STIs were treated effectively by general practitioners in the private sector. Another study in rural
South Africa found that private practitioners knowledge of syndromic management was extremely limited. 4
These studies reinforce the importance of seeking effective strategies to improve comprehensive
management of people with STIs in all health services.
2 The Public health approach to STI control UNAIDS Technical Update, May 1998.
3 Grosskurth H et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomized
controlled trial. Lancet 1995 Aug 26; 346(8974):530-6.
4 Conolly AM et al. Inadequate treatment for sexually transmitted diseased in the South African private health sector. Int J STD
AIDS 1999 May; 10(5):324-7.
4 Using the DISCA Tool

2. Report from the Kopano District Clinics
DISCA forms were returned from 27 clinics in Kopano district in the Free State. These were
predominantly fixed clinics; three mobile units were included. All clinics offer integrated primary health
care except for one which is a single function dedicated STI clinic serving high-risk clients.
2.1 Accessibility
✧
✧
✧
Only 67% (20) of clinics were able to provide a figure for the total number of clients seen in a
month and only 59% (16) were able to provide figures for the total number of STI clients seen in
a month. This may reflect apathy in filling the DISCA form or the fact that this data was not
readily available at clinic level. In either case this is an issue that needs to be addressed.
Of those clinics that did give the statistics, the total number of clients seen at a unit ranged from
8 clients to 7947 per month. This wide range may be a reflection of the incompleteness and
inaccuracies of data collection or may indicate that in some clinics resources are being under
utilized. The reported STI clients ranged from 13 to 1010 per clinic, per month with an average
of 131. A few clinics reported STI numbers greater than total clients seen which may reflect that
supervisors need more training in the use of the DISCA or, that routine clinic data is of poor
quality.
If the dedicated STI clinic is excluded, the range of STI clients is between 13-350 with an average
of 51 clients. This is considerably lower than the initial mean of 131. The percentage of total
clients that were diagnosed as STI clients also drops from 9% to 5%.
2.2 Examination Facilities
✧ All 27 clinics have an examination couch. The number of couches per clinic ranged from 1-11
per unit with an average of 3.5 couches per unit.
✧
✧
Seven percent of clinics had no examination light and almost half (41%) of the clinics had only
one examination light.
Three of the 27 clinics (11%) reported having no sterile specula available. The range in number
of specula available at clinics was 0-10 per clinic, excluding the dedicated STI clinic.
2.3 Provision of Safe Syndromic Treatment
✧
✧
✧
Only 18 clinics were able to give data on the number of STI clients tested for syphilis in the last
month. The average number of STI clients was 30 (range 0-154). There is a lack of clear guidelines
on who should be tested for syphilis and this has resulted in different practices at facility level.
Some clinics report testing all STI clients, some test those with urethral and vaginal discharge and
some say they test those clients with genital ulcers. Overall, about 23% of all STI clients are being
tested for syphilis. On the whole, diagnoses were syndromic and a range of syndromes were
reported. The two most common being urethral discharge and vaginal discharge.
Syphilis testing - Only the dedicated STI clinic had on-site syphilis testing available. For the rest of
the clinics, the turn around time for syphilis results ranged from 1 day to 14 days with an average
turn around time of 5.6 days.
Approximately 65% of drug treatments prescribed were according to the National syndromic
management guidelines. In 25% of cases, clinic supervisors administering the assessment forms
were not able to state whether the treatment prescribed was correct or not. In a third of cases the
clinicians were not able to state the correct drugs for treatment of selected syndromes.
Using the DISCA Tool
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✧
✧
✧
Several clinics did not complete the record review section on STI drugs and treatment. This
section was to be completed by reviewing the client cards and noting diagnoses and treatment for
STI syndromes for the last ten STI clients presenting to the clinic.
Multiple syndromes - There were only three cases of clients with more than one syndrome. This
may suggest that clinicians require training in detection of more than one syndrome and an
awareness that syndromes can and often do co-exist. This may also reflect a failure to do speculum
examinations on women or it may be that the design of the DISCA form is not conducive to
reporting more than one syndrome per client.
The figures shown in Table 1 are cause for concern, especially if one considers that there will be
a significant amount of under detection and misdiagnosis of STIs which cannot be estimated
using the DISCA tool. Thus, even if one assumes that all STI clients who come into a facility are
diagnosed correctly, the percentage that are correctly managed is unacceptably low.
Table 1:
Syndrome
Proportion of clinicians in Kopano reporting incorrect treatment
Clinicians reporting incorrect treatment* (N=27)
(%) n=
Urethral discharge 15 4
Vaginal discharge 41 11
Genital Ulcer disease 43 12
*N= total number / n= number
✧
Antenatal Screening and STI Treatment - All clinics except the dedicated STI clinic provide antenatal
care and report performing syphilis testing on all pregnant clients, and ninety-three percent of
clinics reported treating pregnant clients for STIs other than syphilis.
2.4 STI Drug Supply/Availability
✧
Table 2 shows that drug supply for the syndromic management of STIs is a serious problem that
needs to be addressed.
Table 2: Drug availability for STI treatment in Kopano Clinics
Drug Out of stock at time Out of stock in month
of DISCA assessment prior to DISCA assessment
(N=27)
(N=27)
% of all clinics n % of all clinics n
Ciprofloxacin 4 1 15 4
Flagyl/Metronidazole 12 3 23 6
Erythromycin 27 7 31 8
Doxycycline 15 4 19 5
Benzathine Penicillin 0 0 4 1
6 Using the DISCA Tool

