VI. QUALITY OF CARE AND TARGET-FREE APPROACH Family Planning Programmes
FOR FAMILY PLANNING PROGRAMMES

Atiqur Rahman Khan, Tan Boon-Ann and Suman Mehta *

Introduction

Client expectations have always been the main criteria for the interpretation of what quality of care should be. However, unless people have a clear perception of their own rights, their expectations from services are also likely to be limited. In most Asian and Pacific countries, quality of care has been seen as services rendered by technically competent providers in well-equipped facilities - a connotation which fits better as quality of services rather than quality of care. Emphasis was implicitly placed more on the technical aspects of services, referring to issues such as whether (i) clients are properly screened for contraindications; (ii) the clinical procedures are technically correct; (iii) aseptic precautions are taken; and (iv) services are provided in well-equipped facilities. From these perspectives, quality of service, or what is seen as good service, would generally imply adequate technical competence of the providers and availability of facilities. Client perspectives, especially client-provider relationships, were neglected (Donabedian, 1988). Improved performance of family planning programmes, in quantitative terms, has raised concern about improving quality of care.

1. Quality of care: definition and principles

Despite a widely accepted framework for quality of care, there is some disagreement on an acceptable definition. One author states that quality of care can be defined by the way the clients are treated by the system, or the actual process of care-giving, and by the focus on the client's or user's perspectives of services (Hull, 1994).

Another author (Abou-Zahr, 1994) has tried to simplify the perception of quality of care as follows:

Doing the right thing
Doing things right
Doing things at the right time
Doing things with the right attitude
Notably, these definitions were proposed after the development of the quality-of-care framework by Judith Bruce (1989). Hence, they incorporate a broader concept of care. However, it is still necessary for changing trends in the perceptions and expectations of men and women regarding broader reproductive health services to be studied before quality of care can be defined more appropriately.

2. Quality of care: framework

A comprehensive quality-of-care framework was first proposed by Judith Bruce. The framework described main programme elements relevant to improvement of the quality of care in the context of family planning, which include the following (Bruce, 1989):

• Choice of methods
• Information given to users
• Technical competence
• Interpersonal relations
• Mechanisms to encourage continuity
• Appropriate constellations of services

The framework emphasized previously neglected aspects of clients' perspectives, implying that interpersonal client-provider interactions are equally important in its application. It was accordingly acknowledged that "the interpersonal process is the vehicle by which technical care is implemented and on which its success depends ... Privacy, confidentiality, informed choice, concern, empathy, honesty, tact, sensitivity--all these and more are virtues that the interpersonal relationship is expected to have" (Donabedian, 1988). Previously, the major focuses of family planning programmes had been accessibility and availability, demographic impact and clinical operations. In contrast, the quality-of-care framework focuses on individual clients and the services they receive, especially in respect of the interpersonal dimensions of care.

The framework provides for flexibility in that individual programmes can apply different emphases on different elements according to the maturity and priority of the programme. Since the quality-of-care framework is not a single standard and is applicable to varying levels of standards, individual programmes can also choose the standard of care they want to offer. Again, although the framework originated from concerns to improve quality of care in family planning services, the underlying principles are applicable to a broader spectrum of reproductive health.

3. Application of quality of care in programmes

A major constraint in the application of quality-of-care strategies is an inadequate understanding of the relevant issues, of which broader service options and freedom of choice, discussed above, are integral components. Notably, among the quality-of-care issues, the rationale and objectives of interpersonal dimensions, especially the need for unbiased information on all aspects of services, including possible complications of method use, are least recognized. In many countries, service providers, especially those who are not sufficiently trained in interpersonal communication, particularly in target-driven situations, are influenced by a misbelief that information on the negative aspects of contraceptives, such as side effects and complications, may prevent acceptance.

Two important factors that have affected quality of care in the countries of the region are lack of an appropriate strategy on quality of care and lack of provider skills. For example, while the basic principles of informed choice were neglected in several high-performing countries (China, Indonesia and Viet Nam) for reasons of method-linked priorities, they were not followed in several low-performing countries (Cambodia, the Lao People's Democratic Republic and Myanmar) because of inadequate provider skills.

In general, the focus of contraceptive services in most countries has been on methods, and not on clients. Even research and studies on programme-effectiveness have measured single-method continuation rates, not all-method continuation rates. Little attention was given to contraceptive switching patterns, use dynamics and related factors. In many instances, provider skills were also method-specific. Client perspectives relating to counselling needs on method-switching practices were also missing. Client follow-up systems were inadequate. Follow-up systems, where they existed, were generally method-oriented. Programmes followed users of different methods, not individuals.

Some countries have their own interpretation and meaning of quality of care. For example, some feel that it is a Western concept and is meaningless where access to basic services is lacking. Many see quality of care as what is provided in clean and well-equipped settings by well-trained personnel and, therefore, mainly dependent on the availability of resources.

Despite an inadequate understanding of the quality-of-care framework, there is both a growing interest in and a positive attitude towards improving the quality of care. In Indonesia it is believed that the quality-of-care framework needs to be further built upon the existing model to be applied to services at the community level in the form of "clinics without walls" (Haryono Suyono, 1994). Indonesia has also developed an exclusive project designed to address the quality of care, together with a shift in favour of a more "cafeteria-oriented" approach of providing a broader choice. The project also provides for greater cooperation among the various agencies involved in reproductive health/family planning services, mainly the Ministry of Health and the National Family Planning Coordinating Board (BKKBN). Support for similar projects is being considered in the Democratic People's Republic of Korea and Mongolia. With a view to developing a more quality-oriented service strategy in the Philippines, a research study was conducted to assess the quality of care and identify needs for improvement (Osteria, 1996). Improvement in the quality of care has also been a major thrust of a project on strengthening the management and field implementation of the family planning/reproductive health programme. In Cambodia, the Lao People's Democratic Republic and Viet Nam, training courses, curricula and training manuals for trainees and trainers have been developed in recent years which are more sensitive to quality-of-care issues and show an increasing emphasis on the counselling and interpersonal communication skills of providers. In China, the new Programme for the Promotion of Family Planning in China (1995-2000) recognizes the need for improving the quality of family planning and reproductive health services (China, 1995).

