A "Client Perspective" Helps Improve Services

Frameworks for improving quality of services have common
features, including a client emphasis.

Network: Fall 1998, Vol. 19, No. 1

Copyright Family Health International, 1998. 
Network is reprinted with permission from Family Health International.

Family planning clinics throughout Egypt are displaying gold stars on their front doors, part of a campaign to promote client satisfaction. The Ministry of Health program trains family planning clinic supervisors to use a checklist of 101 indicators to evaluate services, ranging from availability of contraceptive commodities to the condition of facilities. Community television messages and posters ask people to look for the gold stars, which indicate clinics that meet quality service standards. One poster says, "We are behind every door here to serve you and take care of your family." Begun in 1992, the program is currently used by nearly 4,000 clinics nationwide.

Traditionally, family planning services worldwide have concentrated on increasing contraceptive use, in part to reduce fertility rates. More recently, they are focusing on the quality of service as well.

"When we talk about quality of care, we are looking at services from the client's perspective," says Dr. Carlos Huezo, medical director of the London-based International Planned Parenthood Federation (IPPF). Clients have the right to information, access, method choice, safety, privacy, confidentiality, dignity, comfort, continuity and opinion, he says.

In order to achieve these goals, providers need adequate training, current information, infrastructure, supplies, guidance and respect. IPPF has included client rights and provider needs in its service delivery guidelines,¹ and has widely circulated a poster on the rights of clients.

Another approach to thinking about quality care identifies six elements. The "Bruce framework," developed in the 1980s by Judith Bruce and an advisory committee at the Population Council, a research organization based in New York, gives method choice as "not only the first, but the fundamental element of providing quality in services." Other elements are the amount and quality of information given to clients, the technical competence of providers, the interpersonal relations between the client and provider, the mechanisms used by a program to encourage continuity, and the appropriate constellation of services provided.² The Pan American Health Organization and FHI have expanded this framework, adding such elements as the need to coordinate reproductive health services, including family planning, prevention and treatment of sexually transmitted infections and maternal and child health care.

These and other frameworks for improving services tend to have common features: They emphasize better ways to interact with clients, and they often address how to approach specific management concerns, such as maintaining adequate contraceptive supplies.

Client interaction

In recommendations on provider practices, the U.S. Agency for International Development (USAID) has summarized key processes involved in the interaction between clients and providers and the information that clients need during counseling. For services to be most effective, providers need to give clients their preferred method, treat clients well, individualize each session, be interactive and responsive to clients' questions, avoid information overload, and provide memory aids.³

Studies have shown the importance of providing a client's preferred method. A study in Indonesia among nearly 2,000 women found that receiving the desired method resulted in much higher continuation rates. Among the nearly 1,700 women granted their method choice, only 9 percent had discontinued contraceptive use a year later. Among the 266 women who did not get their first choice, 72 percent were not using the method a year later.⁴ A study coordinated by IPPF involving 11,000 women found that a key factor in method continuation was whether the women obtained the method they had intended to use before coming to the clinic. The study was conducted in Guatemala, Hong Kong, Jordan, Kenya, Trinidad and Tobago, and Nepal.⁵

Clear and complete information about side effects is important. FHI's Women's Studies Project found that both real and imagined side effects are a serious concern for many women, more than providers realize. In Bolivia, for example, the 25 percent of the contraceptive users who said they were dissatisfied with their method blamed side effects. The project found similar trends in Bangladesh, Egypt and Indonesia.⁶

"Part of the realignment of programs towards quality is truth in advertising," says an author of the USAID recommendations, Elaine Murphy of Program for Appropriate Technology in Health, a U.S.-based group providing technical assistance. "Good counseling will include the fact that you may have some symptoms that are upsetting but they will generally go away. If a client does not know that, she would not last through those initial symptoms. Where women have been counseled on side effects, continuation is very high."

Counseling about family planning may be more effective if it is not overly promotional. "If you are promotional, you do not talk about the negative aspects of a method," says Murphy, who co-chairs a USAID committee on client-provider interaction.

