The Importance of Quality
Offering good quality of care has always been a goal of family planning programs: Good care helps individuals and couples meet their reproductive health needs safely and effectively (54, 334, 402). Recently, several trends have converged to make quality a top priority.
Programs and providers are seeking to offer better care to more people. Increasingly, family planning programs are looking for ways to serve growing numbers of continuing clients and to serve them better, since the quality of services often affects whether people keep using family planning (168). At the same time, programs are looking for ways to appeal to potential new clients, who often are more skeptical and more concerned with the quality of care than clients in the past (154). The quality of care may be the deciding factor for people who want to avoid pregnancy but who feel uncertain about contraception (168).
Further impetus has come from the women’s health and primary health care movements, which have championed the rights of clients and rejected earlier approaches to family planning services that set numerical goals (134, 161). The Program of Action of the 1994 International Conference on Population and Development (ICPD) in Cairo called for more attention to the quality of care. It urged a client-centered approach to the delivery of family planning and other reproductive health services (371).
In addition, management theories and methods of quality assurance developed in industry to focus on serving customers better are being applied to health care. Today, health and family planning programs around the world combine conventional approaches to quality control in medicine, such as licensing, standard setting, and accreditation, with the industrial philosophies of Continuous Quality Improvement (CQI) and Total Quality Management (TQM) (50, 294) (see p. 8).
The quality movement in family planning is young, and its methods are still under development. Even basic definitions have not yet been standardized. The quality movement is broad, diverse, and changing.
There is already sufficient knowledge and experience, however, for providers and managers at every level to improve service quality. Furthermore, it is clear that quality improvements do not have to cost a lot of money. No matter what the level of program resources, quality can always be improved (337). In fact, improving the quality of services is usually cost-effective (see p. 6).
What Is Quality?
Perhaps the simplest definition of quality is inspired by the work of W. Edwards Deming, a pioneer of the quality movement in industry (see p. 8). At its most basic, providing good quality means “doing the right things right” (38). In health care and family planning this means offering a range of services that are safe and effective and that satisfy clients’ needs and wants.
Quality in health care and family planning has been defined in many ways (39). From a public health perspective, quality means offering the greatest health benefits, with the least health risks, to the greatest number of people, given the available resources (148). For others, quality means offering an appropriate array of services–for example, integrating sexually transmitted disease (STD) services and maternal and child health (MCH) care with family planning services. Still others define quality largely as satisfying the clients’ wishes.
Also, good quality may mean either meeting minimal standards for adequate care or achieving high standards of excellence. Quality can refer to the technical quality of care, to nontechnical aspects of service delivery such as clients’ waiting time and staff’s attitudes, and to programmatic elements such as policies, infrastructure, access, and management (53, 76, 91). Quality is sometimes contrasted with access. In fact, it is difficult to draw a line between them.
Clients, providers, managers, policy-makers, and donors all have differing but legitimate perspectives on what constitutes good-quality care (89):
Providers’ perspective. Historically, for health care providers quality has meant clinical quality of care–offering technically competent, effective, safe care that contributes to an individual’s well-being (89). For their part, program managers recognize that support services—for example, logistics and record-keeping–also are important to the quality of service delivery. For policy-makers and donors, additional key elements of quality include cost, efficiency, and outcomes for populations as a whole (154, 269). The World Health Organization (WHO) definition of quality encompasses the perspectives of all these groups:
Quality of health care consists of the proper performance (according to
standards) of interventions that are known to be safe, that are affordable
to the society in question, and that have the ability to produce an impact
on mortality, morbidity, disability, and malnutrition. (307)
Clients’ perspective. Addressing clients’ concerns is as essential to good-quality health care as technical competence. For clients, quality depends largely on their interaction with providers, such attributes as waiting time and privacy, ease of access to care–and, at its most basic, whether they get the service they want (see p. 10). The value of the client’s perspective on family planning services was increasingly recognized during the 1980s (54, 99, 234, 334, 402). A framework published by Judith Bruce in 1990, together with measurement and assessment tools developed by Anrudh Jain, has been especially influential in focusing attention on the clients’ perspective (53, 166, 168). This model, widely known as the Bruce-Jain framework, includes six elements of quality of care in family planning service delivery (53):
* Choice of methods,
* Information given to clients,
* Technical competence,
* Interpersonal relations,
* Mechanisms to encourage continuity, and
* Appropriate constellation of services.