A. Rationales for family planning prior to the International Conference on Population and Development

Family planning services, pioneered by some NGOs, such as family planning associations, were initially provided to meet unmet needs. Margaret Sanger's ideal is the best example of the underlying rationale for family `planning. However, organized large-scale government programmes in nearly all countries of the Asian region originated with population control as the intent. For example, the family planning policy adopted by Thailand in 1970 was clear in its enunciation to "support voluntary family planning in order to resolve various problems concerned with the very high rate of population growth which constitute an important obstacle to the economic and social development of the nation" (Singh, 1994). Indonesia adopted an antinatalist policy in 1967, by announcing that family planning would be an integral part of the country's development programme (ibid). China's family planning programme, driven by the one-child population policy, was designed to limit population growth (China, 1995). This policy has resulted in a strong, target-oriented family planning programme since 1980. In the Philippines, family planning began in 1970, as a population control programme, with the coordinating responsibility assigned to the Commission on Population.

Many countries, simultaneously or subsequently, have recognized the health benefits of family planning and consequently reflected them in their policy statements and structural organizations. For example, in the Philippines, responsibility for family planning was transferred to the Department of Health in 1988, thereby making family planning essentially a health programme (UNFPA, 1995b). The Philippine policy, representing an example of non-coercion and individual rights in family planning, appears to have been influenced by the resolutions on reproductive rights adopted by the World Population Conference held at Bucharest in 1974 (United Nations, 1974).

B. Programme of Action of the International Conference on Population and Development: new paradigm for family planning

The Programme of Action of the Cairo Conference sets individual rights as the rationale for family planning services in its enunciation to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choices and make available a full range of safe and effective methods (paragraph 7. 12).

This principle clearly places individual desire and childbearing preferences over demographic goals, thereby making unmet need the main reason for the provision of family planning. The Programme of Action states: "Government goals for family planning should be defined in terms of unmet needs for information and services"(ibid.).

Simultaneously with a need-based approach to family planning, the Programme of Action proposes the stabilization of population growth rates and supports country demographic objectives as the basis for development goals: "Demographic goals, while legitimately the subject of government development strategies, should not be imposed on family planning providers in the form of targets or quotas for the recruitment of clients" (ibid.).

Accepting a need-based family planning strategy in principle, the validity of national fertility-reducing goals would be dependent on the premise that there exist sufficient unmet needs or, for that matter, the prospect that an effective development strategy can generate sufficient demand in this respect. Theoretically speaking, a strong fertility-reducing goal may be incompatible with an unmet need-based family planning strategy where people desire a large family size. In order to reconcile reproductive freedom, quality of care and national demographic goals, it is important to define the dynamics of unmet needs and related issues and use this information in the decision-making process.

1. Centrality of family planning

Family planning deserve a special focus within the framework of reproductive health. The health and economic benefits of family planning constitute good reasons for making it the central focus of national programmes. Through promotion of the practice of family planning, a programme can achieve many other reproductive health or related goals. For example, family planning prevents unwanted fertility and thereby provides freedom outside of pregnancy and childbearing, and creates opportunities for women to participate in productive activities. It also improves the health of mothers and children significantly and is associated with declines in maternal and infant mortality. Women's participation in social and economic activities and improved health contributes to their status in the family and society. Family planning reduces the incidence of induced abortion and also helps in the prevention of STDs/HIV. In addition, family planning services offer an excellent opportunity to integrate some reproductive health components effectively with little additional cost and effort. For example, as a part of family planning services, potential acceptors are given a routine gynaecological check-up for the screening of contraindications. This contact can be an economic way of diagnosing reproductive tract infections and providing treatment. Since some contraceptive methods (for example, IUDs) cannot even be prescribed without ensuring that the woman has no reproductive tract infection; in fact, diagnosis and treatment of reproductive tract infection would be in the best interests of promoting family planning practice. In this regard, family planning and reproductive health are mutually reinforcing.

Hence, family planning represents the single most important component of reproductive health services which can help achieve maximum impact over a broad range of reproductive health components. An important challenge that the UNFPA programme may confront in the aftermath of the Cairo Conference is how to broaden the scope of its support for a range of reproductive health services without losing the necessary focus and priority on family planning.

2. Relevance of individual rights and freedom of choice to quality of care

A wider choice in family planning services can contribute to increased contraceptive effectiveness through three mechanisms. First, individual preferences vary and the reproductive health needs of individuals and couples change in the course of a lifetime; no single method can meet everyone's needs. Therefore, a broader method option is more likely to meet the needs of a larger number of couples. Second, the availability of a broader choice can allow users to switch from an unsuitable method to another which might be more acceptable. In this regard, single-method continuation rates conventionally used as an indicator of programme effectiveness can be misleading. A follow-up survey, as shown in table VI.1, found that the continuation rate at 30 months of first-IUD use was only 27.5 per cent, as compared with 47.2 per cent for all-IUD use, 72.8 per cent for all-method use and 78.9 per cent for effective prevention of unwanted births through the combined use of contraception and abortion (Freedman and Takeshita, 1969).

