RHO archives : Topics : Family Planning Program Issues

Annotated Bibliography

This is page 3 of the Family Planning Program Issues Annotated Bibliography. This page contains:

• Training and performance improvement
• Supervision
• Quality improvement strategies
• Integrated services

To access more bibliographic entries, visit page 1, page 2, or page 4, or return to the complete list of topics covered in the Family Planning Program Issues Annotated Bibliography. Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

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Training and performance improvement

Baraitser, P. et al. Multidisciplinary learning in family planning clinics. British Journal of Family Planning 26(2):107–108 (2000).
During a multidisciplinary, family planning training workshop in the UK, clinical (doctors and nurses) and nonclinical staff (receptionists, administrators) were trained together in some sessions and were asked to consider how effective teamwork might contribute to the efficient running of the clinics. Most participants felt comfortable learning in multidisciplinary groups and gained in knowledge. The facilitators also reported few difficulties. The authors conclude that excluding nonclinical staff from interdisciplinary learning programs misses an opportunity for the exchange of ideas.

Best, K. Training involves many factors. Network 19(1) (Fall 1998). Available at: www.fhi.org/en/fp/fppubs/network/v19-1/nt1914.html.
This article, which is also available in French and Spanish, reviews effective approaches to training reproductive health providers. Training all staff members at a facility, on site, increases motivation while reducing disruptions. The process of training is as important as the content because it helps ensure that training will change provider behavior. Effective techniques build on personal experience, are interactive, use models and coaching, and assess how well trainees perform a skill. Anatomic models are especially helpful for training in clinical procedures, such as inserting an IUD. The training process can be modified for self-study. Training, and the improvement in skills it brings about, have been directly linked with changes in family planning knowledge, attitudes, and behavior in several studies. To produce lasting changes in behavior, training must be repeated or supported by supervisors.

Bradley, J. et al. Whole-site training: a new approach to the organization of training. AVSC Working Paper 11 (August 1998). Available at: www.engenderhealth.org/pubs/workpap/wp11/wp_11.html.
Conventional training approaches are divorced from supervisory systems, lack follow-up, ignore the systems in which individuals work, and disrupt services; as a result new knowledge and skills may not be applied on the job. To address these and other problems, AVSC has developed whole-site training that addresses the training needs of the entire staff of a service delivery site with on-site instruction. Whole-site training stresses the development and training of teams, rather than individuals, so that staff can support one another and so that gains are sustainable. The level of training is tailored to the needs of different employees and the training process is supported by facilitative supervision. There are three challenges facing this model: maintaining the quality of such localized training, promoting needs assessment and priority setting at site, and changing preconceptions about how training ought to be done.

Caiola, N. and Sullivan, R.L. Performance Improvement: Developing a Strategy for Reproductive Health Services. JHPIEGO Strategy Paper. Baltimore, Maryland: JHPIEGO (May 2000). Available at: www.reproline.jhu.edu/english/6read/6pi/pistrat/pistrat1.htm.
Because training is not always the solution to performance problems, this strategy paper examines performance improvement's broader approach to diagnosing and solving performance gaps. After reviewing the general management literature on performance improvement, the authors present the performance improvement process developed by JHPIEGO for analyzing and improving performance in health care organizations.

Halawa, M. et al. Assessing the impact of a family planning nurse training program in Egypt. Population Research and Policy Review 14:395–409 (1995).
This operations research program examined the impact of a new training program on the performance of family planning nurses, client knowledge and attitudes, and contraceptive use. Approximately 250 nurses each were assigned to new and old training programs in Egypt. The new curriculum devotes more time to counseling and education skills, is competency-based, emphasizes that practical curriculum is theory-based, measures success by trainee attendance, and evaluates students through a written test.

Jain, S.C. et al. Improving family planning program performance through management training: the 3Cs paradigm. Journal of Health & Population in Developing Countries 2(1):1–25 (1999).
This article examines the development and impact of a 14-week management training program in Bangladesh attended by 20 thana (county) family planning officers who had at least five years of experience. The training was explicitly designed to improve the performance of the thana family planning programs managed by the trainees and focused on improving trainees' competence. The curriculum covered needs assessments, data use, finance, service quality, human resource management, managerial behavior, strategy, operations management, and performance improvement. Each trainee wrote a detailed action plan to improve the contraceptive prevalence rate (CPR) in his or her thana after their return to work. During a 12-month follow-up period, trainees submitted monthly reports, received some feedback, and attended a six-month review conference. Verification studies designed to eliminate problems with over- and under-reporting of family planning statistics found that CPR increased an average of 9.8 percentage points in each thana over a nine-month period. Gains ranged from 4.8 to 13.1 percentage points and were generally higher in lower performing thanas.

Kim, Y.M. et al. Improving the quality of service delivery in Nigeria. Studies in Family Planning 23(2):118–127 (1992).
This study evaluates the effect of a nurse training program in family planning counseling skills on the quality of family planning service delivery and on client compliance with prearranged appointments. Two groups of nurses in Ogun State, Nigeria, are compared; both groups received six weeks of technical training but the experimental group received an additional three days of training in interpersonal communication and counseling (IPC/C) skills. According to exit interviews with clients, nurses in the experimental group were significantly more likely than those in the control group to listen attentively, make clients comfortable, and be polite; they also explained family planning more clearly. Nurses with IPC/C training excelled in requesting new acceptors to repeat instructions for the method chosen, asking them if they had any questions, demonstrating the use of the method, and showing booklets about the method. Expert observers confirmed these results. Clients of nurses with IPC/C training were significantly more likely to schedule a follow-up visit (96% versus 78%, P < 0.001) and to return for that visit (84% versus 44%, P < 0.001). The authors conclude that brief counseling training can significantly improve the quality of care provided by family planning workers as well as client compliance with follow-up appointments.

Knebel, E. The Use and Effect of Computer-based Training in Health Care: What Do We Know? Operations Research Issue Paper 2. Bethesda, Maryland: Quality Assurance Project (April 2000). Available at: www.qaproject.org/pubs/PDFs/researchcbtx.pdf.
This exhaustive literature review examines research on the effectiveness of computer-based training (CBT) in health care, focusing on its implementation in developing country settings. Advantages of CBT are that it is self-paced, interactive, just-in-time, inexpensive, accessible, satisfying to students, and consistent in quality. Disadvantages include the need for technical support, high development costs, rapid changes in technology, technophobia, and limited access to computers. The experience of developing countries in applying computer technology to training needs in health care, although limited, is highly encouraging—as is its application in developed countries. Meta-analyses demonstrate positive effects on student learning, although the impact depends on how the material is presented and how it relates to students' professional responsibilities. Since CBT is as effective and possibly even more cost-effective than traditional training, further research on the optimal delivery of CBT is recommended.

Kortmann, G. Putting principles into practice. Health Action 8:8–9 (March–May 1994).
This article discusses how to motivate community health workers (CHWs) through continuing education. Too often, health workers receive no further education after their initial training. Three ideas are to: learn what CHWs perceive their training needs to be; provide regular, supportive supervision focused on learning; and organize refresher courses and assessment to ensure new developments are incorporated into practice. Examples are given of training programs in India and Nigeria that teach traditional birth attendants to serve as health workers. Both programs have supervisors meet monthly with workers to discuss and help solve problems and to teach new skills. Both also schedule regular refresher courses or workshops for the workers.

Lande, R.E. Performance improvement. Population Reports, Series J, No. 52. Baltimore, Maryland: Johns Hopkins Bloomberg School of Public Health, Population Information Program (2002). Available in English, French, and Spanish at: www.infoforhealth.org/pr/online.shtml#j.
This review examines how reproductive health organizations can use the performance improvement (PI) process pioneered in industry to meet the needs of staff members and improve quality of care. Performance improvement offers a systematic way to identify and address the reasons for poor performance, including often neglected factors like unclear expectations or infrequent feedback. The report details each step in the PI process: agreeing on objectives, defining desired performance, describing actual performance, measuring the performance gap, finding the root causes, selecting and implementing interventions, and monitoring and evaluating performance.

Limpaphayom, K. et al. The effectiveness of model-based training in accelerating IUD skill acquisition. A study of midwives in Thailand. British Journal of Family Planning 23:58–61 (1997).
This study compared the traditional approach to IUD clinical training (two weeks of classroom training followed by four weeks of clinical practice on clients) with an alternative approach (home study of clinical guidelines followed by one week of classroom training with an anatomical model and one week of clinical practice on clients). Among 300 Thai midwives trained to insert IUDs, those receiving alternative training were more likely to achieve competency than those receiving traditional training (148 versus 137, P = 0.0036), and they required fewer insertions to do so (1.6 versus 6.5, P = 0.0001). There was little difference in client satisfaction levels between the two training groups. Midwives in the alternative training group were more likely to say the course was too short (46.7% versus 11.3%, P = 0.0001). The alternative training course cost about one-third as much as the traditional course, making it far more cost-effective. The authors conclude that students in clinical family planning training programs can achieve competency more quickly when guidelines are standardized and when they practice procedures on anatomic models before practicing on actual clients.