Another influential framework, developed by the International Planned Parenthood Federation (IPPF), empowers clients and motivates providers by presenting these same six elements as a list of clients’ rights. This framework adds access as another basic element of quality (see box, p. 12).
With growing recognition of the clients’ perspective, quality in family planning and health care is being redefined as “the way clients are treated by the system” (154). When health care systems–and those who work in them–put clients first, they offer services that not only meet technical standards of quality but also satisfy clients’ need for other aspects of quality, such as respect, relevant information, access, and fairness (53, 91, 92, 262).
Benefits of Good Quality
Assuring the good quality of services is an ethical obligation of health care providers. Research is beginning to show that good quality also offers practical benefits to family planning clients and programs. These benefits include:
* Safety and effectiveness,
* Client satisfaction and, as a result, longer continuation,
* Wider use of contraception,
* Job satisfaction for providers,
* Better program reputation and competitiveness,
* Expanded access to services.
Safety and effectiveness. Good-quality care makes contraception safer and more effective. If poorly delivered, some family planning services can cause infections, injuries, and, in rare cases, even death (109). Poor services also can lead to incorrect, inconsistent, or discontinued contraceptive use and thus to unwanted pregnancies (71). Good-quality family planning services are safe and effective because they:
* Offer a range of methods that the program has the human, technical, and financial resources to deliver safely;
* Fully inform clients about methods, including possible side effects;
* Screen clients for medical eligibility;
* Help clients choose for themselves methods that suit their individual circumstances;
* Teach clients how to use their methods properly; and
* Support clients when they encounter problems or decide to switch methods (53, 136, 153, 210, 333, 338, 388).
Greater client satisfaction and continuation. Good care attracts, satisfies, and keeps clients by offering them the services, supplies, information, and emotional support they need to meet their reproductive goals (388). Interviews with clients in Chile, for example, found that good-quality clinical services reduced clients’ fears, increased their confidence in the care received, and generated loyalty to the clinic (376). In contrast, poor care can discourage women from seeking family planning or prompt clients to discontinue using family planning (400).
Studies find that good services encourage people to continue using contraception when they want to avoid pregnancy. In China, for example, women were far more likely to continue using injectable contraceptives when they had been thoroughly counseled on how the method works and its side effects. Only 11% of women receiving good counseling had dropped out at one year compared with 42% of women receiving limited counseling (208).
In the Philippines, among family planning clients in Bukidnon Province, women were more likely to continue using their method if they thought the provider was friendly, if they were satisfied with services, and if they had been told about the advantages and side effects of several methods (321). In Bangladesh rural women were asked whether field workers serving them were responsive, sensitive to their need for privacy, dependable, sympathetic, and informative. Women who felt they received good care, as judged by their answers to these questions, were 27% more likely to adopt a family planning method and 72% more likely to continue using a method for up to 30 months than women who felt they had received poor care (195).
Other studies have found that poor care explains why some people stop using family planning. In general, research finds that poor medical care dissatisfies patients, discourages them from seeking care and returning for services, and prompts them to switch physicians (126, 183, 214). Family planning clients may discontinue their method or stop using family planning altogether:
* If use of the method is not explained and unintended pregnancy occurs (20, 71, 111, 120, 147, 152, 201, 358, 368, 369);
* If possible side effects are not explained in advance, or if side effects occur and are not taken seriously or managed appropriately (71, 111, 128, 152, 201, 208, 267, 312, 358, 368, 369, 400);
* If the program runs out of supplies (71, 152);
* If providers treat clients rudely (369);
* If clients cannot get the method they want (283).
