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QUALITY OF CARE Defining Quality Very few systematic studies are available to guide us in defining and measuring the quality of services, but we do not begin at zero. The extraordinary analysis and documentation of the family planning programs operated by the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) in Matlab Thana, and its efforts to transfer this knowledge to the regular government program in what are known as the "extension areas," provide an unparalleled picture of the features of a supply system, its management structure, workers' roles, and clients' responses. The recent assessment of family planning effectiveness by the National Academy of Sciences (Lapham and Simmons, 1987) was a masterful synthesis of knowledge about programs and gave a good deal of weight in its analysis to client/provider transactions. Lapham and Mauldin's (1985) review of program effort in 100 countries, though relying upon informants rather than clients, sought to go beyond official enunciations about availability to describe services in more realistic terms. Analyses of the availability of services (Hermalin and Entwisle, 1985) and the monetary costs of services to clients have necessarily involved considerations of quality. Indeed, these three issues—quality of services, their cost, and availability—are difficult to consider discretely: a choice of methods is not possible without sufficient supply points. The interpersonal dimensions of care are strongly influenced by the quantity of care—the amount and nature of contact between the client and the provider system. The continuity of care provided is similarly influenced by access to supply points and/or staff. Health planners and individuals alike link costs and quality in their decisionmaking. Health planners' determinations about which improvements in quality to pursue are founded to some extent on considerations of cost. At the individual level, the client's willingness to pay for services may vary with their perceived quality. Though it is acknowledged that these topics—availability, cost, and quality—are related and indistinctly bounded, the purpose of this article is to draw a box around the phrase "quality of care" and identify its fundamental elements in family planning and related reproductive health programs. Confusion about the meaning of the word "quality" itself may have inhibited more rapid progress in this area. Quality, by its connotation, implies an intimidating, possibly costly standard. It is not a standard at all, though; rather, it is a property that all programs have (Donabedian, 1980, as cited in Simmons, 1987).1Only a judgment can determine whether quality is good or bad, satisfactory or unsatisfactory. The word and its imputed meaning have emerged in contradictory contexts: early family planning literature discussed quality largely with regard to clinical operations; this approach neglected the interpersonal dimensions of care and suggested to some that high quality meant technically sophisticated, expensive equipment. Quality has sometimes been counted as synonymous with the availability and/or accessibility of contraceptives. Both quality of care and availability of services are vital determinants of contraceptive use, but studies of availability rarely provide descriptive material on the unit of service clients receive. Quality has also been defined in terms of potential demographic impact; a recent evaluation of a major Asian family planning program included the proportion of women using long-term methods as a measure of quality (Bair et al., 1987). These conflicting approaches to the definition of quality and the suggestion that it is immeasurable may have discouraged managers from incorporating quality of care indicators in their management information system (MIS) and evaluation protocols. Managers have been accustomed to measuring quantity of services provided, by type. Donors' evaluation frameworks, the daily mechanism of management, bureaucracies and their own internal reward systems, and the national government's desire to meet targets—whether counted in demographic terms or numbers of services rendered—have all led to a strong bias to evaluate performance based on volume of activities, sometimes calculated from the base (the individual worker) up to program, subnational, and national levels. The quantitative bias is a powerful force with which to contend. The sources of information, of tools, and of intellectual sustenance in developing measures of quality will not be found in the scientific literature alone. This literature assists us to some extent, but learning the family planning field's experience, much of it transmitted orally or noted in site visit reports, is also vital. Managers, technical specialists, and workers alike have their own folk knowledge about what constitutes good or adequate quality. This knowledge needs to be revived, revalued, and structured. One is often struck by the dichotomous nature of the population field's self-expression. Quantitatively oriented research and evaluation studies give a dry, satisfyingly organized, if partial picture of the supply of services. In contrast, accounts of personal experiences and trip reports have quite another flavor. Some anecdotes convey a world of meaning about the quality of the service received; for instance, when one woman who had purchased her first pills from a pharmacist asked how to take them, she was told, "The way you take all other pills." A family planning evaluator who recently returned from the field described seeing several women lined up on examining tables, with their legs open, as a physician moved among them inserting IUDs in a space less like a medical facility than a "cage." Most professionals in our field are troubled by this insensitivity and incompetence, but no ready means exist for integrating this discomfort into an evaluation framework. If quality of services is going to rank alongside quantity of services as an indicator of program performance, the "classical" clinical dimensions of quality of care and the subjective interpersonal aspects must be brought together in a simple and generally agreed upon framework. Donabedian (1980, 1988) has provided a generic foundation for assessing the quality of health services. This present paper, informed by Donabedian's technical/interpersonal model of care, seeks to specify the quality of family planning and related reproductive health care services. The selection of the six elements and the emphasis placed on them reflects not only logic, but the author's view of the field's experience and the tension created when family planning services are caught between two potentially conflicting mandates: promoting the achievement of demographic objectives and meeting individual health and welfare needs. The framework seeks to respond to the common sense and commitment to human welfare that motivated the work in this field in its early stages.
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