2.5 Comments from the clinics
Almost all DISCA assessments received from the clinics included some comment regarding the poor
rates of partner notification. Five of the clinics reported a policy of “no partner, no treatment”, suggesting
withholding treatment from clients unless they present at the clinic with their partners, and one clinic
reported that clients were getting re-infected due to “a lack of morality”. The nature of these comments
suggests that there is a need to improve the attitudes of clinic staff.
In response to the question “what are the problems that affect the daily delivery of quality STI care in
the facility?”, three clinics responded, “none”. In each case these were clinics where either a high percentage
of recorded treatments were incorrect and/ or several sections of the DISCA were not completed.
Several clinics mentioned the problem of drug shortages, but considering how widespread this problem
was, it was surprising that it was not mentioned more frequently.
Five clinics stated the need for training.
One or two clinics were aware of the need to be sensitive to clients’ situations as indicated by the
recommendation to “make the service user-friendly, develop communication skills, and gain the trust of
the client”.
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3 Report on the IPU district clinics
A total of 9 DISCA forms were returned from the 13 clinics in IPU district in KwaZulu Natal. These
were all fixed clinics.
3.1 Accessibility
✧
✧
Five of the 9 clinics (56%) were able to provide a figure for the total number of clients seen, and
the total number of STI clients seen in a month.
The total number of clients seen at a clinic ranged from 18 clients to 2114 per month, with an
average of 907. Of these, the reported STI clients ranged from 17 to 32 per clinic, with an average
of 23 per clinic per month. A total of 3.6% of all attendees were STI clients.
3.2 Examination facilities
✧
✧
✧
All 9 clinics had an examination couch. The number of couches per clinic ranged from 1-5 with
an average of 3.4 couches per clinic.
Approximately half of the clinics reported having no examination light. The number varied
from 0-7 lights per clinic, with an average of 3 lights per clinic.
The range in number of specula available was 4-5 per clinic. All apart from one clinic reported
having sterile specula available.
3.3 Provision of Safe Syndromic Treatment
✧
✧
✧
One clinic had Rapid Plasma Reagin (RPR) testing available on site. For the other clinics, the
turn around time for syphilis results ranged from 1 day to 30 days, with an average turn around
time of 11 days.
Only 5 of the 9 clinics (56%) were able to give data on the number of STI clients tested for
syphilis in the last month. The quality and accuracy of this data was not validated. This ranged
from 0-34 clients with an average of 9.8 clients. The number of tests reported indicates that about
42% of all STI clients were tested for syphilis.
Although only 9 clinicians were interviewed, the findings in Table 3 are consistent with those
from other districts in that not all clinicians were able to correctly report management of all
syndromes, particularly vaginal discharge and genital ulcer disease.
Table 3: Proportion of clinicians in IPU reporting incorrect treatment
Syndrome
Clinicians reporting incorrect treatment (N=9)
% n
Urethral discharge 0 0
Vaginal discharge 33 3
Genital Ulcer disease 11 1
8 Using the DISCA Tool

