FHI - Maximizing Access to Quality Family Planning and Reproductive Health Services

Expanding Access

Programs should address five aspects of access to provide clients with increased choices for reproductive health services and contraceptive methods1.

Physical access is improved when service delivery points are conveniently located and can be reached by a large segment of a country's population, including underserved populations. For example, community-based distribution mechanisms, commercial and private sector services complement clinic services to increase physical access.
Economic access is enhanced when the costs of obtaining services are within the financial means of a significant portion of potential clients, and when the indirect costs of obtaining services (such as the time it takes to receive services) is affordable to most people. Programs have sought to increase economic access by offering free or subsidized services and through making service delivery more efficient and by eliminating unnecessary procedures.
Psychosocial access can be improved by making family planning and reproductive health services socially and culturally acceptable within a society, among policymakers, community and religious leaders, and extended families. Extensive media and educational campaigns have helped lower psychosocial barriers to contraceptive use.
Cognitive access is heightened when potential clients know about family planning and reproductive health care and where they can go to get services. Advertising and better informational materials, including clinic signs have helped inform clients about service delivery points.
Administrative access can be improved by program managers taking stock of the administrative and medical rules and regulations governing all aspects of services. Service guidelines can be improved to reflect current scientific information on contraindications and procedures, and nurses and other health staff can be given more authority to provide various contraceptive methods. Clinic hours can be extended.

FHI has worked to expand access through a number of programs. For example, FHI has worked to improve the scientific basis of service delivery guidelines. FHI has assisted programs to examine and update selection criteria that guide safe client care, taking into account both the latest scientific information and the local context. FHI's series of presentation modules conveys the latest information on contraceptives. Regional and national level seminars allow exchange of ideas on barriers to quality services and diverse experiences in improving access by removing the barriers. Country studies help to identify barriers to access and quality in service delivery practices, including those that affect economic and administrative access.

Quality of Care

Family planning programs are increasingly focusing attention on the quality of care provided to clients. Quality of care in family planning, at the point of interaction between the client and the service delivery system, encompasses six components.

Choice of methods is expanded as programs make a range of contraceptive methods available to clients. Regulatory approval has been sought and logistics systems have been strengthened to ensure continuous supply of methods. Method mix can be examined to ensure that programs do not promote only certain methods to clients.
Information to clients. Providers should give clients complete, accurate, scientifically sound and understandable information to help clients make optimal contraceptive choices.
Technical competence can be improved by ensuring that all providers receive pre-service and periodic refresher training as techniques for service delivery are updated based on new scientific information. In addition, strong supervision can reinforce good technical practices among staff.
Interpersonal relations between providers and clients are the cornerstone of good quality services. Clients who are welcomed, treated with respect and encouraged to ask questions and participate in their health care are more likely to be satisfied contraceptive users. Training and strong supervision can help promote good interpersonal relations.
Continuity of care. Clients should be assured of receiving follow-up contraceptive and reproductive health care. They need to know when to return for services and that they have access to services when needed.
Appropriateness and acceptability of services. Services should be designed with the needs of clients in mind, rather than the convenience of program staff. Clinic hours should be convenient, and services delivered in privacy. Service sites should be clean and inviting to clients.

The need to improve quality of care may be specific to a particular contraceptive method, clinic, or aspect of service delivery; or it may require a larger change in service delivery management or policies at the local and national level.

While clients' opinions on quality of care are ultimately important, a key consideration for programs is: which aspects of programs do managers have control over and resources with which to make improvements. Program managers must examine the service delivery process and management inputs in order to uncover the root causes of service delivery problems as a first step toward corrective action.

To incorporate quality of care into expanded reproductive health services, new packages of services must be examined. FHI is working with the Pan American Health Organization (PAHO) to develop an integrated model of quality of care for reproductive health that establishes linkages between family planning, maternal health and STD/HIV. In addition to studying quality of care related to specific contraceptive technologies and service practices, FHI has also translated the concepts of total quality management, a method for continuous quality improvement involving all levels of staff, into tools for use by family planning and health organizations. These tools have been shared with program managers in Latin America, Asia and Africa.

Bertrand, J, K Hardee, R Magnani and M Angle. 1994. "Access, Quality of Care and Medical Barriers in Family Planning Programs." Paper presented at the USAID Cooperating Agencies Meeting, Washington, D.C., March 1994.
Bruce, J. 1990. "Fundamental Elements of Quality of Care: A Simple Framework." Studies in Family Planning. Vol. 21, No. 2.

August 1994

This work was funded by the FHI Contraceptive Technology and Family Planning Research Program through a Cooperative Agreement with the US Agency for International Development