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Quality of Care: Our Calling

Can 2018 be the “year on quality of care?”  We think so, and we’re not the only ones.

Two notable global reports on quality of health care were recently released—one from the World Health Organization (WHO), the World Bank, and the Organization for Economic Cooperation and Development and another from The Lancet Commission.  Both reports press for imminent investments in improving quality of care—particularly in low- and middle-income countries—as we move toward universal health coverage.

Although we are making great progress in improving access to health care around the world, the work on quality of care is far from complete.

At Pathfinder, we laud the attention given to quality of care. As an organization that has led family planning programs for more than 60 years, we know that if family planning services are not conducive to the rights and needs of clients, there will be little demand for and use of those services. We therefore invest as much—or more—in improving quality of care as we do in expanding access and coverage.

By quality of care, we mean family planning counseling that honors a client’s right to make a voluntary, well-informed choice about contraception in a private setting with a skilled, unbiased provider and provision of contraceptive methods that adheres to clinical guidelines.

In many ways, quality of care is an inherent part of what we do.

It’s our calling.

Our commitment to quality is why we were disheartened to read the Lancet Commission report, which includes data conveying that the quality of family planning services around the world is low. In the 18 countries where quality of care was measured, only 44 percent of family planning providers, on average, comply with evidence-based guidelines (see page 8 of report). The report also measures quality of three additional maternal, newborn, and reproductive health areas—antenatal care, labor and delivery care, and sick child care—all of which had reportedly higher compliance rates to guidelines than family planning.

Standards of care: are they comparable?

We dug deeper into the report to find out where the family planning community, as a sector, is failing. To our surprise, we noticed a big discrepancy in evidence-based guidelines used to measure quality across the four health areas. The family planning guidelines cover issues critical to quality of care, not covered by the other health areas: privacy, confidentiality, asking clients about concerns, and ensuring the use of visual aids.

Why are there such different standards for different health areas?

A transformative history toward choice and consent

The answer is history.

During population control programs in the 1950s, family planning was framed, not by a client’s right to choose if and when to use contraception, or what method the client wished to use, but by an approach to stymie population growth.

It was not until the landmark 1994 International Conference on Population and Development that the global discourse on family planning changed—from one of population control to one of rights-based voluntary choice and informed consent.

Voluntary choice and informed consent remain central to the quality of family planning programs today.

Well before 1994, however, Pathfinder predicated its programs on ensuring clients’ informed choice during family planning counseling. In fact, we recently came across Pathfinder training curricula from 1986 that defines “informed choice.”

The curricula state:

‘Informed’ means that …clients have the clear, accurate, and specific information that they need to make their own reproductive health choices.

‘Choice’ means that … clients have a range of family planning methods to choose from… clients make their own decisions.

Pathfinder continues to uphold these same values today.

A case in point—the MAIS project

Our MAIS project in Mozambique is an example of this.

MAIS works with facility-based providers and health facility managers in Maputo City and Matola, Mozambique, to recognize and overcome their biases—both conscious and unconscious—which may prevent them from offering high-quality family planning counseling that honors clients’ rights to voluntary choice and informed consent. At the same time, MAIS trains community health workers to counsel in a way that empowers their clients to voluntarily choose whether they want to use contraception and the type that is best suited for them. Mentors work closely with all providers to improve service quality beyond initial trainings.

Clients report on the services they receive by filling out a digital “citizen report card” at follow-up visits with community health workers. Results of the report card inform mentors.

For example, a client reported an instance of provider bias through the digital platform. Mentors and our program team followed up with the facility where the incident was reported and conducted additional training and sensitization.

MAIS is providing rich insights to inform how family planning programs can be designed to ensure quality of care.

This method of working to improve services can be seen across all Pathfinder programs.

After all, quality of care is inherent to Pathfinder. It’s our calling.