Third, provision of many methods in the programme would ensure the availability of some even in the face of short-term out-of-stock or delay in supplies, owing either to resource constraints or a lack of adequate forward planning for timely procurement.

C. Current practices in family planning programmes

1. Reproductive rights and quality of care

Individual desire to exercise reproductive intentions forms an important basis for reproductive rights. There are several aspects of reproductive life that determine individuals' physical and emotional well-being and psychological satisfaction. In a broader sense, although reproductive rights may be assumed to cover physical, mental and social well-being, its attainment is dependent on specific aspects of programmes designed to meet reproductive intentions, such as accessibility to services, broader contraceptive options, freedom of choice and a non-coercive environment to attain the above.

Following the Cairo Conference, many countries have adopted policies in favour of reproductive rights. For example, Cambodia adopted a Birth Spacing Policy in 1996, which, despite its narrow title, sets broader principles, in conformity with the Programme of Action, as stated: "Everyone has the right to the enjoyment of the highest standard of physical and mental health" and "Couples and individuals have the right to decide freely and responsibly on the number and spacing of their children and to have the education and means to do so." China formulated its Programme for the Promotion of Family Planning in China (1995-2000) with a provision that "Quality service in family planning should be provided to the people of childbearing age, particularly reproductive health care for women to protect their health". The Philippines has withdrawn method-related financial subsidies and taken steps to integrate family planning and other reproductive health services.

(a) Accessibility

Lack of basic access to fertility regulation was the main concern in most countries in the 1970s. Since then, access to family planning has improved significantly in all parts of the world, and more significantly in Asia. In 80 per cent of Asian countries, more than half the people have access to at least one method, as compared with 60 per cent in Africa (UNFPA, 1997a).

As shown in table VI.2, people in Asia have greater and more equitable access to different contraceptive methods as compared with other regions, especially Africa.

The extent of unmet needs for selected countries of the region, shown in table VI.3, indicates a wide diversity. While most countries in the list have created basic access to fertility regulation services and thereby raised contraceptive prevalence to above 50 per cent, unmet need in a few countries, such as Cambodia, the Lao People's Democratic Republic and Myanmar, has remained very high, estimated at 76.3, 62.0 and 64.2 per cent of married women of reproductive age respectively.

Estimated unmet need in Cambodia, the Lao People's Democratic Republic and Myanmar stands out in clear contrast to other countries in the list, where unmet need varies from a low of 10.6 per cent in Indonesia to a high of 23.5 per cent in the Philippines. The high level of unmet need in Cambodia, the Lao People's Democratic Republic and Myanmar indicates, on the one hand, a basic lack of access to fertility regulation information and services, while, on the other hand, it suggests that with increased accessibility, contraceptive prevalence would rise rapidly.

However, this macro-level analysis may not reflect accurately the real extent of unmet needs. As indicated by available evidence, a certain proportion of respondents in conventional surveys desire additional children, but, at the same time, practise contraception. There is also evidence to show that the levels of unmet need grow with initial rises in contraceptive prevalence. Therefore, the level of unmet need as shown in the high-prevalence countries should not be seen as the final limit. With further improvement of accessibility, especially to currently under-served segments of the population, especially adolescents, and improved quality of care, demand is likely to grow further. Individual follow-up is essential to ensure that the services are meeting unmet need.

(b) Broader contraceptive options

The rights of couples and individuals to choose freely depend on the availability of a broader range of methods in the programme, as well as access to full information on their use and source and convenient ways to obtain them. There is clear evidence that a broader range of methods would result in an overall higher level of contraceptive use, and this is well documented by many researchers (Ross and others, 1989). Table VI.4 shows the overall contraceptive practice and method mix for selected countries in the region.

China, the Democratic People's Republic of Korea, Mongolia, the Republic of Korea, Singapore, Sri Lanka, Thailand and Viet Nam, have achieved a contraceptive prevalence rate above 60 per cent. Of these, some countries (China, the Democratic People's Republic of Korea, Mongolia and Viet Nam), despite an overall wide coverage, lack broader contraceptive options owing to limited focus in their strategies. Among these countries, China and Viet Nam have emphasized methods, such as IUDs and sterilization, which would be programmatically more cost-effective or would appear to have a greater demographic impact. Notably, they have achieved a high contraceptive prevalence, even with a narrow range of methods.

A few other countries, such as India and Nepal, have emphasized sterilization strongly. Limited contraceptive options have constituted one of the main reasons for which these countries have met the unmet need only marginally. Despite the fact that the family planning programme of India started long before those of other countries in the list, contraceptive prevalence has grown to only around 41 per cent. Although sterilization was emphasized in Sri Lanka, other methods were not neglected. As a result, despite the predominant use of sterilization, Sri Lanka has also achieved overall high contraceptive prevalence.

It is both desirable and legitimate to make a wide range of methods available, especially more effective methods, where demographic goals are the major concern, but without specific emphasis on any one method. Regarding the method-mix in programmes, it has been concluded by Bongaarts (1997) that "the wide availability of effective methods through the public or private sector is required to achieve high levels of effectiveness." By the same token, he also concluded: "Efforts to promote the most effective methods without giving women a wide choice (as was done, for example, in India's programme with its emphasis on sterilization) are counter- productive and should be avoided".