✧
✧
The record review section of the DISCA questionnaire was not completed in most cases. Thus,
no meaningful analysis could be performed to establish the proportion of the various syndromes
treated correctly.
Antenatal Screening and STI Treatment - All clinics provide antenatal care and reported doing
syphilis testing on all pregnant clients, and all reported treating pregnant clients for STIs other
than syphilis.
3.4 STI Drug Supply/Availability
The records from the IPU clinics showed that no STI drugs were out of stock at the time of the
assessment. Only Ciprofloxacin was out of stock in only one clinic in the past month. This suggests that
drug supply for the correct management of STIs is adequate in IPU.
3.5 Comments Section
Many of the DISCA forms were not filled in with regard to the record review of client management.
Requests were made for:
Training in STIs for the staff by 2 clinics
Dildos by one clinic
Education materials in local languages in several clinics
Partner notification cards by 1 clinic
Problem areas identified by clinics:
Partner notification by 4 clinics
Delayed seeking of treatment in almost all clinics
A lack of privacy for consultations in 3 clinics
Suggestions for improvement included:
Partner packs to improve partner treatment rates
Use of volunteer health workers to provide health education
The use of males to counsel other men and provide health education on STIs
The limited sample size of clinics in the assessment necessitated conducting discussions at district
level with role players in the design of an appropriate training schedule.
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4 Report on the Tonga district clinics
A total of 12 DISCA forms were returned from the fixed clinics in Tonga district in Mpumalanga.
4.1 Accessibility
✧
All clinics were able to provide a figure for the total number of clients seen in a month and for the
total number of STI clients seen in a month. The total number of clients seen at clinics ranged
from 305 clients to 1800 per month. The average monthly number of total adult clients was 1065
per clinic. Of these, the reported STI clients ranged from 15 to 150 per clinic, with an average of
81 per clinic. This represents 7.4% of all clients.
4.2 Examination facilities
✧
✧
✧
All 12 clinics had an examination couch.
More than half (7) of the clinics reported not having an examination light.
Only one of the 12 clinics reported having no sterile specula available. The range in number of
specula available was 0-11 per clinic.
4.3 Provision of Safe Syndromic Treatment
✧
✧
✧
✧
✧
✧
✧
✧
✧
None of the clinics had on-site RPR testing available. The turn around time for syphilis results
ranged from 7 days to 14 days with an average turn around time of 7.6 days.
All clinics were able to give data on the number of STI clients tested for syphilis in the last month.
The quality and accuracy of this data was not validated. The number given indicates that 39% of
all STI clients were being tested for syphilis. The proportion of those tested varies from clinic to
clinic.
On the whole, diagnoses were syndromic and a range of syndromes were reported. The 2 most
common being vaginal and urethral discharge.
Approximately 67% of drug treatments prescribed and recorded in the record review section of
the DISCA forms were according to the National syndromic management guidelines. In almost
all (91%) of cases, supervisors were able to correctly report whether the treatment prescribed was
correct or not.
No clients diagnosed with an STI were tested for syphilis.
18 cases of all those reported on the forms had more than one syndrome. This may suggest that
clinicians require training in diagnosing multiple syndromes and to be aware that syndromes can
co-exist.
All except one of the 12 clinicians that were asked, reported the correct treatment for urethral
discharge, vaginal discharge and genital ulcer disease.
One clinic reported, six out of nine cases of STI as Pelvic Inflamatory Disease (PID). This could
suggest delayed treatment, failure to detect STIs at an earlier stage or misdiagnosis.
Antenatal screening and STI treatment - All clinics provide antenatal care and reported doing
syphilis testing on all pregnant clients and reported treating pregnant clients for STIs other than
syphilis.
10 Using the DISCA Tool

4.4 STI Drug Supply/Availability
Table 4 shows that drug supply for the syndromic management of STIs is a problem that needs to be
addressed in Tonga. This was not evident from the assessment of drugs currently in stock but was highlighted
in the records for the previous month.
Table 4: Drug availability for STI treatment in Tonga Clinics
Drug Out of stock currently Out of stock in last month
(% of all clinics) (% of all clinics)
% n % n
Ciprofloxacin 0 0 25 3
Flagyl/Metronidazole 0 0 17 2
Erythromycin 8 1 42 5
Doxycycline 0 0 58 7
Benzathine Penicillin 0 0 0 0
4.5 Comments Section
Almost all DISCA assessments received from the clinics had some comment regarding the poor rates
of partner notification and problems with drug supply.
Several of the comments included requests for education although it was not clear whether this
referred to health care providers or community. Some specific requests were made for improved community
education.
One comment stated that “commercial sex workers” were a problem that affected daily delivery of
quality STI care. The context of this statement was unclear but could suggest judgemental attitudes towards
high risk groups.
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5. Comparing the findings between the
three health districts
5.1 Client load and STIs
Figure 2: Client Loads and STI’s
1475
1600
1400
1200
1122 1065
1000
600
400
200
130
79
41
0
Kopano
IPU
Tonga
(9%)
(4%)
(7%)
Total STD attendances per month
1800
Total adult attendances per month
STI client load as a proportion of total client load is given in brackets for each district. Although the
expected proportion of STI clients is difficult to determine, one would expect a higher proportion of STI
clients in IPU. This could indicate that there are many missed cases of STI at clinics, that STI clients are not
presenting to public sector clinics, or that the data is inaccurate. The IPU district team should therefore
investigate the cause for the low proportion of STI clients. If the reason is found to be that STI clients are
not using public sector clinics, then the district team should find out why, for example, is it because there
is a perception that quality of care in the private sector is better? Are nurses attitudes poor? Etc.
12 Using the DISCA Tool