Long, P. and Kiplinger, N. Making It Happen: Using Distance Learning to Improve Reproductive Health Provider Performance. Chapel Hill, North Carolina: INTRAH (1999). Available at: www.intrah.org/rtlpubs.html.
Distance learning presents course content in pre-produced instructional packages that do not require face-to-face interaction with a teacher. It may employ print materials, audiotapes, radio and television broadcasts, computer software, or electronic conferencing. Advantages of distance learning over traditional training include increased access, greater flexibility, learner empowerment, and cost-effectiveness. This publication explains each of the steps needed to design, build, implement, and evaluate a successful distance-learning program. The authors also discuss the challenges that distance learning must address, including communicating across a distance, developing new roles for learners and facilitators, dependence on electronic technology and other means to deliver instructional content, and recruiting support for a largely invisible program. Case studies of distance learning programs in Tanzania and South Africa are presented, and there is a list of print and Internet resources for additional help in designing distance education.

Mariani, E. and Klaus, D. Training Manager's Guide. Bethesda, Maryland: Quality Assurance Project.Available at: www.qaproject.org/pubs/PDFs/M_TRAIN.PDF.
The purpose of this monograph is to help health managers design, develop, and deliver efficient and cost-effective training. It presents practical guidelines for creating successful learning experiences and provides step-by-step instructions in key training elements, including assessing the need for training, analyzing the performance problem, designing the training strategy, developing training materials and media, preparing a participant workbook, producing training materials, delivering the course, and evaluating its impact. The instructions cover multiple training options, including distance learning and on-the-job training as well as formal workshops.

Mumtaz, Z. et al. Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health Policy and Planning 18(3):261-269 (2003).
In South Asia, health care systems have created cadres of female community-based workers to overcome gender-based constraints on women’s access to services. This qualitative study examined the experience of women health workers in an agricultural area of Punjab through in-depth interviews and a focus group discussion. Women health workers complained about unsupportive management, the oppressive use of power, disrespect and sexual harassment by male colleagues, insensitivity to gender-based cultural constraints on their behavior, unrealistic demands for mobility, lack of rewards or career advancement, inadequate resources, and hostile community and family attitudes toward their work. The authors conclude that the gender system which demands their appointment also permeates their work conditions and impairs their performance. They recommend extensive organizational changes, including formal gender training for staff at all levels, to encourage respect and support for women health workers.

PRIME II and JHPIEGO. Transfer of Learning: A Guide for Strengthening the Performance of Health Care Workers. Chapel Hill, North Carolina: INTRAH (March 2002). Interactive version available at: www.intrah.org/tol/index.html. Print versions available in English, French, and Spanish at:
www.intrah.org/rtlpubs.html and at: www.reproline.jhu.edu/english/6read/6training/tol/.
This guide is designed to share strategies and techniques that can be used before, during, and after training interventions to ensure that new knowledge and skills translate into improved performance on the job. It outlines specific actions that supervisors, trainers, learners, and co-workers can take to improve the transfer of learning. Users of the guide are encouraged to examine their work environments to identify and understand the factors that affect worker performance so that they can choose strategies appropriately.

Shelton, J.D. The provider perspective: human after all. International Family Planning Perspectives 27(3):152–153, 161 (2001). Available at: www.agi-usa.org/pubs/journals/2715201.html.
Understanding health care providers is essential to improving their performance, but little information is available. The author speculates about some key factors that may affect their behavior. Given the minimal financial rewards of the work, providers presumably are motivated more by altruism and the desire for enhanced social status. They also are influenced by medical culture, which is conservative, emphasizes technology, creates an emotional distance from patients, and places decision making firmly in providers hands. To create a controlled and comfortable work environment, providers hold on to long-established practices and consider their own convenience. Finally, the social system within which providers work discourages change, promotes a scarcity mentality, and creates social distance from clients.

Storey, J.D. et al. Distance education works. Communication Impact! No. 1. Baltimore, Maryland: Johns Hopkins University Center for Communication Programs (January 1998). Available at: www.jhuccp.org/pubs/ci/1/index.shtml.
Because of the difficulties of the terrain in Nepal and a shortage of funds, an innovative distance-education program was created to improve the family planning knowledge and counseling skills of rural health workers. A 52-episode radio soap opera entitled "Service Brings Rewards" was broadcast weekly to health workers, who were also provided with support print materials. The program alternated drama segments with interactive question and answer segments. Events and situations in the drama provided listening health workers with a clear and personal understanding of their clients' needs and also role-modeled effective client-provider interactions. Over the course of the program, providers' test scores increased for technical knowledge, attitudes toward family planning, and counseling scenarios. Overall, their scores rose from 57 to 74 (out of a total of 100).

Sullivan, R.S. The competency-based approach to training. JHPIEGO Strategy Paper 1 (1995). Available at: www.reproline.jhu.edu/english/6read/6training/cbt/cbt.htm.
Competency-based training (CBT) measures progress in terms of the mastery of specific knowledge and skills, rather than time or attendance, and is centered on the learner rather than the teacher. Models and simulations are used extensively, and evaluation is based on the ability to perform key tasks. Advantages of CBT include achievement of competencies required to perform essential job skills, increased confidence of trainees, and more efficient use of training time. However, it is not easy to switch from traditional to competency-based training. The author outlines the four-step process used by JHPIEGO to transfer specific clinical skills and knowledge from experts to service providers, beginning with standardizing the provision of clinical services and developing needed training materials.

Sullivan, R.S. and Smith, T. On-the-job Training for Family Planning Service Providers. JHPIEGO Strategy Paper 3 (1996). Available at: www.jhpiego.jhu.edu/pubs/SP603WEB.PDF.
This strategy paper applies on-the-job training (OJT) to the demands of family planning programs. While OJT can be delivered in an impromptu fashion by pairing a trainee with an experienced worker, more can be gained from a highly structured approach in which an experienced employee is assigned to train a novice in specific knowledge and skills using standardized materials and techniques. Advantages of OJT include timeliness, the ability to meet local needs, sustainability, and cost-effectiveness, but it can be hard to maintain the quality of OJT across different sites. Structured OJT requires carefully selecting and preparing service providers to act as OJT trainers and providing needed supplies and materials. To illustrate the relevance of OJT for family planning, the authors outline a program for IUD instruction.

Valadez, J.I. et al. Assessing family planning service-delivery skills in Kenya. Studies in Family Planning 28(2):143–150 (1997).
This study demonstrated the use of an industrial approach (Lot Quality Assurance Sampling, or LQAS) to evaluate the technical competence of family planning service providers trained with a new curriculum. QAS was used to minimize the number of observations need to judge providers' skills; the approach calculated both the sample size needed and the number of errors acceptable. To measure trainees' retention of skills, supervisors used an observation checklist. The providers showed more need for improvement in counseling than in other skills. Providers' retention of skills was not affected by the amount of time that had elapsed since training, but it was affected by whether they were using those skills on an ongoing basis. Service delivery problems were far more common among caregivers who were not currently providing services.

Wolff, J.A. et al., eds. Training for effective performance. In: The Family Planning Manager's Handbook: Basic Skills and Tools for Managing Family Planning Programs, chapter 6. West Hartford, Connecticut: Kumarian Press (1991). In English, French, Spanish, Bangla, Arabic, and Portuguese. Available at: http://erc.msh.org/fpmh_english/chp6/index.html).
This standard text offers practical advice on how to train staff members to improve their performance. It offers a thorough review of how to determine whether training is needed and then discusses how to design and implement a training program, beginning with the earliest design stage and moving through evaluations and follow-up visits. Also included are sample forms, checklists, and other tools as well as multiple country examples.

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Supervision

Ahmed, A.M. et al. The national guidelines for supervision checklist: a tool for monitoring supervision activities at district level in Tanzania. Annali di Igiene 6:161–166 (1994).
In 1987 the Tanzania Ministry of Health issued National Guidelines for Supervision to help supervisors of peripheral health workers provide comprehensive and more meaningful supervision. An evaluation over a four-year period (1989–1992) found that 90 percent of health units in one district and 66 percent of units in a second district were visited twice a year as planned. Supervisory visits were frequently too short (a median of four hours, with 25 percent of all visits lasting less than two hours). The composition of the supervision team varied and did not regularly include recommended (and trained) personnel. Ninety-two percent of heads of health units confirmed that supervisors met with all health workers and provided on-the-job training; 80 percent were satisfied with feedback they received from supervisors. The guidelines were used consistently at every visit, and the authors recommend that they be periodically revised.

Ashraf, A. et al. Strengthening Front-line Supervision to Improve the Performance of Family Planning Field Workers in Bangladesh. Dhaka: International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Working Paper No. 47 (1996).
This paper reviews the role and performance of Family Planning Inspectors (FPIs) in Bangladesh, who supervise the lowest cadre of field workers in the National FP-MCH Programme. Constraints on FPIs' performance include poor motivation, ambiguous job descriptions, no job manuals, inadequate training, no tools to measure supervisory functions and progress, inadequate supervisory support and guidance, no control over targets set by headquarters, inadequate transportation, and excessive administrative requirements. As a result, FPIs do not fully understand their duties and responsibilities, make far fewer field visits than expected, spend too much time on paperwork and meetings, and focus on inspection and policing rather than providing support and guidance to field workers. The authors recommend providing a clear job description, job manuals, supervisory training, necessary logistic support, and a supervisory monitoring tool to FPIs. In addition, they recommend developing a nationwide system of performance monitoring and strengthening the supervisory capabilities of higher level managers.