Wider use of contraception. Does quality of care influence contraceptive prevalence? The evidence is limited, largely because there is no agreement on how to measure quality in service delivery (64, 76, 154). For example, methodological problems frustrated attempts in Brazil, Morocco, and Peru to link levels of contraceptive use with quality of services (51, 146, 247, 250).
A more recent study in Peru, however, suggests that quality of services does matter to levels of contraceptive use in an area (248, 250). Women who had told the 1996 DHS that they wanted to avoid pregnancy were asked 29 months later whether they had become pregnant (248). Unintended pregnancies were twice as common among women in areas with poor-quality services as among women in areas with adequate services–22% versus 11%. Quality was rated on a combination of eight indicators including contraceptive choice, provider bias, provider training, information to clients, and privacy.
Other studies have linked whether a person uses contraception with various specific aspects of quality of care, including the thoroughness of counseling (71, 346, 347), receiving one’s preferred method (283), and the availability of services (24, 359).
More job satisfaction for providers. Providers derive greater personal and professional satisfaction from their jobs when they can offer good-quality care and can feel their work is valuable (393). For example, in Uganda both clinic- and community-based providers agreed that the most satisfying aspect of their jobs was helping people and the community recognition they received for it (150).
Giving providers the authority to solve problems and improve services, as many quality improvement methods do, raises morale (219, 242, 266). For example, projects that empowered health care workers to develop their own solutions to local problems reduced workers’ absenteeism in Uganda (278) and increased staff motivation in Niger (272). In contrast, when health personnel feel that conditions prevent them from offering good quality care, they may become discouraged, and they may put most of their effort into other jobs (375).
Better program image and competitiveness. Programs that are known for good quality attract and retain clients and become competitive in service delivery. For example, 25% more pregnant women came to deliver at Kigoma Regional Hospital in Tanzania after the community recognized that the quality of maternal care had improved (233). A client of a maternal and child health (MCH) clinic in Chile summed it up simply: “You logically go where you are treated better” (376). Even where the choice of providers is limited, people can still turn to less effective traditional methods or not use family planning at all.
Programs that consistently provide good services enhance public perceptions of modern family planning and health services in general as well as their own public image. Conversely, if quality is poor, people may start to assume that serious problems are typical of contraceptive use. For example, a study in Nepal found that severe infections after sterilizations and IUD insertions were so common that villagers considered them to be a characteristic side effect of modern contraceptive methods rather than the result of poor care (341).
Ensuring access to services. Most health and family planning programs are built on the premise that people have a fundamental right to health care (371). In many countries governments are responsible for ensuring that everyone has access to health services (387). Governments also assume a regulatory responsibility to protect clients from harm caused by poor care–especially if the providers are government employees (269). Family planning associations and other nongovernmental providers also seek to assure universal access to health care (159, 160).
Quality of care is closely linked to accessibility. Ensuring access to services means making good-quality, affordable care available where and when convenient to the public. Access means more than the mere existence of a nearby health worker or facility. When a facility lacks properly trained staff, opens irregularly, suffers from supply shortages, charges high prices, or blocks care with unnecessary medical barriers, the community does not have adequate access to services (41). Improving the quality of services helps programs pursue their goal of making services universally available.
Good Quality Can Cost Less
Where resources are very limited, good quality may seem to be an unaffordable luxury (154, 252, 398). Managers may worry that better care will cost so much that their programs will have to serve fewer people. It is true that some large-scale projects to improve the quality of family planning and other reproductive health services in developing countries have had big budgets. Quality is determined not only by the resources available, however, but also by how resources are used (49, 154, 269). Furthermore, poor care has its own costs: It limits the number of clients, wastes resources, and restricts revenues. Good quality avoids these costs.