A study among 650 new contraceptive users in Niger and 570 in The Gambia assessed the reasons for discontinuation of use. After eight months, about 30 percent of new users had discontinued use. The most commonly cited reasons were side effects and fear of side effects. Among the women in Niger who said they did not receive adequate counseling, 37 percent discontinued using a method, compared to only 19 percent discontinuation among those who reported receiving good counseling. In The Gambia, 51 percent of those who said they received poor counseling discontinued, compared to 14 percent discontinuation among those who said counseling was adequate.⁷

In addition to adequate information about side effects, good counseling should include effectiveness, advantages and disadvantages, how to use the method correctly, when to return, and STD prevention. However, providing too much information can be counterproductive. "There are limits to the amount of information people can understand and retain counseling should not be dominated by a recitation about every method offered in a program," say the USAID recommendations. "Instead, providers should focus on the client's selected method and be brief, non-technical and clear."

Counseling on proper use of the method is the critical element for changing contraceptive use behavior, says Dr. Deborah Oakley of the University of Michigan in the United States. Dr. Oakley, who has studied correct method use, has found that about 30 percent of women need more individualized counseling to help them use oral contraceptives effectively. "Most counseling deals largely with method choice and exhortation about only one specific use behavior, taking a pill every day at the same time," she explains.⁸ Rather than giving uniform, generalized answers to all women regardless of their specific situations, individualized care should be provided. Providers should consider how different life stages or life situations affect counseling. A young woman who is a first-time user, a breastfeeding mother who wants to space the next birth, and an older woman who wants no more children have different counseling needs.

Individualizing a counseling session can also help first-time family planning users. Women under 24 years old have the highest discontinuation rates, according to an analysis of Demographic and Health Survey data.⁹ These clients may benefit from the attention of individualized counseling.

Some providers should talk less and listen more. In Ghana, Kenya and Indonesia, studies found that providers spoke about two-thirds of the time during counseling. In addition, more than 70 percent of the clients' participation was passive, often involving short responses or showing agreement with the provider. When clients actively participate, they often elaborate on a response and ask important questions.

"The findings suggest that changes are needed in both providers' and clients' behaviors if clients are to play a more active role in counseling sessions," says Young Mi Kim of Johns Hopkins University's Population Communication Services, who worked on the studies.¹⁰ For example, at the beginning of a session, a provider could say, "I would like you to speak freely with me today. Please ask me anything you wish." Providers should lead less and respond more, while clients should be encouraged to voice their needs and opinions. Local programs could use videos and audiotapes in the waiting rooms, hold group talks while clients wait, and have providers encourage clients to participate.

Outreach efforts can improve contraceptive use. A study in Bangladesh found that simply contacting the client at home contributes to better contraceptive continuation rates. "Overall odds of discontinuation are reduced by 65 percent if women are contacted at home at least once in a 90-day period," the study found.¹¹

Management concerns

Approaches to improve reproductive health services management skills have emerged, with names such as "total quality management," "continuous quality improvement," "continuous assessment," and "Client-Oriented, Provider-Efficient (COPE)." In general, these approaches arrive at solutions for addressing specific problems, and include ways to motivate staff to use these solutions. Most of the approaches attempt to involve staff in the process and to include a regular assessment of progress.

"Quality improvement is not a one-time exercise but an ongoing and ever-changing process," explains Janet Bradley in a review of how the Family Planning Association of Kenya (FPAK) has used the COPE approach. Working with New York-based AVSC International (AVSC), which works to improve reproductive health services worldwide, FPAK began using the four-step COPE system: self-assessment, client interviews, client flow analysis and a plan of action. It trained staff to perform these exercises at each clinic, since this approach emphasizes involving all staff at a location.¹²

Some changes have been simple, such as staff deciding to stagger their lunch breaks so that clients' waiting time could be shortened. In another case, a clinic had an inconsistent water supply, and managers were considering expensive solutions such as installing a new pump. Because the COPE process involved everyone at the clinic, including the groundskeepers, they learned that simply fixing a leaking pipe could solve the problem.

Now used in about 35 countries, COPE can help motivate staff to work towards improving quality. "We have come to see that supervision is a very critical piece of the process," says Maj-Britt Dohlie, who heads an AVSC team that focuses on service quality. "But supervisors alone cannot improve quality. They need to involve staff at all levels." The approach encourages small groups to assess specific problems and develop action plans based on their assessments.

To gain a better understanding of how to motivate staff, IPPF has recently conducted a study in Uganda and Bangladesh involving about 40 workers and managers at government and nongovernmental clinics. Among the factors that seem to motivate them to perform better are a sense of altruism and learning that clients appreciate their work. Negative factors included low pay, delays in getting paid and job insecurity. Solutions to these problems may be difficult, but at least payments could be made on time. "The concepts of quality of care are now quite clear, but still nothing happens in many service delivery systems," says IPPF's Dr. Huezo. "One of the main reasons is the lack of motivation of the provider.

