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Enhancing Quality for Clients: The Balanced Counseling Strategy
Program Brief no. 3, July 2003

The findings from the studies in Peru were disseminated to key stakeholders in and beyond Peru by means of regular bulletins. This dissemination not only helped stimulate efforts to scale up the use of the counseling strategy within Peru, but also generated an opportunity to test the balanced counseling strategy in other settings.

Replication in Guatemala

In late 2000, based on the findings reported in the initial progress bulletins and personal presentations on the Peru intervention, the Guatemalan government expressed interest in testing the counseling strategy and the job aids for use within the Guatemalan context.

Ministry of Public Health and Social Assistance (MSPAS)

In mid-2001, the Guatemalan MSPAS began working with Calidad en Salud (Quality in Health), a project implemented by the University Research Corporation, LLC and supported by the U.S. Agency for International Development (USAID), to test the effectiveness of the balanced counseling strategy and job aids among providers at Guatemalan health centers and rural health posts. In contrast to Peru, where providers are generally obstetric nurses with university degrees, most providers in Guatemala are paraprofessionals: auxiliary nurses with two years of training.  

For this group of providers, researchers, trainers, and health authorities developed a 22-step algorithm offering detailed instructions, eight method cards corresponding to the methods offered at MSPAS health centers, and one card for ruling out pregnancy. Providers in the Guatemalan study received four revisits to reinforce training on the use of the algorithm. Supervisory nurses from the participating health districts were also trained in the use of the algorithm and job aids, and were instructed to monitor its use and offer feedback on the interaction between providers and clients. 

Approximately 320 providers from 40 health centers and posts in two departments (administrative regions) populated by Mayan- or Spanish-speaking ethnic groups received training in the algorithm and the use of the method cards and pamphlets. At 40 control facilities (located in two departments with demographically similar populations), providers received only the method pamphlets. Simulated clients enacting two profiles visited both experimental and control clinics, and filled out checklists to assess the quality of care before and after the intervention. 

Findings

• Quality of care improved. The quality of care improved significantly among the experimental clinics following the intervention. Mean quality of care scores, as rated by simulated clients, increased from 18 to 43 of a possible 65 points in the experimental sites. This represents an increase of about 80 percent over the control sites. At control sites, the mean scores increased from 20 to only 24 (see Figure 5).

Figure 5. Average quality scores of providers at experimental and control clinics in Guatemala Source: León et al. 2003a.

• Most providers used the algorithm and job aids. Simulated clients reported that nearly three-quarters (72%) of the providers in the experimental facilities used the algorithm with both job aids. Eighty-five percent of the providers used the method cards. The main reason for not using the method pamphlets, according to Guatemalan providers, was that they were not available at the time. This result is considerably better than the 37 percent use achieved in Peru and suggests that the four revisits provided important reinforcement of the training.
   

• Time used during each session increased. Counseling session length increased from 12 to 14 minutes in the control group and from 13 to 24 minutes in the experimental group. Improvements in quality of care were associated with the increased counseling length. As in Peru, increased counseling time is unlikely to hinder client flow, as long as the proportion of new users remains around 10 to 15 percent (León et al. 2003a). 

Beginning in January 2003 MPSAS and Calidad en Salud expanded training in the use of the balanced counseling strategy to 3,600 service providers throughout Guatemala. The results of this expansion will be available on completion of the activity in 2004.  

In spring 2001, the Guatemalan Institute of Social Security (IGSS) tested the strategy and job aids for use in its Gynecology and Obstetrics Hospital, a large facility in Guatemala City that provides family planning to over 12,000 postpartum and postabortion clients annually.  

IGSS worked with Calidad en Salud to adapt the MSPAS algorithm and job aids for use among its clients. Preliminary findings showed significant improvements in quality of care. Clients’ knowledge about their chosen method increased following the intervention (León and Ríos 2003). Knowledge about preventing sexually transmitted infections also increased. IGSS is conducting activities to scale up the intervention at six more IGSS hospitals that provide services to 95 percent of family planning users served by the institute. 

Scale-up in Peru  

The Peruvian MOH began preparations to scale up use of the balanced counseling strategy in early 2001 based on encouraging preliminary findings. The Ministry printed posters describing the balanced counseling strategy and reproduced the method cards and pamphlets for use during counseling sessions. The job aids were distributed to facilities in all the 12 experimental districts. It is anticipated that the MOH will incorporate the strategy into its training plans and revise its guidelines for family planning counseling to include the strategy and job aids nationwide.

While research on the new counseling model was still underway, Peru’s MOH shifted its emphasis from family planning to an integrated approach to reproductive health services. A test of the strategy at EsSalud, the former Institute of Social Security of Peru, showed that the balanced counseling strategy could be incorporated into an integrated care model. As part of the dissemination process, the Council presented three one-day workshops at EsSalud clinics to introduce the balanced counseling strategy and the operations research approach. 

EsSalud adapted the strategy using the algorithms developed in Guatemala. They expanded the algorithms to incorporate various aspects of reproductive health and conducted a limited test on 15 experimental providers and 15 control providers in the department of Lima. The intervention improved the quality of care provided during counseling. However, providers did not implement the counseling strategy unless they were being observed. When asked why they did not use the strategy, the providers said that its use would add too much time to counseling sessions, and that they were uncertain of the benefits of the strategy. Nevertheless, EsSalud found sufficient positive results to request assistance in scaling up the use of the strategy.  

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Hard copies available free of charge from frontiers@popcouncil.org; also available in PDF (520 KB)

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Population Council
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Telephone: +1 202 237 9400
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This page updated
03 January 2009