Improving Quality of Care in Family Planning

Population Council researcher Anrudh K. Jain provided some of the first empirical evidence for the relationship between family planning method choice as an aspect of service quality and the prevalence of contraceptive use. Since then, several studies have demonstrated that improving the quality of reproductive health services increases contraceptive use.

The Landscape

Population Council policy analyst Judith Bruce expanded upon Jain’s observations. Bruce maintained that family planning is a vital social investment and an essential aspect of development, independent of a country’s demographic interests. She also contended that when the quality of family planning services is improved, more women would become committed and satisfied users, with clear demographic benefits. These outcomes would include a healthier and more empowered female population. Improving the quality of family planning services would also help a country meet its distinct but important goal of slowing population growth.

To make these good intentions a programmatic reality, Bruce developed the family planning quality of care framework, which motivated widespread reassessment of how family planning services could be improved.

The Paradigm Shift

Bruce detailed six “salient elements of family planning programs that together constitute quality”:

  1. Choice of methods: “Choice is not only the first, but the fundamental element of providing quality in services,” wrote Bruce. Clients’ needs and preferences change over time; having the ability to switch methods when women desire is a foundation for satisfied and sustained use of family planning. The spectrum of methods offered must have sufficient diversity to meet the varying needs of clients.
  2. Information given to clients: “There persists poor knowledge of the proper use, risks, and benefits of contraceptives,” wrote Bruce. Providers often do not inquire about clients’ intentions and health and fail to offer information necessary to help users select and practice contraception effectively.
  3. Technical competence: “Clients bear the consequences of poor technique in the form of unnecessary pain, infection, other serious side effects, and in some circumstances, death,” Bruce wrote.
  4. Interpersonal relations: It is often assumed that providers can’t be taught better interpersonal relations. However, they can, Bruce maintained. And, “for many clients,” Bruce wrote, “being treated badly is worse than receiving no care at all.” Providers must recognize and address all of the personal dimensions of service, including sensitivity and respect.
  5. Mechanisms to encourage continuity of care: The broad objective of encouraging continuity of care is to ensure that after the first contact with a family planning provider, the trail does not end. “Effective follow-up and support of clients may demand some new resources,” wrote Bruce, “but they also require a stronger marketing sense and innovative thinking.”
  6. Appropriate constellation of services: Programs can go beyond the conventional boundaries of family planning to offer reproductive health services as well as the diagnosis and treatment of reproductive tract infections and sexually transmitted infections, among other services. “The appropriate constellation of services is one that responds to clients’ rhythms and health concepts,” Bruce wrote, “rather than inflexible medical demarcations of where a need begins and where it ends.”

The Council has developed and refined strategies—including situation analysis, operations research, and the HARI (“helping achieve reproductive intentions”) index—to measure and improve quality of care. In seeking to enhance program quality, the Council urged program managers to ask and answer four key questions:

  1. What standard of care does the program wish to offer?
  2. What standard of care is the program able to offer?
  3. What quality of care is actually offered to and received by clients?
  4. What effects do services have on clients’ health and wellbeing?

This assessment tool has paved the way for national program managers to expand and improve their services and eliminate practices that fail to protect and promote the health and wellbeing of individuals.

The Lasting Impact

For more than two decades Bruce’s Quality of Care Framework has guided the design and delivery of services in the fields of family planning and reproductive health. The framework has been modified over the years, with components added or broadened depending on the context and scope of a program, yet it remains the foundation for defining the goals and evaluating the outcomes of family planning programs.


Miller, Robert, Andrew Fisher, Kate Miller, Lewis Ndhlovu, Baker Ndugga Maggwa, Ian Askew, Diouratie Sanogo, and Placide Tapsoba. 1997. The Situation Analysis Approach to Assessing Family Planning and Reproductive Health Services: A Handbook. New York: Population Council.

Bruce, Judith. 1990. “Fundamental elements of the quality of care: A simple framework,” Studies in Family Planning 21(2): 61–91.

Jain, Anrudh K. 1989. “Fertility reduction and the quality of family planning services,” Studies in Family Planning 20(1): 1–16.

Kumar, Sushil, Anrudh K. Jain, and Judith Bruce. 1989. “Assessing the quality of family planning services in developing countries.” Programs Division Working Paper (no. 2). New York: Population Council.


United States Agency for International Development