0
5.2 Clinicians trained in STI management and counseling
Figure 3 highlights the need for training, particularly in IPU and Tonga. This could reflect either the
overall lack of training in STI management or that if training has been done, it has failed to cascade
throughout the clinics.
Figure 3: Percentage of clinicians trained
70
66
60
56
50
40
43
30
20
10
0
26
Kopano IPU Tonga
% clinicians trained in STI syndromic management
% clinicians trained in counselling
Table 5 shows that there is a need to train clinicians in all three health districts in STI management and
counseling. In IPU there is also a need to identify clinicians to take responsibility for STI quality of care at
facility level.
Table 5: Summary of staff training indicators
Percentage
Indicator Kopano IPU Tonga
Average number of clinicians* working average 3.7 average 2.9 average 1.75
on day of assessment (Range 1-16) (Range 2-4) (Range 1-3)
% of clinicians with formal STI training 56% 26% 66%
% of clinicians* with training in
counseling 43% 14% 0%
% clinics with nurse or doctor with 63% 22% 92%
responsibility to supervise STI care in
the facility
* clinicians defined as any health care provider examining and treating clients
Using the DISCA Tool
14
13

5.3 Availability of Partner Notification (PN) cards
Figure 4
90
81
80
75
70
60
50
42
40
33
30
23
20
10 8
8
0
0
Kopano IPU Tonga
testingRPR PN cards (LL)
PN cards in rooms
50
5.4 RPR testing: turnaround times
Figure 5
Partner notification (PN) cards were not available at all clinics. This was particularly a problem in
Tonga. Partner notification cards in local languages (LL) were scarce in all three health districts.
Figure 5 illustrates long turn around times for syphilis tests, particularly in IPU. Only one clinic in
Kopano health district had access to on site testing. Further investigation of the cause of delayed turn
around times should be investigated and the feasibility of on site testing be explored. What is not known,
however, is the percentage of clients who actually come back for their syphilis test results.
Days
14
12
10
8
6
4
2
0
14 Using the DISCA Tool
5.60
12.20
7.60
Kopano IPU Tonga

5.5 Condom shortages
Figure 6 shows that condom shortages were experienced in two of the three districts in a significant
proportion of clinics in the month prior to the assessment. The district team should investigate the source
or cause of the shortages.
Figure 6
Percentage
30
25
20
15
27
25
10
5
0
Kopano IPU Tonga
0
5.6 Syndromic Management
Figure 7 shows the proportions of effectively managed syndromes. There was, unfortunately, no data
available from IPU.
Figure 7
Kopano
Tonga
35.5%
35.9%
64.5%
64.1%
Correct
Incorrect
Using the DISCA Tool
15

Table 6 shows that correct treatment was more often cited for male urethral discharge than for vaginal
discharge or genital ulcer disease. The table also highlights the fact that supervisors were unable to identify
correct treatment in many cases and also need training in STI drug management. Sterile specula and
condoms were also in short supply in some districts.
Table 6: Summary of safe syndromic management indicators
Indicator Kopano IPU Tonga
Proportion of clinicians* citing correct treatment
for urethral discharge 78.6% 100% 92%
Proportion of clinicians citing correct treatment
for vaginal discharge 61% 55.5% 92%
Proportion of clinicians* citing correct treatment
for genital ulcer disease 57% 89% 92%
Proportion treated correctly from record review
Sample size
(all syndromes) 64.5% too small 64.1%
% cases where supervisor able to give correct Sample size
treatment for STI syndromes 75% too small 92%
% of clinics with specula available 89% 87.5% 91%
% clinics with condoms available 73% 75% 100%
* clinicians defined as any health care provider examining and treating clients
16 Using the DISCA Tool

5.7 STI drug supply: currently out of stock
Figure 8 shows that at the time of assessment a large proportion of the Kopano clincs were experiencing
shortages of STI drugs, particularly erythromycin. Clinics in Tonga were also affected by shortages of
erythromycin, but were otherwise well stocked.
The DISCA is able to identify which drugs are out of stock in what districts.
Figure 8
27
25
20
15.4
15
11.5
10
8.3
5
3.8
0 0 0 0 0 0 0
0 0
30
0
0
Kopano IPU Tonga
Benzathine Penicillin
Metronidazole
Doxycycline
Ciprofloxacin
Erythromycin
Using the DISCA Tool
17

5.8 STI drug supply: out of stock in the month prior to the
assessment
Figure 9 shows that both Kopano and Tonga had problems with the supply of STI drugs. These
problems were more serious in Tonga, although by examining currently available drugs only this would not
have been evident. Examining the two graphs for a given health district would indicate whether drug
problems have improved or become worse in the month preceding the assessment.
Figure 9
60 58.3
50
50
40
33.3
30.8
30
23.1
20 19.2
16.7
15.4
10
7.7
3
0 0 0 0
0
0
Kopano IPU Tonga
Benzathine Penicillin
Metronidazole
Doxycycline
Ciprofloxacin
Erythromycin
Percentage
18 Using the DISCA Tool