It may be noted that most countries, except China, the Republic of Korea and Singapore, have very low use of male methods such as condoms and male sterilization. Use of these methods, as a percentage of all methods, is most frequent in Singapore (33.8 per cent), Republic of Korea (27.9 per cent), Nepal (25.6 per cent) and China (15.9 per cent), as compared with the Democratic People's Republic of Korea (0.5 per cent), the Lao People's Democratic Republic (2.0 per cent), Indonesia (2.9 per cent) and Thailand (3.2 per cent). Although Thailand has otherwise promoted a broader contraceptive mix, the use of male methods has remained low. Although it is desirable that countries at a high risk of the spread of HIV should promote condom use, four countries categorized as high-risk in this regard (Cambodia, India, Myanmar and Thailand) have very low use rates of condoms, at 0.3, 2.4, 0.1 and 0.5 per cent of eligible couples respectively (table VI.4).

In recent years, some of the countries have adopted policies to diversify method options. However, success has been limited, in some cases owing to inadequate strategies to promote equal choice. In other cases, this was due to method-related incentives which, deliberately or unintentionally, promote the use of specific methods. As shown in table VI.4, the contraceptive method mix in these countries still shows the predominant use of one or two methods. The IUD and female sterilization are still the major methods used in China. Sterilization use is also most dominant in India, Nepal and the Republic of Korea. The IUD is the main method used in the Democratic People's Republic of Korea, Mongolia and Viet Nam.

Viet Nam has reaffirmed its intention to broaden contraceptive options and has adopted several measures to broaden contraceptive services. Although the programme strategies are still inadequate to achieve this objective in full, recent trends in the contraceptive mix indicate a slow shift toward a broader mix (as shown in table VI.5). Condom use rose from 1.2 per cent in 1988 to 4.0 per cent in 1994, and pill use from 0.4 to 2.1 per cent during the same period. In order to achieve more significant shifts in method mix, the Viet Nam programme may review present financial remuneration systems.

(c) Freedom of method choice in programmes

Free choice of methods can significantly affect contraceptive use continuation and effectiveness. A study of 2,500 new acceptors in East Java, Indonesia, found a discontinuation rate of 85 per cent among those who did not receive the method they originally requested, as compared with only 25 per cent among those who received the method of their choice (Pariani and others, 1991).

Besides the lack of availability of a broader range of methods in the programme, there are other factors that can limit freedom of choice. As noted earlier, a programme can stress selected methods, especially those which are perceived to be more effective, because of a primary concern for population control goals. Examples have been drawn from China and Indonesia. Method-specific emphasis also arises from a prevailing notion among many programme managers that free choice may not always be best for the clients. According to this notion, asking illiterate or semi-literate women, who are unaware of their own health problems and needs, to choose for themselves, may not be meaningful. On the other hand, choices made for them by an experienced and trained service provider, taking into account their needs, were felt to offer a better choice. The inappropriateness of this position has been explained earlier.

Emphasis on more effective methods in Indonesia arises from the law, which provides for "methods which are efficient and effective and which can be accepted by husband and wife couples in accordance with their choice" (Indonesia, 1993). Interpreting this legal provision, the Indonesian programme promotes the use of more effective methods and, inadvertently or unintentionally, discourages the use of condoms and oral pills. The effects of method-specific programme emphasis are reflected in the patterns of method-mix shifts during the last 20 years in Indonesia.

As shown in table VI.6, the combined use of IUDs, injections, sterilization and Norplant (which are perceived as more effective methods) in Java-Bali increased from 6.1 per cent in 1976 to 38.8 per cent in 1994, whereas, during the same time period, the combined use of pills and condoms increased from 16.7 to 17.6 per cent (Indonesia, 1995).

(d) Method-linked incentives

Target-oriented strategies led to the adoption of method-linked incentives in many programmes in the 1960s and 1970s. Incentives were provided to acceptors, providers and motivators/referrers of acceptors. A few well-known examples of programme use of incentives were Bangladesh, India, Nepal, Pakistan and Sri Lanka. Programmes in these countries provided financial remuneration to acceptors on several justifications, such as reimbursement for transport or compensation for loss of time and wages. To the extent that poverty was a major barrier in contraceptive acceptance, financial compensation was found to remove the barrier and promote acceptance. In many instances, it was presumed to have a triggering effect, sometimes expressed as "leading the client over the fence". However, in many instances, the amounts of remuneration far exceeded what would be needed for transport and wage loss. In such cases, incentives created a positive inducement among potential acceptors to override other factors in the decision-making process and led to dissatisfaction and regret among acceptors of permanent methods. Such inducements are also known to have led to overreporting, and neglect of counselling and quality of care.

A study of financial compensation, conducted in Bangladesh with World Bank support, provides some insights (Cleland and Mauldin, 1991). The study found that the amounts of client payments made exceeded the costs associated with the procedures and acted as positive inducements, especially among poorer sections of the population. It also found that, despite an overall high level of client satisfaction, 25 per cent of the acceptors of permanent methods subsequently expressed regret that they had been sterilized. Payments also played a major role in acceptance.

As shown in table VI.7, money played a direct or contributory role in the acceptance of 37 per cent of the tubectomy cases and 53 per cent of the vasectomy cases. In addition, financial remuneration to motivators referring clients led to the targeting of poor people and the promotion of sterilization at the expense of other methods.

Trends in contraceptive mix in two neighbouring countries, Bangladesh and Nepal, in which incentives have been widely used on different scales and forms and at different times, show an interesting pattern. Both these countries started promoting contraceptive practice with a large emphasis on sterilization through method-linked incentives. This resulted in a high rate of sterilization use, accounting for 53.6 per cent of all modern methods in Bangladesh in 1983 and 76.3 per cent of all modern methods in Nepal in 1981 (table VI.8). Thereafter, with changing policies on incentives, the contraceptive method mix changed significantly in Bangladesh, with sterilization declining to only 25.1 per cent of modern methods in 1993, whereas sterilization continued to dominate in Nepal at 67.0 per cent of modern methods in 1996.