Ben Salem, B. and Beattie, K.J. Facilitative supervision: a vital link in quality reproductive health service delivery. AVSC Working Paper 10 (August 1996). Available at: www.engenderhealth.org/pubs/workpap/wp10/wp_10.html)
This paper outlines an innovative approach to supervision that empowers site staff and gives them the support they need to participate in the quality improvement process. In this model, supervisors facilitate local-level problem solving in addition to serving as an intermediary to higher levels of management. Supervisors help site staff implement the quality management process, plan objectives and evaluation, ensure availability of equipment and supplies, apply service standards, and address training needs. Introducing facilitative supervision requires substantial training and reorientation for supervisors, who must learn new attitudes and roles. The paper provides examples of facilitative supervision from Tanzania and Bangladesh .

Benavente, J. and Madden, C. Improving supervision: a team approach. Family Planning Manager 2(5):1–18 (1993). Available at: http://erc.msh.org/mainpage.cfm?file=2.2.3.htm&module=hr&language=English.
This article outlines an alternative approach to supervision, in which the supervisor who periodically visits a clinic shares supervisory responsibilities with the clinic manager and staff. Establishing this kind of team makes it possible to have a supervisory system that functions between scheduled supervisory visits. Practical advice is offered on developing an effective team that can meet periodically to solve problems. In addition, this article discusses the full range of responsibilities an outside supervisor should undertake, including providing technical support and training in clinical activities, advising on effective management practices, and reinforcing the clinic manager's ability to handle personnel issues. Step-by-step directions are given for conducting supervisory visits using the team supervision process.

Combary, P. et al. Study of the Effects of Technical Supervision Training on CBD Supervisors' Performance in Seven Regions of Ghana. Technical Report 7. Chapel Hill, NC: Intrah (January 1999). Available at: www.intrah.org/Techreports/TR07.pdf)
This quasi-experimental study compared two groups of Ghanaian CBD supervisors, one of which had received training in technical supervision. Training increased the mean knowledge index of supervisors from 32 percent to 88 percent and their mean skill index from 63 percent to 95 percent. Four months after the training, the knowledge index of trained supervisors had fallen to 67 percent and the skill index to 90 percent. In contrast, knowledge and skill levels in the control group (which had not received training) remained flat over the course of the study. In focus groups, CBD supervisors identified transportation as the single biggest obstacle to carrying out their duties and also expressed concern about the lack of pay, incentives, materials and supplies. Training supervisors also had a positive impact on the skills of the CBD agents they supervised: the mean skill index in the experimental group rose from 56 percent to 71 percent while it declined slightly in the control group. According to the CBDs, trained supervisors more often informed them about upcoming supervisory visits, discussed issues rather than giving instructions, and addressed a wider range of topics. Further improvement is needed in maintaining supervisors' knowledge after training and in raising the skills of CBDs to the level required for optimal practice.

Jacobson, M.L. et al. Individual and group supervision of community health workers in Kenya: a comparison. Journal of Health Administration Education 5(1):83–94 (1987).
This operations research project tested two forms of supervision of village-based primary health and family planning workers: one- to two-hour visits with individual workers and three- to four-hour visits with a group of three to five health workers. The same supervisor worked with all the health workers, and both groups were visited monthly over a one-year period. There were no significant differences between the two supervision regimens in health workers' knowledge or in the number of services they rendered. Group supervision cost half as much as individual supervision, and it would allow each supervisor to cover 2–3 times as many health workers per month.

Kim, Y.M. et al. The quality of supervisor-provider interactions in Zimbabwe. Operations Research Summary. Bethesda, Maryland: Quality Assurance Project (2000). Available at: www.qaproject.org/pubs/PDFs/zimbabweoresults.pdf.
Working together, researchers and supervisors developed a rating guide and set of structured observation instruments to assess supervisors' performance. Sixteen supervisors from four provinces in Zimbabwe were evaluated. Supervisors' main strengths were in technical competence, their ability to interpret and analyze data, their ability to rapidly identify errors and problems at the facility, and their reference to standards manuals at the facilities. However, providers generally failed to involve providers in problem identification and solving, to innovate, to use checklists, to espouse a vision of quality, to refer to past or future supervisory visits, to pay attention to client-provider interactions, or to seek client input into the quality of services. Based on these results, local organizations agreed that they should move away from a hierarchical, top-down approach to supervision toward a team-based approach in which providers and supervisors work synergistically as partners.

Kim, Y.M. et al. Self-assessment and peer review: improving Indonesia service providers' communication with clients. International Family Planning Perspectives 26(1):4–12 (2000). Available at: www.agi-usa.org/pubs/journals/2600400.html)
This study tested low-cost alternatives to supervision to reinforce the impact of interpersonal communication and counseling (IPC/C) training. After attending an IPC/C training course, 20l Indonesian service providers were divided into three groups for follow-up: the control group received no reinforcement, a second group conducted weekly self-assessments over a four-month period, and the third group attended peer-review meetings in addition to conducting self-assessments. Training doubled the length of family planning counseling sessions, the amount of medical and family planning information offered by providers, the frequency of provider facilitative communication (which fosters rapport and client participation), and the number of client questions. The self-assessment and peer review interventions helped providers maintain their performance after training and also prompted further improvements. During the reinforcement period, provider facilitative communication, client active communication, and client satisfaction increased in the self-assessment group but did not change significantly in the control group. Adding peer review to self-assessment boosted provider facilitative communication and client active communication further but did not affect clients' perspectives on the counseling experience.

Lammerink, M. Ways of working. Health Action 8:10 (March–May 1994).
This article outlines two approaches to integrating education with everyday work: supportive supervision and the process approach to learning. Supervision can be used to provide on-the-job training, help identify and solve problems, create a better working environment, and identify training and resource needs. Autocratic supervision may be important for staff with limited skills, but a more democratic style of supervision results in improved performance among experienced staff. The process approach empowers staff to work through problems and find solutions for themselves. A facilitator leads a group of participants through four steps: discussing what they need to learn and why; exchanging and analyzing individual experiences; diagnosing problems and reflecting on solutions; and placing past experience and new knowledge into a clear frame of reference.

Loevinsohn, B.P. et al. Improving primary health care through systematic supervision: a controlled field trial. Health Policy and Planning 10(2):144–153 (1995).
Field visits found supervisory visits to Philippine health units were sporadic and that checklists were rarely used because they were long and complicated. A new supervisory checklist was developed with just 20 easily scored indicators. The checklist was tested in four remote provinces with poor health status; six other provinces served as a control group. After six months, performance improved 42 percent in the experimental group and 18 percent in the control group. In the experimental group, there was a dose-response relationship between improvements and the amount of supervision: scores improved 57 percent in health facilities visited three or more times compared to 27 percent in those visited less than three times. The initial cost of implementing the checklist was US$19.92 and the annual recurrent cost was $1.85.

Marquez, L. and Kean, L. Making supervision supportive and sustainable: new approaches to old problems. MAQ Paper No. 4 (2002). Available at: www.maqweb.org/maqdoc/MAQno4final.pdf.
This literature review concludes that a supportive approach to supervision is better able than traditional approaches to improve the performance of health workers. Supportive supervision expands the scope of supervision methods by incorporating self-assessment, peer review, and community input. It shifts responsibility for supervision away from a single designated official to a wide range of staff members and peers. It transforms supervision into a continuous, rather than an episodic, process that takes place in a variety of locations. To succeed, supportive supervision requires new thinking about who does supervision and how and when; staff who are motivated to adopt new behaviors; locally appropriate and tested tools; time and investment; the commitment of top management and some decentralized decision-making authority; and integration into existing human resource management systems.

Simmons, R. Supervision: the management of frontline performance. In: Lapham R.J. and Simmons G.B. Organizing for effective family planning programs. Washington, DC : National Academy Press, 233–261 (1987).
Supervision is critical to the effectiveness of a family planning program, and senior managers and researchers have not given it sufficient attention. This chapter reviews the management as well as family planning literature to explore what the best approach to supervision might be and who makes the best supervisor. The author concludes that there is no single answer to these questions: it varies with a program's strategy and design, the nature of the organization, and the needs of the client sector. The supervisor's role and tasks are reviewed, including the five classic operational functions of planning, organizing, staffing, directing, and controlling. Also discussed is the quantity of supervision needed and the impact of organizational design, structure, and climate on supervision.