5.9 Accessibility and client load
Table 7 shows that STI services were accessible during the day in all districts but few facilities were
open after hours. The very high proportion of consultation rooms used for STI treatment also suggests that
this service is well integrated with other services. Privacy for STI consultations is a problem particularly in
IPU.
In Kopano and IPU not all clinics were able to provide data on total client attendances and STI
attendances. Data collection was complete in Tonga because data was collected by the ISDS facilitator in
conjunction with the district communicable disease co-ordinator. The figures suggest that workload varies
highly from clinic to clinic judging by the wide range in figures. This may also suggest inaccuracies in data
collection.
Table 7: Summary of accessibility and client load indicators
Indicator Kopano clinics IPU clinics Tonga clinics
STI treatment offered at all times
(8am-4pm weekdays) 100% 100% 100%
% of clinics providing after-hours services 11% 0% 17%
Adult consultation rooms, mean 3 2.9 2
Adult consultation rooms used for STI
treatment 96% 78% 100%
Privacy for STI clients 96% 67% 75%
Percentage clinics able to provide data
on client load indicators 67% 71% 100%
Total and mean adult attendances in past Range 8-7947/ Range 18-2114/ Range 305-1800/
month average 1400 average 907 average 1065
Total STI attendances in past month Range 13-1010/ Range 17-32/ Range 15-150/
average 135 average 23.4 average 81
Percentage STI clients of total adult
client load 8.9% 3.6% 7.4%
5.10 General comments on the findings
In summarizing findings from the three health districts it should be noted that common issues emerge,
and that some aspects of STI care are better developed than others.
✧
✧
✧
Access during working hours seems to be well established. All clinics offer STI treatment during
normal working hours. Most rooms were used for STI consultations. After hours access in clinics
was not so well established and varies from district to district.
Completeness of data collected varied in the districts, with a significant number of clinics in IPU
not being able to provide any statistics whatsoever. Even where some figures were provided the
range of values was wide, raising the question of the reliability of the data. This is an issue that
needs to be explored further as it has implications for other aspects of the DISCA assessment.
All clinics reported having an examination couch, but not all had working examination lights.
Using the DISCA Tool
19

✧
✧
✧
✧
✧
The availability of treatment guidelines was good. However, the availability of educational materials
was variable, and particularly scarce were education materials in local languages.
Condom shortages occurred in a significant proportion of clinics in two of the health districts
and this is of concern. The majority of clinics reported showing clients how to use condoms
even though dildos were not always available.
All clinics reported providing antenatal care and testing for syphilis. The reliability for the figures
reported for STI clients being tested for syphilis is doubtful. Several clinics gave numbers higher
than the total STI clients and in the client record reviews very few were recorded as being tested.
The number of trained clinicians in a clinic and the proportion trained in STI management and
counseling also differed between districts. However, these figures are difficult to interpret at this
stage. Questions remain about whether all clinicians should be trained in both STI case management
and counseling.
There may be a significant amount of under-detection and misdiagnosis of STIs which cannot be
picked up or estimated using the DISCA tool.
5.11 Summary of issues arising from the assessment in the three
health districts
Table 8 illustrates that although the clinics are situated in different regions with varying capacities and
different populations, many of the issues raised by the assessment were common across all sites.
Table 8: Summary of issues arising from the assessments in the three districts.
Issues arising Kopano IPU Tonga Common
issues
Attitudes of health care providers ✗ ✗ ✗ ❖
Provision of STI training ✗ ✗ ✗ ❖
Provision of training in counseling ✗ ✗ ✗ ❖
Provision of drugs and supplies ✗ ✗
Partner notification strategies and cards in
local languages ✗ ✗ ✗ ❖
Data collection and routine record keeping ✗ ✗
Syphilis testing and reduced turn around times ✗ ✗ ✗ ❖
DISCA evaluation – use of forms ✗ ✗ ✗ ❖
Health education materials in local languages ✗ ✗ ✗ ❖
Access to after-hours services
✗
Addressing issues of privacy in clinics
✗
Condom accessibility ✗ ✗
Provision of referral policies
✗
20 Using the DISCA Tool

6. Responding to the DISCA findings
The following section illustrates the use of the DISCA tool results at both facility and district level in
a stepwise sequence.
6.1 Clinic level use of DISCA data
Step 1: Summary of issues from a mobile clinic
(see Appendix 1 for completed DISCA form)
1. Under diagnosis or misdiagnosis of STIs suggested by low proportion of STI clients compared to
total adult attendances.
2. Condoms have been out of stock in the past month.
3. Erythromycin was out of stock at time of assessment.
4. Incomplete treatment for vaginal discharge. (All women with vaginal discharge were treated only
with Flagyl 2gm stat; no ciprofloxacin or doxycycline was given)
5. Incorrect treatment for genital ulcers and warts. (Both these conditions were treated with flagyl
2gm stat and ciprofloxacin 500mg stat)
6. All incorrect treatments were considered to be correct by the clinic supervisor.
7. All treatments stated by one of the clinicians for three syndromes were incorrect.
8. The clinicians felt that there were no problems in delivering quality STI care.
9. In response to what recommendations could be made to improve any aspect of STI care, the
answer was “none”, that is, providers reported that they did not need to improve STI care.
10. Despite one of the two professional nurses having attended a formal STI course, the quality of
care for STIs at this facility still needed much improvement.
Step 2: Feedback
1. The issues identified need to be discussed with the person in charge of the mobile clinic. This
would help to identify the likely cause of some of the problems identified.
2. Together (ie supervisor and person in charge of facility) they should decide on the main problems.
Using the DISCA Tool
21

