Quality Of Family Planning Programs Research Paper

1. The Concept Of ‘Quality Of Care’

The concept of quality has been difficult to pin down precisely. Bruce (1990) defined quality as an important but neglected ‘dimension’ that all family planning services have. Whether the quality of a given service is good or bad is a matter of judgment. Bruce identified six elements in the quality of care framework as ‘critical’ aspects of services from the perspective and experience of clients. These are: choice of methods; information given to users; technical competence of providers; interpersonal relations between providers and clients; follow-up or continuity mechanisms; and appropriate constellation of services. While the use of these elements will assess from client’s perspectives, their actual articulation in the framework are not based on any systematic or random surveys of clients’ attitudes toward and expectations from services. Furthermore, clients may not be able to assess the adequacy of elements such as the technical competence of providers or what information they should have received at the time of interaction. The main purpose of this framework has been to draw attention to a neglected dimension and to generate interest among managers and donors toward improving the quality of care.

One criticism of Bruce’s framework has been that clients themselves may not necessarily define these elements as critical in their decision to use family planning services. In this sense, quality needs to be distinguished from other concepts, such as availability, accessibility, and cost of services—all of which may also influence an individual’s decision concerning the use of services. Sometimes there is a tendency to discuss all these factors together; but that is not useful for understanding and improving any particular dimension of services. While availability simply refers to the physical availability in an area, accessibility to a service delivery point (SDP) is usually defined and measured in terms of the available mode of transportation and the time taken in reaching that SDP. The cost of utilizing services is typically defined and measured by financial cost involved in getting services once the client reaches that SDP. At times, total cost also includes other costs that the client may bear— social, psychological, and the opportunity costs. Quality, on the other hand, reflects what happens to the client once they reach the SDP.

Often the two terms—‘quality of services’ and ‘quality of care’—are used interchangeably. Nevertheless, a distinction must be made between them. The quality of services refers to attributes of the family planning services, e.g., the number and types of contraceptive methods, staff, and equipment available at an SDP. In comparison, quality of care refers to the way clients are treated by the system providing these services. For example, choice can be offered to clients only if the SDP stocks various methods; on the other hand, availability of methods at an SDP does not guarantee that a choice will be offered to a particular client. In this sense, quality of care places additional emphasis on the interpersonal interactions between providers and clients.

1.1 Improving Quality

A distinction must be made between determinants, indicators, and impact of quality. The determinants of quality include factors such as national population policies, resources allocated to services, and other social and cultural factors. The impact of quality, by contrast, can be considered in terms of improvements in clients’ knowledge and behavior with respect to contraception, fertility, and health. As mentioned above, quality is a dimension that all programs have. In this sense, there is always room for improvement, irrespective of the current level of quality. There is no real maximum or upper limit. As far as the minimum level of quality is concerned, such standards should be set locally and explicitly through a process of discussion, which should seek to address the following four interrelated questions:

1. What quality of care does a program intend to offer?
2. What quality of care is a program prepared to offer?
3. What quality of care is actually offered to clients?
4. What quality of care is received by the clients?

The process of quality improvement can start with any question. The process is illustrated here by considering the element of choice. The first question deals with the explicit statement at the policy level about clients’ right to choose among appropriate methods. The statement then has to be translated into practice through asking the second question, i.e., by considering the type and number of methods that are approved by the program in a country and by considering how appropriate the logistic system to deliver these methods to SDPs is. The next step in the process will be to ascertain whether the intended methods are actually available at an SDP and whether the providers are prepared to offer these methods, i.e., whether they have the requisite training and equipment. This type of assessment at the SDP level will inform the program managers about the extent to which the SDPs are prepared to offer a choice.

Next comes the assessment of the interactions between providers and clients, and this can be done from two perspectives, namely (a) whether the provider has actually offered a choice to clients, and (b) whether the client has received the choice. A particular program may, for example, decide to include three methods, improve the logistic system to get these methods and other required equipments to SDPs, and train providers to offer these methods, i.e., the program intends and is prepared to offer three methods. When a client walks into the SDP, the provider may even offer a choice between two methods; but the client’s experience may be that she was not offered the third method of her choice even though all the procedures were in place and even though she had no medical contraindication.

Thus, it is important to think of quality at three levels—policy, SDP, and client. Quality at the policy level and quality of services at the SDP level can be considered as determinants of quality of care actually received by clients. What a particular client receives is the most important basis for assessing, monitoring, and improving quality of care. The identification of gaps between intention, preparedness, services offered, and care received through self-assessment and through systematic data collection is important for an eventual improvement of the quality of care received by clients over time.

The management literature suggests that the commitment of top management is critical in improving quality of care. But how one can generate commitment to quality of care among top management of family planning programs remains an unresolved issue. Unlike in the private sector, a commitment to improve quality in public sector programs with no competition cannot be generated by the motivation of maximizing profit or by the fear of going out of business if consumers do not like the product. Nevertheless, a combination of various approaches can make it happen.

One way to generate commitment to quality of care is through an organized movement of consumers to demand services of good quality. Another way could be for international donors and institutions to lobby for good quality of care from the consumer’s-right perspective. A third possibility is for the top management to realize that improvements in quality will help them to achieve their stated goals of providing services in the first place. A fourth way is for the research community to generate empirical evidence to demonstrate the effect of improved quality of clients’ knowledge and their reproductive behavior and health.