Valadez, J. et al. Supervision of primary health care in Costa Rica: time well spent? Health Policy and Planning 5(2):118–125 (1990).
All nurse supervisors and rural health supervisors in Costa Rica were asked to record the number of days they had performed various tasks during the preceding months and to describe their mode of transport. However, the nurse supervisors were excluded from analysis after it was discovered that they only interviewed community health workers visiting the health center and rarely observed them. Data show that the rural health supervisors spent only six days a month on supervising community health workers, 41 percent of the 15 days required by the MOH. This may be due in part to a heavy additional workload. Inadequate transport also may have contributed: 26 percent of supervisors did not have access to adequate transportation and the rest had 28 percent less fuel than they needed. The authors suggest four strategies to improve the situation: shifting supervisors' other responsibilities to different personnel, prioritizing supervisors' activities, providing additional transport, or simplifying the supervision system by making rural health supervisors responsible for both technical and administrative supervision.

Vernon, R. et al. A test of alternative supervision strategies for family planning services in Guatemala. Studies in Family Planning 25(4):232–238 (1994).
Because Ministry of Health supervisors in Guatemala found it difficult to provide sufficient guidance and training during brief visits to scattered health units, this operations research project tested two alternative supervision strategies. The first, indirect supervision, replaced one of two scheduled annual supervision visits with a one-day group meeting at the district level with the supervisor. This meeting included training activities as well as routine data collection and resupply. The second strategy, self-assessment, replaced one supervision visit with a two-day workshop during which participants filled out self-assessment checklists identifying quality-of-care problems and devised plans to solve those problems. Supervisors were able to reach a higher percentage of health care units using the alternative strategies than with the traditional system. The alternative strategies also were more cost-efficient and may have contributed to higher increases in productivity. The authors conclude that the alternative strategies offer an important advantage over traditional supervision because they allow supervisors more direct and substantive contact with service-delivery staff.

Wolff, J.A. et al., eds. Supervising and supporting your staff. In: The Family Planning Manager's Handbook: Basic Skills and Tools for Managing Family Planning Programs, chapter 5. West Hartford, Connecticut: Kumarian Press (1991). In English, French, Spanish, Bangla, Arabic, and Portuguese. Available at: http://erc.msh.org/fpmh_english/chp5/index.html)
This standard text offers practical advice on providing support and supervision to improve staff performance. It discusses how to identify and handle performance problems, manage conflict, improve staff motivation, build a supervisory system, prepare a supervisory schedule, develop a supervisor's session plan, and develop a performance appraisal system. Also included are sample forms, checklists, and other tools to help set up a working supervision system as well as multiple country examples.

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Quality improvement strategies

Aldana, J.M. et al. Client satisfaction and quality of health care in rural Bangladesh. Bulletin of the World Health Organization 79(6):512–517 (2001). Available at: www.who.int/docstore/bulletin/pdf/2001/issue6/vol.79.no.6.512-517.pdf.
Exit interviews were conducted with 1,913 patients immediately after receiving care in government health facilities. The most powerful predictors for client satisfaction with services were (1) politeness of provider, (2) providers respect for privacy, and (3) waiting time. Providers technical competence and the length of the consultation (which average less than two and a half minutes) were far less important to clients. Thus, clients may be highly satisfied with care that meets their emotional and social needs but fails to meet their medical needs.

Bradley, J.E. et al. Participatory evaluation of reproductive health care quality in developing countries. Social Science & Medicine 55:269–282 (2002).
To illustrate the benefits of involving local people in development efforts, specifically in evaluation, this article describes a quality improvement program in Tanzania. In the mid-1990s, the program adopted a strategy of building the capacity of local staff to manage the quality improvement process, initially using a self-assessment technique called COPE and a facilitative model of supervision. Supervisors and staff, however, identified a need for a simpler tool to assess a sites progress toward improved quality services. They created, tested, and refined such a tool, which several sites then further adapted to meet local needs. Experience from Tanzania shows that participatory assessment is a valid and effective way to operationalize quality improvement and empower local staff. The authors conclude that involving local stakeholders in the evaluation process can improve project performance, develop local sustainable capacity, and provide useful data for project monitoring.

Bruce, J. Fundamental elements of quality of care: a simple framework.Studies in Family Planning 21(2) (March–April 1990). Available at: www.popcouncil.org/rhfp/qocfundamentals/index.html.
This landmark article develops and describes a six-part framework for quality of family planning care that analyzes quality from the client's perspective. The first element, choice of method, refers to having a range of contraceptive methods available to suit the varying needs of clients. The second element, information giving, ensures that clients are given enough information to choose and employ a specific contraceptive method with satisfaction and technical competence. The third element, technical competence, encompasses the clinical technique of providers, observation of protocols, and maintenance of asepsis to ensure client safety. The fourth element, interpersonal relations, refers to how well providers treat clients, that is, affective dimensions like respect and courtesy. The fifth element, follow-up and continuity mechanisms, refers to continuing support of clients over time. The sixth element, appropriate constellation of services, means configuring family planning services to make them convenient and acceptable to clients and suit local needs.

Buxbaum, A. et al., eds. Using CQI to strengthen family planning programs. Family Planning Manager 2. Boston: Family Planning Management Development, Management Sciences for Health (January–February 1993). Available in English at: http://erc.msh.org/mainpage.cfm?file=2.2.1.htm&module=quality&language =English, in French at http://erc.msh.org/readroom/francais/cqi.htm, and in Spanish at http://erc.msh.org/readroom/espanol/cqi.htm)
Introducing a Continuous Quality Improvement (CQI) process to family planning programs requires a change in management style, with heightened respect both for clients and staff, a shift in focus to fixing processes rather than blaming staff, and the systematic collection and use of data to improve operations. It also requires long-term organizational commitments, including the support of top leaders, and teamwork. This article offers practical tips on how to recruit and train CQI teams and reviews the each step in the cyclical CQI problem-solving process. A case study from MEXFAM illustrates the text.

Cross, H. et al. Reforming operational policies: a pathway to improving reproductive health programs. POLICY Occasional Papers 7. Washington, DC : POLICY Project (December 2002). Available at: www.policyproject.com/pubs/occasional/op-7.pdf.
Frequently program weaknesses can be traced to inadequate, inappropriate, or outdated operational policies, that is, the rules, regulations, and administrative norms that translate national laws and policies into local services. After discussing the nature and role of operational policies, this paper outlines a framework for operational policy reform. The four-step reform process begins by understanding the nature of the public sector, then sets up a collaborative system with managers and providers to identify operational barriers to quality care, conducts analyses to determine the operational barriers at the root of those barriers, and finally adopts recommendations to remove the operational policy barriers. Examples from a variety of countries are described to illustrate the negative impact of outdated or nonexistent policies on reproductive services and the reform process.

DiPrete Brown, L. Lessons learned in institutionalization of quality assurance programs: an international perspective. International Journal for Quality in Health 7(4):419–425 (1995).
This article outlines practical guidelines to make quality assurance (QA) a routine and sustainable part of health systems based on experiences in Chile, Jordan, Costa Rica, Niger, and Egypt. Topics discussed include understanding an organization's strengths and weaknesses, weighing whether to assess the existing quality of care at the start of a program, balancing standardization and flexibility in the QA methodology, the importance of training, developing a QA structure gradually, forming a close alliance with the existing Ministry of Health structure, the need for both top-down and bottom-up strategies, gaining political support, dealing with personnel turnover, developing mechanisms for dissemination, financial sustainability, and documenting results.

DiPrete Bown, L. et al. Quality Assurance of Health Care in Developing Countries. Quality Assurance Methodology Refinement Series. Bethesda, Maryland: Quality Assurance Project (1993). Available in English at: www.qaproject.org/pubs/PDFs/DEVCONT.pdf, and in Spanish at: www.qaproject.org/pubs/PDFs/M1.pdf.
This guide defines quality and quality assurance and concludes that quality assurance is feasible for developing countries because it can improve primary health care programs without requiring additional supplies, logistical support, or financial and human resources. Quality itself includes technical competence, access to services, effectiveness, interpersonal relations, efficiency, continuity, safety, and amenities. It must be defined from the client's, provider's, and manager's perspectives. Most of the publication is devoted to a description of the quality assurance process developed by the Quality Assurance Project, which rests on the development and communication of guidelines, monitoring, and team-based problem-solving, and advice on how to build an effective quality assurance program.

Donabedian, A. The quality of care: how can it be assessed? JAMA 260(12):1743–1748 (1988).
This seminal paper analyzes key theoretical and practical issues in measuring the quality of health care. Quality can be assessed at three levels: most narrowly on the provider's performance, which encompasses both technical and interpersonal processes; next at the level of the patient; and finally, at the level of the community, where access and equity are important issues for quality. Cost also may be an appropriate consideration, with the goal to optimize quality (weighing benefits against costs) rather than to maximize quality at all costs. Quality assessments must cover three areas: structure, process, and outcome. Structure refers to the facilities, equipment, and personnel available and how they are organized. Process refers to the patient's and provider's actions in seeking and giving care. Outcome refers to the effects of care on the health status of patients and populations. Measurements of process and outcomes are equally valid measures of quality, but serve different purposes. The article also discusses how to sample patients, develop measurable criteria, and decide on information sources for quality assessments.