Step 3: Develop an action plan
Problem Cause Action By whom? By when? Evaluation
Wrong treatment lack of motivation/ Increased frequency of Supervisor Starting this month – After six months
support support visits Supervisor ongoing monthly
lack of cascading inform- In service training/ support Supervisor Starting this month On monthly support visits
ation by trained staff to
other staff
Stock out of Erythromycin Shortage in the district Meet with pharmacist District manager As soon as possible Next month
Ensure sufficient stocks are Sister in charge Monthly Monthly
ordered on time
Stock out of condoms Under ordering at Increase order by 25% Sister in charge Next month Monthly
clinic level
Under or misdiagnosis of Speculum examinations In service training District trainer Next district in service 3 months after in service
syndromes not done and support meeting training
Incomplete histories In service training District trainer
taken from FP and and support
ANC clients
RPR not taken from any Uncertainty around Clarify district policy on District manager Next district meeting Subsequent district
STI clients which STI clients to RPR testing and comm- meeting
test unicate to all clinics
22 Using the DISCA Tool

Step 4: Monitoring and evaluating the action plan
Figure 10
Joint responsibility of
District Manager and/or
Clinic Supervisor
Diarise dates of proposed
actions (by whom)
Did it happen?
Yes
No
What were the results?
Why not?
Any further action
required?
Plan
unrealistic
Lack of
commitment
Lack of skill
or resources
Yes
No
Adjust plan
Identify
reason
Training and
support plan
Plan
accordingly
Plan
accordingly
Monitoring and evaluation of these subsequent plans would follow the same process
Using the DISCA Tool
23

6.2 District level use of DISCA data
Step 1: Identify the key areas of focus at district/provincial level according to the
five categories below:
1. Clear policy guidelines
2. Adequate supply of resources (equipment, drugs, condoms, educational materials)
3. Provision of adequate training and support for implementation
4. Continued monitoring and supervision (including ensuring accurate data)
5. Improvement of health care seeking behaviour
Step 2: Develop a plan of action
1. POLICY GUIDELINES
Problem Cause Action By whom? By when? Evaluation
Unclear RPR - Develop District Manage- Next District Subsequent
testing policy policy ment Teams in Meeting meeting
consultation with
Province
Distribute District Manager Following -
policy
policy
development
2. ADEQUATE SUPPLY OF RESOURCES
Problem Cause Action By whom? By when? Evaluation
Shortage of STI Payment of Alert provincial District Manager Immediate Intense follow
syndromic account in arrears programme
management
manager
drugs
Shortage of Insufficient Increase order District STI Immediate Intense follow
condoms ordering co-ordinator up
Delay in Meet with District STI Immediate Intense follow
distribution depot manager co-ordinator up
Shortage of Insufficient Put in next District Manager End of -
examination supply budget budgeting
lights
cycle
Lights needing Inform District Manager Next week Next month
repair
maintenance
manager
24 Using the DISCA Tool

3. PROVISION OF TRAINING AND SUPPORT
Problem Cause Action By whom? By when? Evaluation
Poor implem- Lack of support Highlight issue District STI Next district Subsequent
entation of training with supervisors co-ordinator meeting district meetings
training
and trainers
Lack of Increase support Clinic Supervisor Next Month Ongoing
motivation
District Manag.
Team Meeting
Provide incentive District
e.g. certificates/ Management
district prize for Team
improved
management
Step 3: Monitoring and evaluation
Refer to flow chart Figure 10 on page 23.
Using the DISCA Tool
25