1.2 Monitoring Quality

There is considerable interest in creating indicators to measure and monitor quality. This interest stems from the observation that what gets measured and monitored also gets improved. Various efforts have been made to create indicators of quality. A breakthrough came with the methodological invention— Situation Analyses—to collect data from SDPs by actually visiting them. The technique usually involves collection of data about services on the day of a team’s visit to a SDP through four questionnaires. The inventory questionnaire collects data about equipment and commodities available at the SDP. Information about provider’s background, training, experience, attitudes, and knowledge is collected by interviewing providers working at the SDP. Information about quality provided and received is collected by observing client–provider interactions and by interviewing clients after they finish receiving services. These surveys conducted throughout many developing countries, especially in Africa, have provided important and useful information about the service environments. Surveys conducted over time on a representative sample of SDPs are also useful in measuring, monitoring, and improving quality. However, there is no agreed and tested set of indicators of quality. Additional efforts continue to be made.

Regular monitoring of commodities, equipment, and staff is equivalent to monitoring quality of services, which is sometimes included in what is called ‘quality assurance.’ Quality assurance is, however, not the same as quality of care, and it may be more difficult to measure and monitor the latter regularly. The problem is created by the small number of clients who use the SDP on the day it is visited by the data collection team. In some surveys, many SDPs visited did not have a client, and quite a few had just one or two clients. Biases are also introduced simply by the presence of an ‘observer’ at the time of interaction. Finally, it is difficult to assess the effects of variations among SDPs and providers on the overall quality of care indicators developed on the basis of only a few observations. Some of these issues are also being addressed by ongoing research.

2. Impact Of Quality

Clients deserve services of good quality, and they deserve to be treated with dignity and respect while accessing these services. From this perspective, there is no need to demonstrate the effect of improving quality on the reproductive behavior and health of clients. However, since family planning programs in developing countries have also been justified and evaluated in terms of their contribution to fertility decline, an assessment of the effect of improved quality on some indicators of fertility becomes critical in the process of improving quality.

Women who are very motivated (or desperately want) to control their fertility would do so even without the public sector services or even if these services were of poor quality. At the other extreme, women who do not want to regulate their fertility would not use services provided even if they were of the best quality and were available next door at no cost. Improved quality is hypothesized to affect the behavior of women in between these two extremes— those who are ambivalent about their fertility intentions, and those who do not go to services or discontinue the use of contraception because they feel that they receive poor quality or bad treatment. Improvements in quality of care thus can be expected to contribute to the reduction of unintended (unplanned and unwanted) pregnancies and not so much to the reduction in intended pregnancies.

Empirical studies to demonstrate the effect of improved quality on women’s reproductive behavior are limited. It has been suggested that a focus on decreasing discontinuation of contraceptives is a better strategy than a focus on attracting new users and not taking good care of their needs. There is also some indication that improved quality in terms of providing a choice among methods increases contraceptive use by attracting new users, as well as by improving continuity of use. Moreover, improving the contents of information exchange between clients and providers improves the initial selection of the method and also improves continuity of contraceptive use. Additional studies are underway in Pakistan, the Philippines, Senegal, Zambia, and other countries, and they will shed further light on the effect of improved quality on clients’ knowledge and behavior.

3. Future Directions

Quality was a neglected dimension of family planning services until about a decade ago. Clients have the right to, and they deserve, services of good quality. Therefore, program managers need to pay attention to improving quality of services. Empirical studies to demonstrate the effect of improved quality on clients’ knowledge and behavior can only provide additional justification for improving quality; they cannot replace the main rationale of improving quality—clients’ right to good quality.

The original framework of quality assessment was developed for contraceptive services provided through the public sector and through its fixed SDPs. Moreover, the framework is primarily applicable to first-time users of these services. This does not mean that services provided through the private sectors are of good quality or are monitored regularly. This also does not mean that repeat users of a SDP receive services of good quality. There are some efforts to extend the framework to other services and also to incorporate the experiences of repeat users. Such efforts need to be continued. Above all, there is a continued need to initiate processes in developing countries to improve quality of care received by clients.

It is possible to improve quality. It is true that improvements in certain elements (e.g., improving choice of contraceptives by adding new methods) will imply additional costs to the program. It is also true that poor quality resulting in the underutilization of services is costly. Moreover, an improvement in certain other elements is unlikely to cost much. This is especially true for items such as treating clients with respect and dignity and providing them with adequate and accurate information.

Providers often go through initial and refresher training programs. It should not be costly to modify the content and philosophy of these training programs so that providers learn how to solicit information from clients about their reproductive intentions, prior contraceptive experience, and to learn about other pertinent social factors which might influence the selection and use of a particular contraceptive method. It should also be possible to modify training programs so that providers learn how to offer clients adequate and accurate information about how to use the method selected and its adverse effects, how to manage those effects, when to come back for a checkup or a new supply, protection against transmission of disease, and the possibility of switching between methods or sources of supply whenever the method or source initially selected does not remain suitable for the client. Such a transformation, however, would require a shift from using family planning programs as a tool to reduce aggregate fertility and population growth to helping or empowering clients to achieve their own stated reproductive goals in a healthful manner.

Bibliography:

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