QUALITY OF CARE
Fundamental Elements of the Quality of Care: A Simple Framework
Judith Bruce

(originally published in Studies in Family Planning, Vol. 21, No. 2, March/April 1990, pp. 61–91)

This article argues for attention to a neglected dimension of family planning services—quality. A framework for assessing quality from the client's perspective is offered, consisting of six parts (choice of methods, information given to clients, technical competence, interpersonal relations, follow-up and continuity mechanisms, and the appropriate constellation of services). The literature is reviewed regarding evidence that improvements in these various dimensions of care result in gains at the individual level; an even scarcer body of literature is reviewed for evidence of gains at the level of program efficiency and impact. A concluding section discusses how to make practical use of the framework and distinguishes three vantage points from which to view quality: the structure of the program, the service—process itself, and the outcome of care, particularly with respect to individual knowledge, behavior, and satisfaction with services.

The last decade has seen considerable interest in identifying the critical features that make family planning (FP) services effective in meeting demand. Concurrently, the family planning field has rearticulated its commitment to individuals' and couples' right to make voluntary choices about the number and timing of the children they want, and select compatible means to achieve their goals. Yet, despite intensified concern with program performance and the ethics of family planning service provision, appraisals of family planning programs have generally neglected a central dimension—the quality of care rendered. The time has come to reverse this neglect. Improvements in the quality of services will result in a larger, more committed clientele of satisfied contraceptive users. Over the long term, this expanded base of well-served individuals will translate into higher contraceptive prevalence and, ultimately, reductions in fertility. Within private and commercial programs, where clients provide all or partial cost-recovery, the laws of the marketplace suggest that better services at the right price will attract more patrons. Within publicly supported programs, both clinic and community-based, it is likely that improvements in the quality of services will result in greater initial acceptance and more sustained use.

Though the value of improved care will differ by setting, universal gains would be expected at the individual level in terms of personal well-being and the ability to regulate one's fertility. Speculating more broadly and in very simplified terms about the societal impacts of improved care, in parts of Asia, it is inadequacies in the array of services, and not simply limited contraceptive supply, that constrain expanded use of contraceptives and, in the long run, further reductions in fertility. In Latin America, contraceptive prevalence is generally high, with the stark exception of some indigenous populations and continuing but declining differentials between urban and rural prevalence. Concern exists in many Latin American and Caribbean countries that substantial misuse of self-employed methods occurs as well as overuse of sterilization, and excessive related unhealthful practices, such as delivery by caesarean section when unnecessary. Thus, in this region, the immediate impact of improving services and increasing effective use of temporary methods may be seen in improved client health rather than in the reduction of fertility, but over time, effects are expected in both. In sub-Saharan Africa, underlying health and cultural factors are complex and institutional capacity is limited. Though it may be tempting to make institutional improvements rapidly, services must be built up carefully, so as to engage the trust and patronage of African women and men in cultures where large numbers of children are still highly desired and uncertainty about and unfamiliarity with modern contraceptives may overpower an emerging and co-existent interest in birth spacing.

Beyond the global hypothesis that improvements in the quality of care are essential from human rights and demographic perspectives, it has been proposed that the largest potential reward for improving services exists where societal demand for child spacing and fertility regulation is low or unsteady—and, as a corollary, where maternal and child health (MCH) is poor. At both ends of the spectrum, whether demand is intense or very limited, improvements in the quality of services may only marginally increase contraceptive prevalence. Individual women who are virtually desperate to control their fertility will tolerate almost any type of care, including accepting methods that are unproven, incompatible with their health, and even life-threatening, such as unsafe abortion procedures. Nineteenth-century Europeans evolved social customs, engaged in specific sexual practices, and employed a high degree of abstinence to achieve fertility decline. On the other hand, for those who wish to have as many children as possible, with no or minimal spacing between pregnancies, an appealing family planning clinic or hospitable fieldworker may make no difference.

However, most societies and most people hold preferences between these extremes. Most do not want all the children they can physiologically produce, even if they hold high fertility goals. Most couples would prefer, if possible, to find an acceptable and safe way to enjoy an active sexual life while successfully avoiding constant pregnancy. In numerous different settings, the availability of services of reasonable quality will be of humane value to the prospective clients and, over time, should assist the achievement of national demographic goals.

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