Dwyer, J. and Jezowski, T. Quality management for family planning services: practical experience from Africa. AVSC Working Paper No. 7 (February 1995). Available at: www.engenderhealth.org/pubs/workpap/wp7/wp_7.html.)
AVSC experience in Africa has identified a series of obstacles to the effective utilization of services, including that: quality remains an abstraction for staff; the client perspective is missing; services are isolated, fragmented, and vertical; service sites are unable to adapt to growth; training does not reflect real-life needs and conditions; and supervision is at most superficial. The authors recommend using the COPE self-assessment methodology to overcome some of these obstacles, because COPE demands that staff members develop a personal vision of quality services before evaluating the shortfalls in their own facilities. However, staff can do only so much themselves. Facilitative supervision can supply the missing link between service sites and headquarters. In addition, COPE exercises have revealed the need for on-site training to strengthen staff knowledge and skills.

Family Planning Service Expansion and Technical Support (SEATS II) Project. Mainstreaming Quality Improvement in Family Planning and Reproductive Health Services Delivery: Context & Case Studies. (January 2000). Available at: www.seats.jsi.com/mainquality.pdf.
This book summarizes the experience of the SEATS II project in applying the Continuous Quality Improvement (CQI) process to family planning service-delivery projects in a variety of settings, including hospitals, clinics, CBD programs, and private practices. The projects improved the readiness of facilities, provider knowledge and skills, and client satisfaction. The majority of the book is devoted to detailed case studies of programs in Albania, Cambodia, Eritrea, Russia, Senegal, Turkey, Zambia, and Zimbabwe. The book concludes that the keys to success are keeping tools and measurement systems simple, involving all levels of the system, making change worthwhile for providers, and fostering client-orientation among providers. Technical assistance was critical for measuring quality at either the country or facility level.

Franco, L.M. et al. Achieving Quality Through Problem-solving and Process Improvement.Bethesda, Maryland: Quality Assurance Project (1995).
This handbook offers practical help for health care managers in developing countries who want to improve the quality of their services. Problem solving is one of three elements in the quality assurance process, along with setting standards and monitoring quality. This book describes six steps in solving quality problems and improving processes related to health care in developing countries: (1) identifying problems and selecting opportunities for improvement, (2) defining the problem operationally, (3) identifying who needs to work on the problem, (3) analyzing and studying the problem to identify major causes, (4) developing solutions, (5) implementing quality improvement efforts, and (6) evaluation. The remainder of the book explains when and how to apply a variety of quality improvement tools, ranging from brainstorming to statistical analyses.

Haaga, J.G. and Maru, R.M.. The effect of operations research on program changes in Bangladesh. Studies in Family Planning 27(2):76–87 (1996).
This article describes ten years of experience of using operations research to address problems and improve a large-scale, public, maternal and child health program in Bangladesh. Seven cases are described: recruiting and training female Family Welfare Assistants (FWAs), testing home delivery of injectable contraceptives, changing the way workers' performance is measured, developing register and screening algorithms to improve FWA performance, creating supervision checklists, establishing satellite clinics for health and family planning, and charging fees for condoms. The authors discuss the need to change test designs midstream, the use of outside facilitators, problems in maintaining quasi-experimental designs, and challenges in communicating with policy makers. The authors conclude that research, policy decisions, and implementation can occur in any sequence. Operations research can produce useful changes in organizational behavior, but it may be difficult to solve large-scale problems that require changes in power relationships and organizational culture.

Haberland, N. et al. Unrealized quality and missed opportunities in family planning services. In: Miller, K. et al., eds., Clinic-Based Family Planning and Reproductive Health Services in Africa: Findings from Situation Analysis Studies. New York: Population Council, 125–140 (1998). Available at: www.popcouncil.org/pdfs/cbfp.pdf.
Situation Analyses in Botswana, Burkina Faso, Kenya, Senegal, and Zambia suggest that the quality of family planning services can be improved simply by using available resources more effectively. According to the data, new clients were consistently offered fewer contraceptive options than were physically available at the clinic; providers generally did not make use of available IEC materials during counseling sessions; most providers saw three or fewer FP and MCH clients per day, suggesting that there is a significant amount of untapped staff time that could be used to broaden services; providers often failed to follow infection prevention procedures during pelvic exams even when clean water and gloves were in the exam room; providers frequently did not inquire about clients' sexual conduct and so could not fully advise them on appropriate contraceptive methods; and, likewise, providers rarely discussed a method's ability to protects against STIs. The authors conclude that protocols, training, and supervision could change providers' behavior and tap unused resources.

Hanifi, S.M.A. and Bhuiya, A. Family-planning services in a low-performing rural area of Bangladesh: insights from field observations. Journal of Health, Population, and Nutrition 19(3):209–214 (2001).
To understand the low prevalence of family planning (20%) in a remote rural region of Bangladesh, this study draws on informal observations of clinic services as well as interviews with family planning workers and women. Providers and women blamed religious, cultural, and educational factors for discouraging women from using family planning. Observers, however, pointed to programmatic problems: family planning workers made little effort to provide services and ignored clients complaints, and there was no effective supervision or monitoring. Given the success of family planning in other parts of Bangladesh with similar social and religious barriers, the authors conclude that the poor quality of the service-delivery system is to blame for the low contraceptive usage.

Hardee, K. et al. Quality of care in family planning clinics in Jamaica. Do clients and providers agree? West Indian Medical Journal 50(4):322–327 (2001).
This study compares the views of 199 providers and 20 simulated clients on the quality of care offered in public-sector and NGO family planning services in Jamaica. While all of the providers would recommend their clinics to others, only a little more than half of simulated clients would do the same. Weaknesses included inadequate information giving, turning non-menstruating women away without counseling or condoms, limited technical competence, and lack of privacy. However, most simulated clients felt free to choose a method, and providers generally treated clients well.

Hardee, K. and Gould, B.J. A process for quality improvement in family planning services. International Family Planning Perspectives 19(4):147–152 (December 1993).
The authors draw on industrial methods for the management of quality, fieldwork in international health, and the Bruce framework for quality of care in family planning to create a standardized process for quality improvement tailored to international family planning services. Their proposal, service quality improvement (SQI), is an eight-step process that organizes worker teams to address specific problems by analyzing their causes, planning solutions, and implementing improvements. To illustrate the SQI approach, the article details a hypothetical case study in which urban family planning clinics look at the high rate of early IUD removals.

Hardon, A. and Hayes, E., eds. Reproductive Rights in Practice: A Feminist Report on the Quality of Care. London: Zed Books (1997).
This book includes case studies of family planning services in eight countries (Bangladesh, Bolivia, Finland, Kenya, Mexico, the Netherlands, Nigeria, and Thailand), written from the perspective of womens health advocates. Together these case studies reveal where reproductive rights are being respected and where, how, and why they are being denied. The authors conclude that, although the availability of contraceptives is generally good, much needs to be done to ensure that women and men can make a free and informed choice of methods. They list recommendations for change in four key areas: expanding choice, providing adequate and balanced information and conducting good counseling, developing and improving national guidelines on family planning, and broadening family planning services to reproductive health care.

Koenig MA, Ahmed S, Hossain MB. The Impact of Quality of Care on Contraceptive Use: Evidence from Longitudinal Data from Rural Bangladesh. Washington, D.C.: Population Council; 2003. Available at: www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Bangladesh_QOC.pdf.
This study reanalyzed data collected over a three-year observation period from a large representative sample of reproductive-aged women served by 11 clinics and 65 female outreach workers in rural Bangladesh. Respondents’ perceptions of quality of care were pooled to create mean scores for each outreach worker and clinic. High quality of care by outreach workers was associated with about a 60 percent greater likelihood of adopting a modern contraceptive method and about a one-third reduction in the likelihood of discontinuing a method. Further analysis, however, showed that the impact of quality of care on contraceptive continuation (but not adoption) was limited to uneducated women and women from the poorest strata. Because quality of care affected all-method but not first-method continuation, the author speculates that outreach workers who provide better quality of care help women switch methods as needed. Perceived quality of care and access to the clinic also were associated with the adoption of contraceptives.

Kols, A.J. and Sherman, J.E. Family planning programs: improving quality. Population Reports, Series J, Number 47. Baltimore: Johns Hopkins University, Population Information Program (November 1998). In English, French, Portuguese, and Spanish. Available at: www.infoforhealth.com/pr/online.shtml#j.
This literature review places quality improvement efforts in family planning programs in developing countries within the broader context of the quality movement in industry and medicine. A client-centered perspective that helps define quality and sets program objectives and standards is fundamental. Good quality programs also employ management principles that call for information-based, participatory, and collaborative decision-making and that focus on systems and processes to support and enable personnel. To achieve and maintain good quality services, managers must (1) design quality into a program's mission, objectives, allocation of resources, guidelines, and standards; (2) control the quality of day-to-day activities with ongoing supervision, monitoring, and evaluation; and (3) continually improve the quality of services by identifying problem areas, analyzing their causes, and designing solutions.