Another example of the effects of incentives can be drawn from the Philippines. During the pre-Cairo Conference period, service providers used to receive P300 for each female sterilization and P200 for each male sterilization they performed. After the Cairo Conference, the Philippine programme adopted a policy of non-coercion to allow couples "to decide whether to have children, when and how many, or whether to practise family planning" (WHO/WPRO, 1995), and accordingly financial incentives were withdrawn. This policy change appears to have contributed to a shift in contraceptive mix, shown in table VI.9, with a significant rise in the use of pills, injectables and condoms.

The impact of the target-free approach can be illustrated by the findings of an experimental pilot project in two districts (Tonk and Dausa) of the State of Rajasthan in India, where integrated family planning and selected other reproductive health services have recently been provided, without the assignment of any target or quota for the service providers. The project also emphasized the provision of broader contraceptive options. Within two years, contraceptive prevalence in the two districts increased by about 50 per cent, from 31 and 35 per cent to 47.4 and 48.9 per cent respectively (Singh, 1997).

Method-linked financial remuneration for providers is basically designed to create motives among providers to emphasize methods which are user-independent, effective and have higher continuation rates. In Viet Nam, despite a recent government policy of broadening the contraceptive method mix through free and informed choice, the programme still provides financial remuneration for performing selected methods, such as sterilization, IUD and menstrual regulation. In the case of sterilization, the programme persons motivating sterilization acceptors are also benefited by the payment system. This financial incentive system appears to create an unequal opportunity for method acceptance and, perhaps, can potentially affect the quality of care (Knodel and others, 1995). As a result, despite a genuine intention to broaden method mix in Viet Nam, the impact so far has been minimal.

In addition to the above factors, regulatory restriction limits the freedom of choice. For example, restricted eligibility criteria for the acceptance of sterilization and the requirement of bureaucratic approval for sterilization create a significant barrier in Myanmar. Similarly, in Mongolia, female sterilization is provided only on medical grounds. Sterilization has been permitted in the Lao People's Democratic Republic only recently; however, a couple must have more than six children to be eligible for the procedure (UNFPA, 1998). Shortages of supplies, owing either to resource constraints or lack of adequate forward planning for timely procurement, have also been found to impede freedom of choice temporarily.

(e) Practices regarding an integrated approach

The integration of family planning and other reproductive health services can enhance clients' perspectives significantly. Although several alternative modalities for the integration of family planning with health interventions were proposed during the early days of family planning, the concept and rationale for integration have changed during the last two decades. While integration used to be seen as a means to maximize the impact of family planning, under the broader principles of reproductive health, the context of integration has moved towards making services user-friendly and client-centred. However, despite a shift in the basic rationale, the strategy of multiple modalities for integration remains valid from the point of view of programme organization and viability.

A few countries in the subregion, such as Cambodia, the Lao People's Democratic Republic and Myanmar, have weak family planning programmes. Despite their limited institutional capacity, they have one advantage, that is, they have not inherited a divided organizational structure and therefore have a better opportunity to plan and adopt an integrated approach. For these countries, resource constraints and insufficient institutional capacity are, however, likely to impede undertaking a full spectrum of reproductive health services. Therefore, policy would require the application of a selective approach, based on identified priorities and, where appropriate, emphasizing family planning. The immediate concern for these countries should be to give priority to the creation of accessibility to basic services for family planning. As indicated from the present situation in these countries, Cambodia and the Lao People's Democratic Republic will need greater IEC efforts focused on awareness creation, while Myanmar will need more method-specific education and counselling, as initial activities.

(f) Misconceived strategies

Although demographic goals of reducing population growth rates are legitimate in a development context, the strategies of promoting more effective methods for the same purpose are misconceived. As explained earlier, free choice is more likely to result in a more sustained use of contraceptives, and thereby achieve demographic goals as well as meet individual needs (Pariani, 1991). By this token, the one-child policy of China, together with its target-oriented strategy, which puts strong pressure on couples and individuals in favour of more effective contraceptive methods, restricts freedom of choice. Such policies also create additional health risks owing to frequent recourse to abortion whenever childbearing exceeds the accepted norm. As indicated earlier, given appropriate strategies for the quality of care, the demographic rationale for family planning can be compatible with quality-of-care principles.

D. Implementation of quality-of-care strategies

1. Essentiality of quality of care for all programmes

It should be noted that quality is not a standard, but a property that all programmes should have. Since standards may vary according to existing institutional capacity, programmes should decide on the standard of care that they wish to offer. According to the Bruce framework, quality-of-care principles are uniformly applicable under varied levels of standards. Moreover, the application of quality-of-care strategies does not require an appreciable amount of additional resources; what is required is commitment and understanding. Although the quality-of-care framework was developed by Bruce in the context of family planning, its principles are applicable more widely for reproductive health.

2. Need for improved understanding among policy makers
and the adoption of clear strategies: advocacy
In order to create commitment among policy makers in favour of quality-of-care measures, it is essential that they develop a clear understanding of the relevant issues. For the purpose, focused advocacy efforts can convince the policy makers that quality-of-care principles are viable and cost-effective, and especially that free choice can lead to a higher level of practice as well as more effective use. Top-level commitment should also allow the adoption of programme strategies for the application of quality-of-care measures, including a broader range of contraceptive options, informed consent and free choices. Commitment at all levels of services, together with a strategic shift in services, is essential to promote the principles of informed consent. In this regard, it is necessary to dispel doubts and fears that full information, especially on side effects, can decrease acceptance.