7. Conclusions
Although the DISCA tool evaluates some critical indicators, it cannot address all issues. It does not
address the following:
1. The accuracy of the routine data reported in terms of under and over reporting
2. Accuracy of diagnosis
3. Quality of counseling given
4. Proof of physical examination
5. Quality of physical examination, if performed
6. Health seeking behaviour and client perspectives
Ideally, the DISCA findings should be interpreted and used in combination with discussion with
district teams and perhaps also coupled with some observation in the clinic and regular exit interviews.
These duties fall within the mandate of health managers and supervisors.
Who should complete the DISCA form?
It is recommended that the DISCA should be completed by a clinic supervisor, preferably in conjunction
with the facility manager. However, in health districts where there is concern that some supervisors may
tend to over / under estimate quality of care, it can be completed for all clinics in the district by an
independent supervisor or co-ordinator from another clinic or programme. It is important that all clinics
be included in the assessment and that they follow the same approach for the sake of uniformity and
comparability.
How good is good enough – when do you decide to train?
Interpretation of indicators and the cut off level at which to intervene with a formal training programme
is very much a decision that will be taken by health districts and provinces bearing in mind:
1. Discussion of priorities and experiences in the clinics
2. Available resources
An integrated supervision tool – the way forward?
The DISCA is a specific monitoring and supervision tool, dedicated to one set of diseases. This brings
advantages but also disadvantages in that the focus and depth of a tool designed for one set of diseases may
perpetuate a fragmented and vertical programme approach. This could also be problematic in a context
where most clinics provide a broad range of primary health care services, however, sexually transmitted
diseases are very high on the priority list and perhaps such a focus is justified. This approach may also lead
to development of an individual supervisory tool for each set of diseases.
Although the DISCA does focus primarily on STIs, it collects information on indicators that impact
both on STI quality of care as well as in other areas of health care provision eg clinic statistics, drug supply,
infrastructure.
Managers wishing to adopt this tool for monitoring and evaluation must realize that a great deal of
support needs to be given to clinics in order to make sure that the data collected is accurate and regularly
collected and that feedback results in actions at all levels. The DISCA is a useful tool because data can be
used at both clinic level and district level.
26 Using the DISCA Tool

Appendix 1:
DISCA tool: Example of a DISCA
completed for a mobile clinic
District STI Quality of Care Assessment
DISCA
INSTRUCTIONS:
Please fill out this evaluation by:
1. Interviewing a senior clinician
2. Inspecting the facilities, equipment and supplies, and
3. Examining the laboratory specimen register and patient medical records
Province: .............................................................. District: ....................................................................
Clinic 2 (Mobile)
Health facility name: ... ................................................................. Tel: ................................................
............................ Fax: ...............................................
06 07 99 8.00 am
Date of visit: /........../.......... /.......... Time of visit: ................. h ............
day month year
Full name and title of district clinic supervisor: .............................................................................................
Name and designation of person filling out the evaluation: ............................................................................
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27

ACCESSIBILITY
1. Does this facility offer STI treatment at all times between 8 am and 4 pm
on all weekdays?
2. Does this facility offer STI treatment as part of after clinic hours services?
✓
YES
YES
✓
NO
NO
3. How many consultation rooms are there in this facility?
1
4. a. Does this facility use all consultation rooms to treat clients with STIs ?
✓
YES
NO
b. If no, how many consultation rooms are used for STI care?
5. Please observe whether this facility offers consultation in private for all
STI clients i.e. consultations cannot be observed by other clients and providers?
YES
NO
6. Please request a caseload book or register and record the following figures for the last month:
a. Total number of clients seen
200
b. Total number of adult clients (13-15 years and older)
c. Total family planning clents:
d. Total ante-natal clients
e. Total number of clients with an STI
13
SAFE EXAMINATION
7. Are the following pieces of equipment available in all adult consultation rooms ?
Total number in this facility:
a. Examination couch
✓
YES
NO
1
b. (i) Examination light
✓
YES
NO
1
(ii) How many are in working order?
c. Vaginal specula
✓
YES
NO
d. Examination gloves
✓
YES
NO
8. Speculum examinations are done on all women with STIs
✓
all most a few none
28 Using the DISCA Tool

PROVISION OF SAFE TREATMENT:
9. a. Are there current STI syndromic management guidelines at this facility?
b. Are there STI syndromic management guidelines in all adult consultation rooms?
✓
✓
YES
YES
NO
NO
c. Are there individual client education materials about STI/ HIV prevention and
treatment available in this facility?
d. Are these educational materials written in a local language?
✓
✓
YES
YES
NO
NO
10. How are specula sterilized in this facility?
.............................................................................................................................................
.............................................................................................................................................
11. a. Is syphilis RPR testing done on site in this health facility?
YES
✓
NO
b. If not, what is the turn-around time* for the RPR test results?
(*The time elapsed between taking blood for RPR from the client
and getting the results back from the laboratory.)
12. Have there been any occasions over the last month when male condoms ran out?
✓
YES
NO
13. Whereabouts in the clinic are condoms available?
.............................................................................................................................................
.............................................................................................................................................
14. a. Are STI clients shown how to use condoms in this facility?
b. Is there a dildo available for condom demonstrations in this facility?
✓
✓
YES
YES
NO
NO
c. If no, how do you make sure that a client knows how to use condoms in this facility?
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
15. Which clients with STIs would you refer for treatment?
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
Using the DISCA Tool
29