Lynam, P. et al. The use of self-assessment in improving the quality of family planning clinic operations: the experience with COPE in Africa. AVSC Working Paper No. 2 (December 1992). Available at: www.engenderhealth.org/pubs/workpap/wp2/wp_2.html.
To evaluate the effect of the COPE clinic self-assessment technique on the quality of care, researchers revisited 11 clinics in sub-Saharan Africa 5–15 months after introducing COPE. The COPE technique consists of a self-assessment conducted by staff with the aid of a checklist and client interview forms, a client flow analysis, and a plan of action drafted by staff on the last day of the intervention. Interviews with 35 service providers found that COPE decreased client waiting times, increased consciousness of client needs, increased staff cooperation and communication, increased staff morale and commitment, addressed shortages of staff and supplies, and increased clients satisfaction. However, COPE was unable to solve problems requiring additional funding. A second client-flow analysis was conducted at five sites where staff identified waiting times as problem during the initial COPE exercise: waiting time declined by an average 42 percent because of solutions devised and implemented by staff members. Researchers also checked whether problems identified during the initial exercise had been solved: 59 percent of all problems were solved, and 88 percent of all "solvable" problems were fully or partly solved.

Quality Assurance Project. Quality Assurance (QA) Kit on CD-ROM. Bethesda, Maryland: Quality Assurance Project (2001). Can be ordered at: www.qaproject.org/pubs/pubscds.html#qakit.
This kit was developed as an alternative, low-cost method to build capacity in quality assurance (QA) skills and to support QA teams in organizations with limited resources, teaching staff, and funding. The kit includes computerized tools, case studies, publications and training materials, a glossary of terms, links to key websites, and a computer tutorial. Together these can provide online QA training for health professionals in a developing-country setting.

RamaRao S, Mohanam R. The quality of family planning programs: concepts, measurements, interventions, and effects. Studies in Family Planning. 2003;34(4):227–248.
This critical review of the literature raises more questions than it answers. Despite the breadth of discourse regarding quality of care in family planning, only 15 studies were found to have rigorously evaluated the effects of quality improvement interventions. These studies include a mix of broad-based and narrowly targeted interventions that addressed the readiness of facilities to offer services, providers’ knowledge and skills, contraceptive choice, and other elements of service delivery. The authors conclude that the most promising interventions are training and job aids designed to improve client-provider interaction. Evidence regarding interventions that identify and resolve problems is limited, and better physical infrastructure does not always result in better care. There is also insufficient evidence to show that quality improvement interventions increase continuation rates.

RamaRao, W. et al. The link between quality of care and contraceptive use. International Family Planning Perspectives 29(2):76–83 (2003). Available at: www.agi-usa.org/pubs/journals/2907603.html.
Over 1,700 new family planning users in the Philippines were interviewed about the quality of care they received. More than 16 months later, a follow-up survey gathered data on continuing contraceptive use by 1,460 of the original respondents. Quality of care was scored on 24 items related to assessment of needs, information received, method choice, interpersonal relations, and continuity of care. After adjusting for the women’s socio-demographic characteristics and reproductive intentions, a multivariate analysis found that women who received better care at the time they adopted a method were more likely to be using it at follow-up. The predicted probabilities of contraceptive use rose from 55 percent for low-quality care to 62 percent for medium-quality care and 67 percent for high-quality care.

Sanogo D et al. Improving quality of care and use of contraceptives in Senegal. African Journal of Reproductive Health. 2003;7(2):57–73.
This study compared the experience of Senegalese women who adopted family planning methods at health centers and at reference centers. To improve the quality of care at reference centers, they were provided with additional supplies and equipment, training, and an improved management information system. A survey of 1,320 women found that the overall quality of care was significantly better at reference centers than health centers, but the reference centers did not exceed the health centers in every element of care. A follow-up survey of 1,110 of the women ascertained their contraceptive status 16 months later. A multivariate analysis found that women who reported receiving good care at their initial visit were 1.3 times more likely to be using a method than other women 16 months later. Attending a reference center also increased contraceptive continuation but to a lesser extent.

Setty V. Organizing Work Better. Population Reports, Series Q, Number 2. Baltimore: Johns Hopkins Bloomberg School of Public Health, INFO Project; 2004. Available at: www.infoforhealth.com/pr/q02/q02.pdf.
Reorganizing work processes can help family planning programs improve services, operate more efficiently, and increase effectiveness. Adopting evidence-based clinical practices removes needless barriers to care. Adaptability enables organizations to cope with unexpected changes as well as everyday fluctuations in client demand and the availability of supplies and staff. Good referral systems offer clients access to every level and kind of care needed. Collecting only essential data increases efficiency. Supplies, equipment, and space all need to be managed. Reorganizing service hours, scheduling, and client flow helps clients obtain services and lets providers do their work better. The division of labor, job design, and social factors are important to providers’ motivation, productivity, and satisfaction.

Simmons, R. et al. Facilitating large-scale transitions to quality of care: an idea whose time has come. Studies in Family Planning 33(1):61–75 (2002).
Small-scale projects from different parts of the world have demonstrated that it is possible to achieve good quality of care in family planning (even in disadvantaged settings), but little attention has been paid to how these innovations can be scaled up to large public-sector programs. Based on a review of relevant literature and experience from family planning projects, the authors set out the following seven key lessons on how to successfully scale up innovations to large public-sector programs. First, do not rely on a spontaneous transfer; make scaling up a concern from the time pilot projects are initiated. Second, acknowledge the political nature of the task and value incremental change. Third, benefit from policy windows and policy entrepreneurs. Fourth, insist on phased implementation while simultaneously addressing broader dissemination of central ideas. Fifth, scale up where there are points of strength. Sixth, use participatory organization development and ensure long-term support from resource systems. Seventh, appreciate the principle of contingency and the need for adaptation.

Stinson, W. et al. Managing programs to maximize access and quality: lessons learned from the field. MAQ Papers, vol. 1, no. 3 (2000). Available at: www.maqweb.org/maqdoc/vol3.pdf.
This paper outlines broad strategies for addressing persistent quality problems in reproductive health programs based on experiences from the field. Achieving quality requires investing in quality improvement and taking a customer orientation. To support quality, leaders at the national program level must articulate the vision, develop guidelines, provide recognition, and define the organization structure. District management teams can promote quality by serving as liaison between the program and facility level and by strengthening supervision, logistics and supply management, referral, and monitoring and evaluation. At the facility level, teams of providers and other staff members can work with supervisors or facilitators to identify problems and opportunities for improvement. Finally, at the community level, program staff can encourage community members to articulate their needs. At every level, individuals and teams who work for quality must be recognized and rewarded.

Thorne, M. et al. District Team Problem Solving Guidelines for Maternal and Child Health, Family Planning, and other public Health Services. Geneva: WHO (1993).
The World Health Organization developed district team problem solving (DTPS) to strengthen lower-level management in decentralized health care systems. Top managers assign a high-priority health problem to a team of 5–7 district-level managers, who are responsible for analyzing and solving it. These guidelines describe the benefits of the process and how to establish, organize and conduct DTPS, based on experience in implementing the approach in different country settings with health personnel of varying training and experience.

Tuoane M et al. Use of family planning in Lesotho: the importance of quality of care and access. African Population Studies. 2003;18(2):105–132.
To identify the impact of socio-demographic factors, access to services, and the quality of care on the use of family planning and the choice of methods in Lesotho, this study analyzes a women’s health survey, information on family planning facilities, and focus group discussions of contraceptive users. Logistic regression shows that both individual characteristics (age, number of children, and education) and the delivery of services affects contraceptive use and method choice. Women are more likely to use contraceptives when facilities are more easily accessible, offer a wider choice of methods, give family planning services top priority, and employ providers who are not biased against any methods.

WHO. Making Decisions About Contraceptive Introduction: A Guide for Conducting Assessments to Broaden Contraceptive Choice and Improve Quality of Care. Geneva: WHO (2002). Available at: www.who.int/reproductive-health/publications/rhr_02_11_contraceptive_introduction/ci-guide.pdf.
This publication covers the first of three stages in WHO’s strategic approach to contraceptive introduction: assessing what actions to take to improve contraceptive choice and quality of care. It gives detailed guidance on planning and implementing a strategic assessment to help make decisions about contraceptive method mix. The framework identifies and addresses management, technical, sociocultural, and economic issues that affect the ability of a health care system to provide a range of methods with good quality of care and attention to reproductive choice.

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Integrated services

Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reproductive Health Matters. 2003;11(22):51–73.
This review analyzes the contributions that sexual and reproductive health services can make to HIV/AIDS prevention and treatment. Family planning services can offer education on unsafe sex and STIs, promote dual protection, detect and manage STIs, and help people with HIV prevent pregnancy. Maternal and child health (MCH) and delivery services can counsel and test pregnant women for HIV, detect and manage STIs in pregnancy, and prevent mother-to-child transmission of HIV. However, neither family planning nor MCH services reach key groups of HIV transmitters, such as men, homosexuals, sex workers, and adolescents. The authors urge the development of integrated programs that combine sexual and reproductive health care with STI/HIV/AIDS control, expanding outreach to new population groups, and creating strong referral links to optimize the outreach and impact of what are currently vertical programs.