In fact, ample resources alone do not guarantee high quality. Research in the United States, for example, has revealed high error rates in the delivery of health services (49, 206). US health care clients share many of the same causes for dissatisfaction as clients where resources are scarcer, including poor interpersonal relations with physicians and inadequate information (31, 85, 212, 304).
Efficiencies and allocation. By deploying existing equipment, staff, and facilities more efficiently, managers often can increase the number of people served without additional funds (109, 375). For example, a health directorate in Jordan was able to increase the number of vaccinations administered by 5% at the same time that it cut the amount of vaccine ordered by 25%, after a quality assurance team reduced the amounts of vaccine that were wasted (87).
Some improvements in quality even pay for themselves in the long run (42, 73, 243). The Central Asian Infectious Disease Program trained health workers to treat acute respiratory illness (ARI) and diarrheal disease appropriately. When these health workers returned to the field, drug costs declined as they prescribed fewer drugs per case, fewer unnecessary antibiotics, and fewer injections. For example, among trained providers in Kyrgyzstan the average cost of treating a case fell 78% for pneumonia, 59% for other ARIs, and 64% for diarrhea–even though the cost of the drugs increased sharply over the same time period (158).
Sometimes resources at the service site are not fully used. For example, assessments in five African countries found that available communication materials were used with fewer than one-quarter of all clients, and most facilities had a light family planning and MCH client load that did not keep providers busy (125). In these facilities there were opportunities to improve services without additional costs (257).
Low-cost improvements. A change in providers’ attitudes or reorganization of service delivery can improve quality at relatively little cost, without additional staff or equipment (336). For example, it costs no more for providers to treat clients with respect (154, 185) or for clerks to administer an efficient registration and payment process (60). Such changes do require training and supervision, but health care programs already pay for training and supervision as part of the basic costs of doing business.
Sometimes, affordable good-quality care means choosing appropriate technology. For example, programs that cannot afford disposable syringes or autoclaves for steam sterilization can still prevent infection by rigorous hand washing, high-level disinfection of instruments, and steaming surgical gloves in a rice cooker (241).
Avoiding unnecessary costs. By preventing injuries, infections, and unwanted pregnancies, good-quality care eliminates costly follow-ups to treat clients who have been harmed (109, 269). In Oyo State, Nigeria, for example, lapses in counseling, screening, and infection prevention sent many IUD clients back to clinics to have side effects explained, infections treated with antibiotics and pain relievers, and expelled IUDs reinserted (293). Such avoidable repeat visits are costly both for programs and for clients, who may have to take time off from work and pay for transportation (275). Poor care also can exact a human toll of anxiety, pain, and suffering.
Even if any harm done does not incur follow-up costs, inappropriate care amounts to a waste of money (293). For example, a 1995 cost analysis of oral contraceptive use in Brazil estimated that cost per appropriately served client was less at a clinic than in pharmacies, even though cost per client overall was higher–US$34 versus $24 per year. Many pharmacy clients were not medically eligible to use the Pill, and most did not feel satisfactorily informed. In contrast, at the Sao Paulo Feminist Sexuality and Health Collective, all Pill clients were appropriate users and three-quarters felt satisfactorily informed. If ill-informed or inappropriate Pill clients are excluded, the annual cost of serving a well-informed, clinically appropriate Pill user at the clinic was $46
a year compared with $200 at the pharmacies (83).
Quality attracts revenue. Improving quality can attract more clients, help programs raise revenue, and attract donor support. Offering good-quality services allows some programs to charge or raise user fees (7). Clients often are willing and able to pay more than they already do for services–but only for services that they consider are of good quality (7, 275, 299, 394, 396, 397). In contrast, when service quality is poor and clients have other options (which may include foregoing care), clients stay away, and financial support dwindles, which often reduces quality even further (157).
Whether or not programs charge fees for services, better quality that attracts more clients can lower per-client costs. For example, the Bangladesh Women’s Health Coalition attracted many clients by offering good-quality services. The high volume of clients allowed the program to spread its fixed costs over a greater number of clients, and the lower cost per client made serving more people affordable (185).
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