(a) Quality-oriented information, education and communication

Informed choice can be promoted through the strengthening of people's knowledge on all aspects of contraceptives, including their side effects, effectiveness, instructions for use and what to do in the case of side effects, and how to obtain services or supplies. IEC efforts are essential to meet the needs of quality-of-care objectives. IEC should be focused on country-specific needs. As examples of need-based IEC efforts, it may be suggested that Cambodia and the Lao People's Democratic Republic focus on basic contraceptive awareness-raising. Myanmar may benefit by aiming at more method-specific knowledge. Viet Nam could aim at more equitable knowledge of all methods. Indonesia may benefit by emphasizing knowledge of temporary methods, especially of condoms.

(b) Gender equity and population stabilization goals

In addition to the above, the programmes and policies to promote gender equity and population stabilization, in the context of development goals, can potentially create a supportive environment for free expression of reproductive rights and thereby promote freedom of choice. Owing to close interlinkages between the quality of care and gender approaches, programme strategies designed to make services gender-sensitive will also improve the quality of care on several counts, including broader options, freedom of choice, informed consent and user-friendly services.

3. Client-centred approaches

(a) Provision of a non-coercive environment

A non-coercive programme environment is a prerequisite for attaining quality-of-care objectives. It is, therefore, necessary to review the practices regarding special method-linked emphasis, use of targets, and quota and incentive systems in programmes. If necessary, studies should be undertaken to determine their impact on choice as instruments to convince policy makers. While targets at the national level are useful tools for the planning process, they should not be assigned to service providers. If financial or material incentives in programmes are unavoidable, amounts should be at levels which do not negate the principle of informed and free choice. Vietnamese programmes can promote equitable choice by reviewing the current payment systems for contraceptive acceptance. China can improve informed choice by reviewing the target system even without giving up the intended goal of fertility reduction. India and Nepal can further promote equitable choice.

(b) Strengthening of interpersonal communication

Considering that the interpersonal aspects of quality of care have been neglected in the past, special efforts are needed to strengthen this aspect of services. Besides placing an increased emphasis on interpersonal communication and counselling as important and integral parts of services, it is essential to improve providers' communication and counselling skills, designed to promote informed choice, in conformity with the recommendation in the Programme of Action: "The principle of informed free choice is essential to the long-term success of family planning programmes. Any form of coercion has no part to play" (paragraph 7.12).

The existing training courses should integrate properly planned modules to strengthen provider skills in interpersonal communication.

It has also been found that training alone may be insufficient to result in the application of quality-of-care measures. The real obstacle is low motivation among staff (Simmons and Simmons, 1992). Therefore, a package of interdependent strategies, including clearly expressed quality-of- care goals, quality-oriented monitoring systems, and supportive supervision and guidance, would be more effective. Nearly all the countries in the region can further improve interpersonal communication and counselling.

(c) User-oriented follow-up systems

Client perspectives in programmes can be improved through reorienting their follow-up systems, not to follow method users, but to follow individuals irrespective of their contraceptive use status and switching practices (Jain, 1992). The service system should follow individuals through different phases of reproductive life, including practice and non-practice, pregnant and non-pregnant statuses, and advise, serve, support and reassure them, as and when necessary. Such honest brokerage can build a mutual trust relationship that would eventually make counselling most effective. Programme record-keeping systems can also be built on such an objective.

(d) Integration of reproductive health services

The integration of family planning with other reproductive health services can meet many other health needs of the clients during a single visit and thereby make services user-friendly and acceptable. This will also improve the programme's credibility among people. Integration should not be viewed as an "all or none" situation. Countries can achieve a great deal, in terms of improved quality of care, even through partial or functional integration, where organizational structures do not permit full integration. Appropriate packaging of service interventions, as an appropriate constellation, can achieve the objectives of integration to a great extent.

Three factors should be taken into account in the packaging of services: perceived priorities, programme capacity, and resources. Broadening of scope can be done gradually on an incremental basis, especially where capacity and resources are limited. For several countries in the subregion, the most appropriate add-on intervention would be STDs/RTIs. Significant health benefits can be derived from the integration of STDs/RTIs with family planning and maternal care, especially preventive counselling, education and referral. Combining contraceptive service skills with those on STD management will improve medical screening of IUD acceptors and, in turn, improve the safety of IUD use. Such action, for example, would be relevant for Viet Nam, because of a high incidence of reproductive tract infections and a high rate of IUD use.

(e) Understanding of users' preferences

The policy of informed choice can be promoted best if consumer preferences of different methods, together with associated cultural, psychological and economic factors, are better understood. Improved knowledge of consumer concerns, possible side effects, effectiveness and convenience of use will strengthen information provision, counselling and IEC functions. However, in the countries of the region, such efforts are minimal. Improved and focused research strategies can generate knowledge to contribute to users' perspectives.

4. Broadening of contraceptive options promoting freedom of choice

As discussed earlier, a broader range of contraceptives in the programme can meet the needs and preferences of more individuals. Even for countries having a primary and major concern to reduce population growth rates, the provision of a broader range of methods with freedom to choose from them would allow a better chance to achieve demographic and health goals. As quoted earlier, method-specific emphasis in programmes can eventually be counterproductive and should, therefore, be avoided.