"If every provider has not been given the training they need, how can we expect them to meet the needs of clients?" asks Dr. Huezo. "Providers also need updated information, a proper infrastructure with properly established and equipped facilities, supervision that is supportive and not based on blaming -- all of these are necessary for providers to perform to the optimum."

Quality makes a difference

Many factors influence why women and men adopt and continue using certain contraceptive methods. These factors include individuals' stage in life, the nature of their sexual relationships, their degree of STD risk, their medical condition, their access to services, the availability of the method they want, and the type of counseling they receive. How the service delivery system addresses all of these issues affects the overall quality of service. Because so many issues are involved, measuring the quality of services is a challenge.

Quality of services can dramatically affect the use of family planning. A study in Peru, for example, estimated that contraceptive use would rise from 16 percent to 23 percent if all women lived where programs provided the highest quality of care, compared to living where programs provide the lowest quality of care. In general, the study found that rural areas had both lower quality and lower contraceptive use than urban areas. The study analyzed services at nearly 3,000 delivery points, measuring quality by such factors as method availability and restrictions, provider training, provider bias, information provided, cleanliness, privacy and interpersonal relations, and other reproductive services provided.¹³

However, quality is a subjective notion. A study in Jamaica assessed the perspectives of providers and clients on quality of services, using surveys and interviews of providers and supervisors. It also used reports from simulated clients (people trained for a study who pretend to be clients and observe the care they receive).

The study found that 93 percent of providers said they would recommend their health facility to others, but only 58 percent of simulated clients said they would recommend the health facility they visited. The study evaluated 344 of the 346 health facilities in Jamaica, interviewing about 1,200 providers and supervisors and using 20 female simulated clients who visited 50 randomly selected clinics. ¹⁴ The study also assessed the training providers have received, the information and services clients are given and how these relate to the training, skills and attitudes of providers, the physical environment of the facilities and working environment of providers.

-- William R. Finger

References

1. Huezo C, Díaz S. Quality of care in family planning: clients' rights and providers' needs. Adv Contracept 1993;9(2):129-39.
2. Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann 1990;21(2):61-91.
3. Recommendations for Updating Selected Practices in Contraceptive Use, Volume II. (Washington: U.S. Agency for International Development, 1997)187-94.
4. Pariani S, Heer DM, Van Arsdol MD. Does choice make a difference to contraceptive use? Evidence from East Java. Stud Fam Plann 1991;22(6):384-90.
5. Huezo C, Malhotra U. Choice and Use-Continuation of Methods of Contraception. (London: International Planned Parenthood Federation, 1993)45-46.
6. Barnett B, Stein J. Women's Voices, Women's Lives: The Impact of Family Planning. Research Triangle Park, NC: Family Health International, 1998.
7. Cotton N, Stanback J, Maidouka H, et al. Early discontinuation of contraceptive use in Niger and The Gambia. Int Fam Plann Perspect 1992;18(4):145-49.
8. Oakley D. Rethinking patient counseling techniques for changing contraceptive use behavior. Am J Obstet Gynecol 1994;170:1585-90.
9. Ali M, Cleland J. Determinants of contraceptive discontinuation in six developing countries. Paper presented at the Population Association of America conference, May 9-11, 1996, New Orleans, LA.
10. Kim YM, Kols A, Odallo D, et al. Analysis of client-provider interactions in family planning consultations in primary health care clinics in Kenya, Ghana and Indonesia. Paper presented at the Communication in Health Care Conference, Amsterdam, The Netherlands, June 10-12, 1998.
11. Hossain MB, Phillips JF. The impact of outreach on the continuity of contraceptive use in rural Bangladesh. Stud Fam Plann 1996;27(2): 98-106.
12. Bradley J. Using COPE to improve quality of care: the experience of the Family Planning Association of Kenya. Quality/Calidad/Qualite 1998;9:16.
13. Mensch B, Arends-Kuenning M, Jain A. The impact of the quality of family planning services on contraceptive use in Peru. Stud Fam Plann 1996;27(2):59-75.
14. McFarlane C, Hardee K, DuCasse M, et al. The Quality of Jamaica Public Sector and NGO Family Planning Services: Perspectives of Providers and Clients: Final Report, Prepared for the Ministry of Health and the National Family Planning Board. (Research Triangle Park, NC: Family Health International, 1996) iii.

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