PROVISION OF SAFE TREATMENT (CONT):
16. Partner Notification
a. Are Partner Notification cards / letters available in all adult consultation rooms?
b. Are the cards written in a local language?
✓
✓
YES
YES
NO
NO
c. How many partner notifications were issued in the last month?
d. How many partners came for treatment in the last month?
No Record
No Record
17. a. Is blood taken for RPR (syphilis) test from all STI clients?
YES
✓
NO
b. If not, for which conditions do STI clients have blood taken for RPR test?
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
ANTENATAL SCREENING AND STI TREATMENT
18. a. Is syphilis screening done on all pregnant clients who attend
antenatal care for the first time?
✓
YES
NO
b. How many first time antenatal clients were seen last month?
c. How many tested positive for syphilis?
19. Do you examine and treat pregnant clients for STIs other than syphilis?
✓
YES
NO
20. Which pregnant women with STIs do you refer for treatment?
.............................................................................................................................................
.............................................................................................................................................
30 Using the DISCA Tool

STAFF TRAINING
21. a. What is the total number of professional nurses working at this clinic?
Number
2
b. How many clinicians who are working here have been on a formal
training course in STI syndromic management?
1
c. How many clinicians working here have been on a formal
HIV/ AIDS counselling course ?
1
d. How many clinicians (doctors or nurses who examine and treat clients)
are working today?
2
22. If you had a problem about STI management who would you consult?
(State name and designation of this person) ...............................................................................................
.............................................................................................................................................
STI DRUGS AND TREATMENT
23. Visit the pharmacy or drug store room. Ask the pharmacist or nurse in charge of drugs the following:
DRUGS Is it currently Over the last month has State the reasons for
in stock? the drug run out? drugs running out.
Yes/No
Yes/No
1. Ciprofloxacin 250mg tabs
✓
No
2. Metronidazole 400mg tabs
✓
No
3. Erythromycin 250mg tabs
✗
yes
No stock
4. Doxycycline 100mg tabs
✓
no
5. Benzathine Penicillin 2.4 mu
✓
No
Using the DISCA Tool
31

STI Syndrome What type of drugs did the patient receive? Correct Correct Correct RPR test
clients drug dosage frequency requested
See codes State the type, dose and duration & duration
below
Yes/No Yes/No Yes/No Yes/No
1
2
3
4
5
6
7
8
9
10
2
1
2
2
2
4
5
2
2
Flagyl 400mg stat
Ciprobay 500mg stat
Ciprobay 500mg stat
Flagyl 2g stat
Flagyl 2g stat
Flagyl 2g stat
Ciprobay 500 mg stat
Flagyl 2g stat
Ciprobay 500 mg stat
Flagyl 2g stat
Flagyl 2g stat
Syndromic Codes: (to be used in the 2nd column above);
1 - Penile discharge 2 - Vaginal discharge 3 - Pelvic inflammatory disease (PID)
4 - Genital Ulcers 5 - Genital warts 6 - Other STI (specify)
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
No
No
No
No
No
No
No
No
No
No
24. Fill in the information below for the 10 most recent clients treated for an STI. Use the client cards, daily
register or pharmacy records to obtain the information
1 Ciprobay 500mg stat
Doxycycline 200 mg t.d.s. x 5/7
Doxycycline 200 mg t.d.s. x 5/7
Doxycycline 200 mg t.d.s. x 5/7
32 Using the DISCA Tool

25. Ask a clinician the following questions: (check answer with STI syndromic management guidelines)
(a)
What drugs (type, dosage, frequency and duration) would you use to treat:
(i) a man with penile urethral discharge?
Ciprobay 500 mg stat
...................................................................................................................
...................................................................................................................
correct
incorrect
(ii) a woman complaining of a vaginal discharge?
Flagyl 2g stat
...................................................................................................................
...................................................................................................................
correct
incorrect
(iii) a man or woman with a genital ulcer?
Ciprobay 500 mg stat
...................................................................................................................
Flagyl 2g stat
...................................................................................................................
correct
incorrect
(b)
How would you treat a pregnant woman with an STI vaginal discharge?
...................................................................................................................
...................................................................................................................
correct
incorrect
(c)
If doxycycline was out of stock what would you use in its place for discharges?
(give drug, dosage and duration)
...................................................................................................................
...................................................................................................................
correct
incorrect
COMMENTS
26. What are the problems that affect the daily delivering of quality STI care in this facility?
.............................................................................................................................................
No problems
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
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33

27. What recommendations will you make to improve the situation:
None
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
28. What is the plan of action resulting from this supervisory visit?
( The supervisor should discuss this with senior clinicians)
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
29. Additional comments:
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
.............................................................................................................................................
The first version of this tool was developed by Nicol Coetzee and Sphindile Magwaza.
This version is the result of further work by the National STI Initiative
The DISCA has been approved by the Department of Health
Funded by the Reproductive Health Fund of the Health Systems Trust
Further copies available from National STI Initiative (Telephone 031-332 8315) or
Health Systems Trust (Telephone 031-307 2954)
This questionnaire may be photocopied for further distribution.
34 Using the DISCA Tool

Using the DISCA Tool
35

36 Using the DISCA Tool