Berer, M. Integration of sexual and reproductive health services: a health sector priority. Reproductive Health Matters 11(21):6–15 (2003).
This editorial reviews the history and success of efforts to integrate family planning with other reproductive health services. Integrating sexual and reproductive health services can improve women’s health by encouraging more comprehensive care, but integration must take place at primary, secondary, and tertiary levels of care. Successful integration also requires a health systems approach that restructures the Ministry of Health, develops integrated goals, eliminates contradictory policies, and reconfigures management, budgeting, and funding. Experience shows that integrating services does not cut costs and that incorporating STI/HIV prevention into maternal & child health and family planning is a logical but insufficient response to these health problems. The author also calls for more comprehensive integrated services that include, for example, fertility awareness, breastfeeding support, and safe abortion.

Briggs, C.J. et al. Strategies for integrating primary health services in middle- and low-income countries: effects on performance, costs, and patient outcomes (Cochrane Review). The Cochrane Library. Issue 3. Oxford: Update Software (2002).
This article assesses whether integrating primary health care services at the point of delivery improves health care delivery and health status, compared to separate vertical programs. A thorough search of the literature found a lack of large, methodologically rigorous studies of the issue. Of the four studies reviewed, three included ways of integrating family planning services, while the fourth examined the integration of services for sexually transmitted infections. Results were inconsistent. Integration had a positive effect on outputs in one study, no effect in one study, and a negative effect in two studies. The authors conclude that further research, using rigorous study designs, is needed to settle this question.

Dehne, K.L. et al. Integration of prevention and care of sexually transmitted infections with family planning services: what is the evidence for pubic health benefits? Bulletin of the World Health Organization 78(5):628–639 (2000). Available at: www.who.int/docstore/bulletin/pdf/2000/issue5/bu0563.pdf.
This comprehensive review of operational experiences with the integration of STI and family planning services draws on published and unpublished studies and interviews with key informants. Integrated family planning programs more often add STI prevention than diagnostic and treatment services. Although the monitoring and evaluation of many projects is weak, anecdotal evidence suggests that integration improves the quality of family planning counseling by opening meaningful discussions of sexual behavior and partner relationships. It also increases client satisfaction and condom knowledge and use. Concerns that STI services drive away traditional family planning clients have proven to be unfounded. However, integration has had little impact on STI risk behaviors and case loads because traditional family planning clients come from a low risk segment of the population, that is, married women. The authors call for more systematic evaluations of the costs and benefits of integration.

Family Health International (FHI). Network. 2004;23(3). Available at: www.fhi.org/en/RH/Pubs/Network/v23_3/index.htm.
This special issue on integrating family planning and HIV services includes articles on: when and how integrating services makes sense; integrating family planning into voluntary counseling and testing (VCT) services; integration efforts in Uganda, Cambodia, Zimbabwe, and Jamaica; the role of family planning services in preventing mother-to-child transmission of HIV; and the need for male involvement so that women can act on HIV-prevention messages delivered through integrated services.

Fleischman Foreit, K.G. et al. When does it make sense to consider integrating STI and HIV services with family planning services? International Family Planning Perspectives 28(2):105–107 (June 2002). Available at: www.guttmacher.org/pubs/journals/2810502.html.
This commentary asserts that three factors argue against total integration of STI and family planning services. First, family planning services typically do not serve the populations most at risk for STIs, including adolescents and men. Second, family planning and STI services have conflicting service-delivery and management requirements. Third, there currently are no simple and effective technologies to diagnose and treat many STIs. The authors conclude that integration should proceed only when an existing clientele needs proposed services and when the service-delivery requirements of the existing and proposed services are compatible. In the case of family planning, this may mean building effective referral systems rather than integrating STI services. It may also make more sense to integrate family planning services into existing STI and youth-friendly clinics.

Fullerton, J. et al. A case/comparison study in the Eastern Region of Ghana on the effects of incorporating selected reproductive health services on family planning services. Midwifery 19(1):17–26 (2003).
This study compared 24 family planning facilities where providers were trained in STI services or postabortion care with 19 facilities where there was no extra training. Service statistics show that facilities offering integrated services received more clients than other facilities. In addition, the number of family planning clients and the number of continuing family planning clients increased over time at the integrated clinics, but not at the other clinics. Interviews with providers, managers, and clients found strong support for integrated services and demand for training on an even broader array of services.

Hardee, K. and Yount, K.M. From rhetoric to reality: delivering reproductive health promises through integrated services. Family Health International, Women's Studies Project (August 1995) Available at: www.fhi.org/en/wsp/wspubs/rhetor.html.
This paper reviews public-sector experiences in formulating, implementing and evaluating integrated reproductive health services in developing countries in order to identify policy and service delivery challenges in implementing integrated reproductive health services. There is general agreement for offering maternity care and STI/AIDS services along with family planning, and support is also strong for addressing infertility and pregnancy termination care. The two main rationales for integrating the delivery of reproductive health services are better meeting client's needs and improving the efficiency and effectiveness of services by sharing facilities and personnel and minimizing duplication. However, integrated programs must make sure that new activities do not overburden staff, divert attention from existing tasks, and lower quality of care. Integrating additional services exacerbates the challenges of service delivery, placing new burdens on supplies and logistics, service delivery guidelines, record systems, staff training, and supervision.

Helzner, J.F. Transforming family planning services in the Latin American and Caribbean region. Studies in Family Planning 33(1):49–60 (2002).
This article describes the experiences of nine family planning associations (FPAs) engaged in three different projects to expand services and shift to a broader sexual and reproductive health approach. Three FPAs participated in a pilot project to integrate HIV/STI prevention; three broadened services by reaching outside the clinic and engaging the community; and three began addressing gender-based violence. Lessons learned from the successful transformation of these FPAs include: the need to address perceived needs of clients and gender dynamics, the importance of building consensus, the slow pace of change, the importance of external linkages with family planning programs in other countries and internal linkages with non-health organizations, the need to carefully consider costs and resource demands, and the importance of evaluation.

Hotchkiss, D.R. et al. The effects of maternal-child health service utilization on subsequent contraceptive use in Morocco. Journal of Biosocial Science 31:145–165 (1999).
This study analyzes survey data on contraceptive use and access to MCH and family planning services in Morocco to test whether integrating maternal and child health (MCH) and family planning services increases contraceptive use. Results show that the more intensely women use MCH services, the more likely they are to subsequently adopt a contraceptive method, after controlling for age, education, residence, and other factors. Further analysis suggests that the counseling and promotional efforts of health staff are more important than the physical integration of services in explaining this link. Simulations suggest that increasing the number of MCH services available in Moroccan communities would increase the use of MCH services which, in turn, would increase contraceptive prevalence.

Lush, L. Service integration: an overview of policy developments. International Family Planning Perspectives 28(2):71–76 (June 2002). Available at: www.agi-usa.org/pubs/journals/2807102.html.
This commentary reviews the history and politics of the international policy-making process that led to the endorsement of integrated reproductive and sexual health services, and then analyzes the political and technical obstacles that have hindered its implementation. The author points to three lessons learned from this experience. First, new paradigms such as reproductive health or integrated services emerge from specific political and economic contexts at the international level. Second, it may be difficult to apply them in national programs where the context is different. Third, effective implementation must reflect and respond to the local situation, including financial realities, capacity issues, epidemiological patterns, and the organization of the health service.

Lush, L. et al. Integrating reproductive health: myth and ideology. Bulletin of the World Health Organization 77(9):771–777 (1999). Available at: www.who.int/bulletin/pdf/issue9/bu0042.pdf.
This article compares the health systems of Ghana, Kenya, and Zambia with that of South Africa. In the first three countries, pre-existing vertical management and service delivery programs have inhibited integration and collaboration. Only the less complex and less sensitive components of HIV/STI services have been added to existing services, and services remain largely restricted to women and children. In South Africa, strong political commitment has led to full integration of health management at the provincial level, although there are conflicts over setting priorities and the focus on clinical and curative services at the expense of health promotion and counseling. The authors conclude that integration is a political response to four agendas (the need to improve the quality of family planning, the need to improve women's health, the rapid spread of HIV, and conceptual shifts in primary health), and that there is no evidence that it can solve reproductive health problems.

Maharaj P. Integrated reproductive health services: the perspectives of providers. Curationis. 2004;27(1):23–30.
This qualitative study collected data at one urban and one rural site in KwaZulu-Natal. Researchers inventoried four government facilities in each location, conducted in-depth interviews with senior staff members, and held focus group discussions with providers who offered maternal and child health and STI services. Providers generally held favorable attitudes to integrated services because they serve the needs of clients more effectively and efficiently. Due to a lack of clear guidelines, however, providers were unsure as to what form integrated services should take. Providers felt ill-prepared and ill-equipped to take on STI services and felt more comfortable with the traditional focus on family planning and MCH.

Mancini, D.J. et al. The effect of structural characteristics on family planning program performance in Côte d’Ivoire and Nigeria. Social Science & Medicine 56:2123–2137 (2003).
Based on a survey of 31 facilities offering family planning services in Côte d’Ivoire and 261 facilities in Nigeria, this study calculated the number of Couple Years of Protection (CYP) produced monthly at each facility and the cost per CYP. In both countries, vertically organized facilities that only provide family planning services produced significantly greater CYP than integrated facilities. The cost per CYP was lower for larger facilities in Nigeria, which also tended to be vertical facilities. The authors conclude that large, vertical facilities are the most efficient and cost-effective way to increase family planning utilization.

