Population Briefs | June 2004, Vol. 10, No. 2 | Family Planning: Review Finds Scarce Documentation on Quality-of-Care Efforts

Population Briefs: Reports on Population Council Research

June 2004, Vol. 10, No. 2

Family Planning
Review Finds Scarce Documentation on Quality-of-Care Efforts

In 1990, the Population Council’s Judith Bruce, now director of the Gender, Family, and Development program, developed a framework for studying quality of care in family planning service delivery and listed its key dimensions. This tool provided a means for researchers to determine what factors hindered or advanced the provision of high-quality care. Since that time, many family planning program managers and providers have instituted changes intended to improve quality, and many believe that a good deal is known about the effect of such changes on client satisfaction and behavior. Population Council program associate Saumya RamaRao and Raji Mohanam of Embryon, Inc. reviewed the available research on this topic and published their findings in Studies in Family Planning. They found that there are, in fact, few rigorous experimental studies of quality-of-care interventions.

RamaRao and Mohanam reviewed studies that assessed the readiness of clinics to deliver services or investigated the effect on clients of their interactions with providers. Readiness to deliver services refers to such factors as buildings, contraceptive supplies, and trained staff. “Readiness alone does not ensure good quality,” states RamaRao. “The communication between the provider and the client may be the most important element.”

Assessing quality
RamaRao and Mohanam outlined ways to measure the quality of services. One technique, situation analysis, was developed by Population Council researchers. Situation analysis is a practical technique for pinpointing problems in many types of service delivery. Researchers employ interviews, inventories, and observations of provider–client interactions to gather data on adequacy of training, staffing, equipment, supplies, and readiness to provide services. Findings from a representative sample of facilities can be used to estimate the needs of the whole system and to develop and test feasible strategies to address these needs. Findings from situation analysis have been used to guide the direction of policies and programs in Botswana, Morocco, Vietnam, and other countries around the world.

Another tool, the “mystery client,” involves sending trained people anonymously to act as clients at clinics; they obtain services and report on their experiences. This method lowers the cost of data collection and reduces the intrusiveness of research. In lieu of mystery clients, exit interviews of actual clients provide information on client–provider interactions.

Undocumented efforts
RamaRao and Mohanam found that although many innovative ideas for improving quality of care are being implemented in a variety of settings, these efforts are largely undocumented and unevaluated. Methodological flaws they encountered included absence of control groups, lack of timely measurements, and inadequate samples. The researchers uncovered only 15 rigorous studies.

The small number of systematic studies that have been published clearly show that quality can be improved and that good care has beneficial effects. The available research, which looks at interventions designed to make both system-wide and specifically targeted improvements, has shown that better physical infrastructure does not always result in better care. The most promising interventions are the ones that facilitate an improved interaction between clients and providers.

Unanswered questions
Their review reveals a number of unanswered questions, say RamaRao and Mohanam. How will health-sector reforms, such as the decentralization of authority that is occurring in ministries of health around the world, influence the process of improving quality of care? What levels of readiness and quality of care can be found in the private sector? Why do family planning clients choose to use some facilities rather than others? What changes would encourage clients to continue to visit facilities and stay with existing programs? How can family planning programs ensure that their services are responsive to the needs of their clients? How can quality of care be improved without extraordinary financial outlays? What curriculums exist or could be developed for medical and nursing schools for integrating quality of care into the training of medical providers?

“We’ve won the battle about giving prominence to quality,” concludes RamaRao. “What the field lacks is rigorous evaluation. Without this we do not know whether we are meeting our objective of helping individuals meet their reproductive goals in a healthy way.”

Source
RamaRao, Saumya and Raji Mohanam. 2003. “The quality of family planning programs: Concepts, measurements, interventions, and effects,” Studies in Family Planning 34(4): 227–248. (PDF)

(Return to issue contents)