(a) Introduction/reintroduction of methods

Broader choice can be promoted in many countries through the introduction of additional methods and the reintroduction of methods or improved methods which were not being appropriately utilized. For example, Viet Nam can introduce injectable contraceptives. Countries, especially those with a high incidence of teenage pregnancy (Indonesia,Myanmar and the Philippines) and unsafe abortion (Cambodia and Myanmar), may consider the introduction of emergency contraception. Through the application of reintroduction strategies, method utilization can be improved. An example would be the possibility of wider use of Copper T 380 in Indonesia, in place of the Lippes loop. Some countries in the South Asian region can promote the acceptability and effectiveness of several reversible methods through the application of well-designed reintroduction strategies.

(b) Broadening of source/channels of services

The use of broad-based channels of services is likely to meet the choices of larger segments of the population. Therefore, services should be provided through as many channels as possible, such as clinical networks, community-based systems, social marketing, NGOs, and places of employment and other settings, and involving the private and commercial sectors. Countries which can potentially broaden contraceptive sources are Cambodia, the Democratic People's Republic of Korea, the Lao People's Democratic Republic, Mongolia and Myanmar through the use of NGOs, community-based delivery and social marketing channels.

5. Need-based monitoring of programmes

The existing systems are not focused on individuals to monitor the extent to which the programmes are able to meet unmet need and prevent unwanted pregnancies. Common indicators used by family planning programmes to measure performance are fertility rates, contraceptive prevalence rates, the number of new acceptors of family planning methods and couple years of protection. These indicators do not show the extent to which reproductive intentions have been fulfilled through meeting unmet need.

A new approach is under trial for monitoring the success of family planning programmes in meeting needs, through use of the HARI Index (Jain and Bruce, 1995). The HARI index is an acronym for "Helping individuals Achieve their Reproductive Intentions". It is based on the percentage of women who are able to effectively avoid unintended pregnancy (or birth) and do not experience morbidity in a 24-month period. The HARI index proposes measures based on the percentage of couples who are able to successfully prevent unwanted pregnancy and maternal morbidity. "Success" is defined by no-pregnancy/ birth for those who do not want any more children as well as pregnancy/birth among those who want more children now. Theoretically speaking, the inability to bear children by one who wants to have a child would be a failure, except for the fact that services in most developing countries are grossly inadequate to assist infertile women in this regard.

Application of the HARI approach can be made in different pathways and programmes can adjust the scope according to the scope of available data. The values of the HARI index, based on secondary analysis of data collected for other studies, for selected countries are shown in table VI.10, as an example.

As noted earlier, when the period of observation in Taiwan Province of China was increased from three to seven years, the HARI index declined, owing to an increase in cumulative failure rates. The low index in the Philippines is perhaps due to low accessibility. Because of the limited scope of the data, the analysis could not distinguish between different types of failures.

Although the principles of HARI have only been tested in a limited field situation, preliminary experience indicates that its use will carry significant implications, not only for the reproductive health strategies and policies but also for the existing management information systems. For example, family planning programme strategies followed in Indonesia and Viet Nam would not provide a suitable situation for the application of the principles unless there was a basic change in strategies regarding the criteria applied to method provision.

The development of an indicator system to meet the data needs of the HARI approach is not a simple matter, especially for unwanted childbearing. Theoretically, most survey data can be analysed by unwanted and wanted childbearing, except for the fact that retrospective data on "wantedness" are likely to be biased. It is, therefore, necessary to develop an indicator system providing for collection of data on reproductive intention and other related information on a prospective basis.

E. Conclusions and observations

1. Target-free strategies

A target-free approach, together with a non-coercive environment, can improve the quality of care
Freedom of choice can lead to sustained and effective contraceptive use and achieve a greater demographic impact
Financial payments and method-linked incentives affect the quality of care and do not necessarily promote contraceptive prevalence
While national-level targets can be useful planning tools, these should not result in quotas to be assigned to service providers

2. Client-centred approaches

Integrated service strategies make services user-friendly and improve the quality of care
Interpersonal communication and counselling are essential tools to provide information, improve choice and thereby the quality of care
Tailor-made IEC efforts can contribute to informed choice, quality of care and freedom of choice
Client-centred follow-up and individual need-based monitoring systems can provide feedback on the quality of care
Because of the commonality of approaches, gender-sensitive strategies can contribute to quality of care
Broader options of sources, through multiple channels such as NGOs, community-based distribution and social marketing, can meet the needs of a wider segment of population

3. Family planning rationale and population goals

Quality-of-care principles are compatible with population stabilization strategies which can create a better environment for the expression of reproductive rights
Unmet need and the demand for family planning are not static, but rise with increased accessibility and improved quality of care, and move in the direction of population stabilization goals

4. Supporting strategies

Focused research to understand client concerns would contribute to improved quality-of-care strategies
Advocacy efforts are needed to create improved understanding and commitment regarding the quality of care among policy makers

End Notes

* Atiqur Rahman Khan, adviser on reproductive health/family planning programme; Tan Boon-Ann, adviser on programme design, development and evaluation; and Suman Mehta, adviser on reproductive health/family planning training research, United Nations Population Fund/Country Support Team for East and South-East Asia, Bangkok.

References

Abou-Zahr, C. (1994). WHO, Should All Research on Quality of Care be Intervention Related? Report on the Workshop on Quality of Care for Women, Budapest, October 1994.

Bangladesh (1994). Bangladesh Demographic and Health Survey,-1993-1994, (National Institute of Population Research and Training (NIPORT), Mitra Associates, Dhaka, Macro International Inc.).