Mayhew, S.H. Integration of STI services into FP/MCH contexts: Health service and social contexts in rural Ghana. Reproductive Health Matters 8(16):112–124 (November 2000).
This article examines the integration of STI services with family planning and MCH services in the rural Upper East region of northern Ghana. Data comes from policy analysis, documentary analysis, semi-structured interviews with health staff, conversations with community members, and focus group discussions with men and women. In reality, the planned integration of services rarely took place. Tensions between STI syndromic management guidelines and safe motherhood and family planning protocols were never fully resolved. The structure of the reproductive health system remained vertical and compartmentalized. Personnel received limited training in STI diagnosis and treatment. Equipment, drugs, and space were insufficient. Widespread absenteeism among senior staff paralyzed services. Strong medical practice hierarchies encouraged nurses to refer STI cases to superiors rather than offer the services themselves. Gender roles and social norms inhibited people from seeking STI services. To encourage integration, the author recommends: addressing entrenched medical hierarchies, conducting community-based awareness raising, collaborating with NGOs to reach men, and empowering nurses to participate in district decision-making.

Mayhew, S.H. et al. Implementing the integration of component services for reproductive health. Studies in Family Planning 31(2):151–162 (2000).
This article reviews the experience of Ghana, Kenya, South Africa, and Zambia in integrating STI services with maternal and child health and family planning. Data come from a policy analysis, a structured survey of 20 health facilities from one region in each country, and national situation analysis surveys. The existence of multiple policies, strategic plans, and technical guidelines on reproductive health creates confusion for providers. Limited legal and administrative support, lack of resources, rigid program structures, and hierarchical lines of authority create other difficulties in the implementation of these policies, both at the management and clinic levels. Perhaps as a result, STI services have not, in actuality, been widely integrated with family planning services in these countries and integration has not generated improvement.

Mitchell, M., ed. Managing integrated services. Family Planning Manager 3(3) (May–June 1994). Available in English at: http://erc.msh.org/mainpage.cfm?file=2.2.5.htm&module=health&language= English, in French at http://erc.msh.org/readroom/francais/services.htm, and in Spanish at http://erc.msh.org/readroom/espanol/services.htm.
Integrating services can mean many different things, for example, adding other reproductive health services to a family planning program, offering existing health and family planning services at the same time and place, or adding family planning services to existing maternal and child health programs. This article helps managers analyze the strengths and weaknesses of their programs and assess the potential benefits and problems of integration. Assuming a manager decides to take an integrated approach, the article offers practical suggestions for strengthening key management systems, including budgeting, internal organization, staff roles, training, supervision, logistics, MIS and monitoring, and client services.

O'Reilly, K.R. et al. Should management of sexually transmitted infections be integrated into family planning services: evidence and challenges. Reproductive Health Matters 7(14):49–59 (1999).
This review article found that the impact of adding STI services to pre-existing family planning infrastructure depended on whether family planning was organized as a vertical program or as part of maternal and child health or primary health care services. The former calls for far more dramatic change than the latter. Family planning programs have integrated STI prevention (counseling and condom promotion) earlier and more often than diagnosis and treatment services. While integrating STI prevention into family planning services contributes to client satisfaction, the quality of services, and family planning objectives, it has little impact on STI caseload and morbidity, in part because the married women who make up the family planning audience are at relatively low risk for STIs. Further information on the benefits and operational challenges of integrating STI management with family planning is needed to decide whether integration is advisable. The authors call for intervention trials and modeling studies to test which integration strategies work and how cost-effective they are. In the short run, they advise avoiding structural integration and using family planning resources to promote condoms.

PATH. STD control and primary health care for women: experiences and challenges.Outlook 15(2):1–8 (October 1997) Available at: www.path.org/outlook/html/15_2.htm#std.
This articles reviews some of the challenges and strategies for providing STD services in low-resource settings, with a focus on issues related to offering integrated services. A review of information on syndromic diagnosis is included, as are implications for program implementation. Benefits of integration include continuity of care, simplified logistics, and broader client access to health services. Barriers include a shortage of resources, lack of privacy and confidentiality for clients, and provider discomfort in counseling on sexual practices and STDs.

Shelton, J.D. Prevention first: a three-pronged strategy to integrate family planning program efforts against HIV and sexually transmitted infections. International Family Planning Perspectives 25(3):147–152 (1999). Available at: www.agi-usa.org/pubs/journals/2514799.html.
This commentary contends that efforts to integrate HIV/STI services into family planning have failed because they focused on syndromic management of vaginal discharge, which is an ineffective approach. The author argues that integrated family planning programs should focus on STI prevention and behavior change communication rather than treatment and clinical services. The recommended strategy includes (1) developing family planning services and sites for "high transmitters" of STIs such as truck drivers and sex workers, (2) targeting men with the social marketing of condoms and antibiotics to treat STIs, and (3) addressing the general population by tapping into family planning experience with the mass media and behavior change to promote condoms aggressively, including STI risk-assessment in contraceptive decision making, reaching out to young adults and adolescents, etc.

Shelton JD, Fuchs N. Opportunities and pitfalls in integration of family planning and HIV prevention efforts in developing countries. Public Health Reports. 2004;119(1):12–15.
Two health interventions should only be integrated if: (1) they are both effective, (2) they share a field of operation and target audiences, and (3) there are synergies between them that enhance the impact of both. Based on this framework, the authors argue that clinical family planning services are a weak platform to effect the behavioral changes essential to HIV prevention. Instead, the synergies lie in family planning support activities that take place outside the clinic, including mass media communication campaigns, youth activities promoting responsible decision making, policy advocacy, and the social marketing of condoms. The emergence of new HIV/AIDS programs, such as Voluntary Counseling and Testing (VCT) and the prevention of mother-to-child transmission, also creates new opportunities for integrated family planning services.

Stewart, J.F. et al. Family planning program structure and performance in West Africa. International Family Planning Perspectives 25 (Suppl.):S22–S29 (1999). Available at: www.agi-usa.org/pubs/journals/25s2299.html.
While international conferences have endorsed integrated reproductive health programs, it is not certain whether they perform better than vertical programs. Integrated programs may make family planning more acceptable to communities, make it more convenient for clients to receive multiple services, utilize infrastructure and personnel more fully, and avoid administrative and service delivery duplication. However, vertical approaches may avoid overburdening fragile delivery system, easier to do one thing well, easier to measure impact for donors. This article analyses family planning services in five West African countries, all of which have vertically organized NGO family planning and social marketing programs as well as integrated public sector, primary health care services. Except for Nigeria, the vertical programs supply most of the couple-years of protection in each country. An analysis of staff utilization rates in Cote d'Ivoire and Nigeria also suggests that vertical programs use labor resources more efficiently than integrated programs. The author concludes that vertical programs may generate more demand for family planning than integrated government facilities because of higher quality services, greater organizational dedication, and the weakness of the government service system.

US Agency for International Development (USAID). Family Planning/HIV Integration: Technical Guidance for USAID-Supported Field Programs. Washington, DC: USAID; 2003. Available at: www.usaid.gov/our_work/global_health/pop/publications/docs/fphiv.pdf.
This document presents best practices, new suggestions, and recent findings regarding the integration of family planning and HIV/AIDS activities. Suggestions include: tailoring integrated programming to the country context, employing “ABC” strategies, prioritizing young people, making sure that family planning is included in initiatives to prevent mother-to-child HIV transmission and offer voluntary counseling and testing for HIV, promoting dual protection, and being cautious with STI treatment approaches.

Vernon, R. and Foreit, J. How to help clients obtain more preventive reproductive health care. International Family Planning Perspectives 24(4):200–202 (December 1999). Available at: www.agi-usa.org/pubs/journals/2520099.html.
"In-reach," that is, promoting additional services to current clients at health facilities, can make the integration of health services more effective. Studies in Latin America have found that clients are not aware of the full range of health services available at the facility they attend, nor do providers encourage them to seek services other than the one they came for. It is more efficient and less costly both for the health facility and for the client when a client receives multiple services during a single visit. One way to make clients aware of other services available and of their own need for preventive health care is for providers to use a simple screening algorithm. After asking clients a few simple questions about their marital status, pregnancy status, and children, providers can recommend family planning, prenatal, well baby, immunization and other services as appropriate.

World Health Organization (WHO). Integrating STI Management Into Family Planning Services: What are the Benefits? Geneva: WHO (1999). Available at: www.who.int/reproductive-health/publications/RHR_99_10_integrating_stis_into_fp_services/RHR_99_10_table_of_contents.htm.
This expert review of experience with integrating services for sexually transmitted infections (STI) and family planning clarifies the public health benefits and operational challenges of integration. It reviews the rationales for integration, describes available data, and summarizes the various ways in which STI management has been integrated with family planning and reproductive health. The report concludes that integration of STI services has been beneficial for family planning: it has improved the quality of services, improved providers attitudes and communication skills, and increased access and utilization of services by reaching out to men and youth. It is less clear whether integration has enhanced STI objectives. Further research is suggested to determine under what conditions integrating STI care into family planning would be cost-effective.

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