September 2002, Vol. 8, No. 2

Quality of Care
Improving Provider–Client Interactions in the Philippines

One way to improve the quality of care provided at family planning clinics is to enhance provider–client communication so that clients will be better able to regulate their fertility in a healthful manner. Making services client oriented is the cornerstone of high-quality care and takes little or no extra funding to implement, an important factor in resource-poor settings in the developing world. Most health care providers already receive regular training. Existing classes can be reconfigured to focus on ways of improving interactions with clients.

Client-centered approach 
The implementation of a client-centered approach requires that providers and programs shift from a reliance on family planning methods to a focus on client needs. To accomplish this, providers need to discover the clients’ desires, particularly women’s plans for future childbearing. They should give clients a range of contraceptive methods from which to choose. They need to convey appropriate and accurate information about the selected method. Finally, the provider must assure the client that she can switch to another method at any time.

At a Population Council workshop, program managers and researchers from the Davao del Norte province of the Philippines stated that a large proportion of family planning clients in their region discontinued contraceptive use. They identified inadequate dialogue between clinician and client as a key source of this behavior. Providers often withhold information about side effects, for example, fearing that the knowledge may frighten potential clients. A number of studies from around the world, however, have illuminated the importance of a thorough exchange of information between provider and client. Many have shown that such conversations increase rather than decrease continuation of contraceptive use. 

As part of the Population Council’s Impact Studies project—which seeks to evaluate the effects of quality-of-care improvements—researchers looked at ways to enhance provider communication skills in the Philippines. Council researchers assessed the effects of these interventions by comparing experimental with control municipalities. 

Davao del Norte province 
One study in the Philippines examined clinics from ten matched pairs of municipalities in Davao del Norte province. One locale from each pair was randomly assigned to the experimental group and the other to the control group. Council researchers collaborated with colleagues from AVSC International (now EngenderHealth) to identify strengths and weaknesses in the experimental clinics, particularly those related to provider–client communication. 

Eight doctors, 11 nurses, and 38 midwives from the experimental clinics received five days of training following this assessment. Midwives also attended three refresher courses over a three-year period, from 1997 to 1999. Service providers from control clinics did not receive this training. Provider knowledge was assessed both before and after these courses using detailed interviews. No appreciable change was found in the knowledge of providers from the control clinics during the study. On the other hand, the knowledge of providers from the experimental areas concerning side effects and warning signs increased significantly. 

The researchers also interviewed 1,728 new contraceptive users—869 from experimental clinics and 859 from control clinics. The researchers evaluated five aspects of quality of care: whether clients’ needs were assessed, whether clients were presented with a choice of contraceptive methods, whether they received necessary information about their selected method, whether they were told when to return to the clinic, and whether they were treated well. Clients who had visited the experimental clinics reported receiving significantly better care than did those who used control clinics. A significantly greater proportion of clients who attended experimental clinics reported receiving complete information.

"Although we did see significant progress after the intervention," says Population Council researcher Saumya RamaRao, "much room for improvement still exists for all dimensions of quality of care." Even in the experimental clinics, one-third of patients did not have all their needs assessed, two-thirds did not get full information, three-fifths reported not being treated well, and nine-tenths were not well informed about follow-up services. 

In a companion study the researchers trained 110 outreach workers in two of the experimental municipalities to use a series of questions to elicit clients' reproductive health needs. Needed services were then offered in the home or clients were referred to a clinic. The trained outreach workers contacted 6,173 married women living in the municipalities and assigned priorities for subsequent follow-up visits. 

"This project demonstrates the feasibility of enhancing providers' information-dispensing capabilities within the confines of existing resources," says Anrudh Jain, senior director of policy and regional programs at the Population Council. During the next phase of the study, researchers will follow up with clients after one and two years to determine contraceptive continuation rates.

Sources
Costello, Marilou, Marlina Lacuesta, Saumya RamaRao, and Anrudh Jain. 2001. “A client-centered approach to family planning: The Davao project,” Studies in Family Planning 32(4): 302–314. (PDF)

Jain, Anrudh, Saumya RamaRao, Marilou Costello, Marlina Lacuesta, and Napoleon Amoyen. 2002. “Learning about clients’ needs: Family planning field workers in the Philippines,” in Nicole Haberland and Diana Measham (eds.), Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning. New York: Population Council, pp. 99–113.

Outside funding
The Rockefeller Foundation and the United States Agency for International Development

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