Bongaarts, J. (1997). Trends in Unwanted Childbearing in the Developing World, No. 98 (New York, Population Council).

Bruce, J. (1989). Fundamental Elements of Quality of Care: A Simple Framework, Population Council Working Paper No 19, and Studies in Family Planning, 21(2):61-91.

Bruce, J., and A. Jain (1991), "Improving quality of care through operations research", in Myrna Seidman and Marjorie Horn, eds., Operations Research: Helping Family Planning Programs Work Better (New York).

Cambodia (1995). Kap Survey on Fertility and Contraception in Cambodia (National Maternal and Child Health Centre, July 1995).

China (1993). China Family Planning Year Book, State Family Planning Commission, Beijing.

____(1995). Family Planning in China (State Council of the People's Republic of China, Beijing).

Cleland, J. and P.Mauldin (1991). "The promotion of family planning by financial payments: the case of Bangladesh", Studies in Family Planning, January-February 1991.

Donabedian, A. (1988). "The quality of care: how can it be assessed?" Journal of the American Medical Association, vol. 260. No. 12: pp. 1743-1748.

Freedman, R. and J.Y Takeshita, (1969). Family Planning in Taiwan (Princeton, Princeton University Press).

Haryono Suyono (1994). Minister of Population, Indonesia, Address at the Population Association of America, 2 May 1994.

Hull, V.J. (1994). "Improving quality of care in family planning: how far have we come?" Sixth Annual Meeting of the Indonesian Epidemiology Network, October 1994.

India (1994), National Family Health Survey (MCH and Family Planning), India 1992-93, Introductory Report (Bombay, India International Institute for Population Studies)

Indonesia (1993). State Ministry for Population, Indonesia, Law on Population Development and the Development of Happy and Prosperous Families (Jakarta).

____(1995). Demographic and Health Survey 1994 (Central Bureau of Statistics, National Family Planning Coordinating Board (BKKBN)).

Jain, A.K. ed. (1992), Managing Quality of Care in Population Programs (United States, Kumarian Press).

Jain, A.K. and J.Bruce (1995). "Implications of reproductive health objectives and efficacy of family planning programs" (Population Council, circulated in a workshop on quality of care).

Knodel, J. and others (1995). Viet Nam's Population and Family Planning Program as Viewed by its Implementors, Regional Working Papers No.2 (Population Council, Bangkok).

Lao People's Democratic Republic (1995). Report on the Fertility and Birth Spacing Survey (National Statistical Centre).

Mongolia (1994). Mongolia Demographic Survey, (Population Teaching and Research Centre, Mongolian National University).

Myanmar (1995). Population Changes and Fertility Survey, 1991 (Immigration and Population Department, Ministry of Immigration and Population).

Nepal (1997). Nepal Family Health Survey 1996, (Family Health Division, Ministry of Health, Government of Nepal, New Era, Nepal and Macro International Inc., United States, July 1997).

Osteria, T. (1996). Assessment of Quality of Family Planning Services in Selected Service Delivery Points in the Philippines (Social Development Research Centre, De La Salle University, Manila).

Pariani, S. and others (1991)."Does choice make a difference to contraceptive use? Evidence from East Java", Studies in Family Planning, vol. 22, No. 6 (New York, Population Council).

Philippines (1996a). "A Gender-responsive population policy framework with reproductive health perspectives (draft) (Commission on Population, Manila).

____(1996b), 1996 Family Planning Survey: Final Report (National Statistical Office, Manila).

Ross, J.A and others (1989). Management Strategies for Family Planning Programmes (Center for Population and Family Planning, Columbia University, New York).

Simmons, R., and G.Simmons (1992). "Moving toward a higher quality of care: challenges for management, in A.K.Jain ed., Managing Quality of Care in Population Programs (United States, Kumarian Press).

Singh, J.S. (1997). "A target-free approach in family planning", E-mail communication from KZPG Overpopulation News Network, 22 December 1997.

Singh, R. (1994). Family Planning Success Stories (Asia, Latin America and Africa) (Bombay, UBS publishers).

Sri Lanka (1994), Demographic and Health Survey, Sri Lanka 1993, Preliminary Report (Department of Census and Statistics, Ministry of Policy Planning and Implementation in collaboration with the Ministry of Health and Women's Affairs).

United Nations (1974). The World Population Plan of Action (World Population Conference, Bucharest), para.14 f.

____(1994), World Contraceptive Use 1994 (New York).

____(1995), Report of the International Conference on Population and Development, Cairo, 5-13 Sept 1994 (Sales No. E.95 XIII. 7).

____(1995a). Guidelines for UNFPA Support for Reproductive Health, Including Family Planning and Sexual Health (New York).

____(1995b). "Fourth Country Programme of Assistance to the Philippines, 1994-1998, Strengthening the Management and Field Implementation of the Family Planning/ Reproductive Health Programme (Manila).

____(1997a). The State of the World Population (New York), p.6.

____(1997b). Draft Programme of Assistance to the Democratic People's Republic of Korea.

____(1997c). Draft Report of the UNFPA Programme Support of Thailand.

____(1998). Official communications, UNFPA, Vientiane, Februry 1998.

____Viet Nam (1990). Demographic and Health Survey 1988 (National Committee for Population and Family Planning, Hanoi).

____(1995). Viet Nam Intercensal Demographic Survey: Major Findings (Statistical Publishing House).

WHO/WPRO (1995). A Reproductive Health Profile of the Western Pacific Region (WHO Regional Office for the Western Pacific, Manila).

WHO/SEARO (1996). Regional Health Report (WHO, Regional Office for South-East Asia, New Delhi).