Posted: December 12th, 2023

Short Paper: Assessing Program Design essay

EVALUATION OF AN INTERVENTION TO
IMPROVE QUALITY OF CARE IN FAMILY
PLANNING PROGRAMME IN THE
PHILIPPINES
ANRUDH K. JAIN*, SAUMYA RAMARAO*, JACQUELINE KIM† 
MARILOU COSTELLO‡
*Population Council, New York, USA, †The Women’s Foundation, Hong Kong and
‡Independent Consultant, Manila, Philippines
Summary. This paper presents the results of a longitudinal intervention study
carried out in the Davao del Norte province of the Philippines. The
intervention, tested through a quasi-experimental design, consisted of training
of family planning service providers in information exchange and training of
their supervisors in facilitative supervision. The training intervention significantly improved providers’ knowledge and quality of care received by clients.
Moreover, good quality care received by clients at the time of initiating
contraception use increased the likelihood of contraceptive continuation and
decreased the likelihood of both having an unintended pregnancy and an
unwanted birth. However, comparison of women in the experimental group
with those in the control group did not show any significant effect of
provider-level training intervention on these client-level outcomes. The
reasons for this conundrum and the implications for quality of care are
discussed.
Introduction
Bruce articulated the quality of care framework in 1990 and emphasized the
importance of organizing family planning services to address the different and
changing needs of a diverse range of individuals over time. Considerable progress has
been made since then and many different approaches and models to improve quality
have been implemented (see, for example, RamaRao & Mohanam, 2003). These range
from system-wide investments to smaller, focused efforts on a specific component of
service delivery. While improvements in such aspects as infrastructure, supplies and
equipment are necessary, they do not always translate into better care for clients.
Client orientation in service delivery is justified in its own right because clients
deserve to be, and value being treated with respect and courtesy and, at the same
time, need to receive accurate information about contraceptive methods appropriate
J. Biosoc. Sci., (2012) 44, 27–41, Cambridge University Press, 2011
doi:10.1017/S0021932011000460 First published online 21 Sep 2011
27
to meet their reproductive health needs. Clients also value receiving individualized
services that address their needs, and which provide them with a choice of methods
and comprehensive information (Kols & Sherman, 1998). In addition, improvements
in quality of care have been suggested as a mechanism to reduce unmet need
(Bongaarts & Bruce, 1995; Robey et al., 1996).
The positive effect of improvements in service quality on contraceptive use, which
was first hypothesized through a modelling exercise (Jain, 1989), has now been
demonstrated in diverse settings through cross-sectional studies (Mensch et al., 1996;
Mroz et al., 1999; Steele et al., 1999; Blanc et al., 2002) as well as through
longitudinal studies (Pariani et al., 1991; Lei et al., 1996; Mensch et al., 1997; Koenig
et al., 1997, 2003; Patel et al., 1999; RamaRao et al., 2003; Sanogo et al., 2003).
Although the accumulated empirical evidence from these studies in favour of
improving quality is strong, this effect has not been demonstrated through an
intervention study in which those exposed to a quality improvement intervention
continue with contraception with greater frequency than those who were not exposed
to the intervention.
This paper examines an intervention study conducted in the Davao del Norte
province of the Philippines to assess whether an intervention that improves quality of
care received by clients also improves contraceptive continuation and reduces the
occurrence of unintended pregnancies and unwanted births.
Methods
Intervention
Quality of care is a comprehensive concept including such elements as choice of
methods, information exchange and provider’s competence. It is programmatically
quite difficult and expensive to expand choice to add a new method to the ongoing
services in many settings. The intervention implemented in Davao del Norte province
therefore aimed to improve quality of care within the constraints of service delivery
in the province and focused on one aspect of quality of care: client–provider
interaction.
The intervention in this study consisted of two components: training of family
planning service providers working in public sector facilities and training of their
supervisors. The service providers were trained in effective information exchange:
carefully listening to clients and responding with relevant, accurate and complete
information (AVSC International, 1995; AVSC International & DoH, Philippines,
n.d.). The design of this intervention was based on the prevailing knowledge about the
poor quality of client–provider interactions at that time. For example, data from
several developing countries indicated that the information exchange between
providers and clients was often poor or inadequate (see, for example, Mensch et al.,
1994; Miller et al., 1998). Moreover, clients often attributed discontinuation of a
method to the side-effects (Ali & Cleland, 1995). Provision of information to clients
has also been shown to result in better selection and continuation of the method
selected (Pariani et al., 1991).
28 A. K. Jain et al.
This training programme was conducted in March 1997 by AVSC International
and three refresher courses were conducted in 1998 and 1999. Supervisors were
trained in facilitative supervision – an approach that emphasizes mentoring, joint
problem solving and two-way communication between the supervisor and those being
supervised (Ben Salem & Beattie, 1996). The intervention was designed and
implemented in partnership with colleagues and researchers based in the Ateneo de
Davao University, Davao city, and with the Department of Health at the national,
regional and provincial levels (see Costello et al., 2001, for further details).
Design
A quasi-experimental design was used to evaluate the effect of the intervention.
The 20 municipalities of Davao del Norte province were matched into ten pairs. One
municipality from each pair was randomly assigned to the experimental group and the
other to the control group. One Rural Health Unit (RHU) and three of its nearest
Barangay Health Stations (BHS) in each municipality participated in the study; hence,
the study covered 20 RHUs and 60 BHSs. The study excluded the city of Tagum
because it was too difficult to match it with any other municipality due to its relatively
greater development and urbanization.
Service providers and their supervisors based in the 40 facilities in the experimental group underwent the training described above. A second aspect of the design was
the constitution of a panel of new family planning clients who had received services
in 80 study clinics between April and December 1997. Thus, women who received
services from 40 clinics in the experimental group during this period were exposed to
providers who had been trained in March 1997, unlike those in the control group.
Use of random allotment increases the likelihood that the experimental and
control groups were similar before the intervention. Hence, any subsequent differences
between the two groups in the knowledge and behaviour of both providers and clients
can be attributed to the intervention. Furthermore, the existence of a control group
allows the net effect of the intervention on the behaviour of clients in the experimental
group to be measured. The following effects were anticipated:
1) Training of providers was expected to improve their knowledge about contraceptive methods and their behaviour towards clients;
2) Clients in the experimental group were expected to receive better quality of care
in terms of treatment and information about contraceptive methods;
3) Improved quality of care received by clients at the time of initiating a method
was expected to result in better continuation subsequently; and
4) Clients in the experimental group were expected to show a higher continuation
of methods than those in the control group.
Data
The panel of 1728 new family planning users was identified from the records of
80 study facilities. Respondents were interviewed at their homes three times: once in
1997 at the time of recruitment into the panel and twice later in 1999 and 2000. The
Quality family planning care in the Philippines 29
first interview collected information on respondent’s socioeconomic and demographic
profiles, the method they had accepted during their visit to the facility, the quality of
care they had received at the time of acceptance and their reproductive intention. This
minimized the effect of recall bias in data collected about quality of care.
At the follow-up interviews, women were asked about their reproductive and
contraceptive behaviour since the time they were last interviewed, i.e. between the first
and second interviews and between the second and third interviews. Information was
collected using a calendar similar to that used in Demographic and Health Surveys
(DHS), except that the period of recall was much shorter than in the DHS. At the
time of the follow-up interviews, starting with the current month and working
retrospectively, respondents were asked about pregnancy and contraceptive status in
each month, type of method used, reasons for discontinuing or switching methods and
the outcome of the pregnancy, if pregnant. In a different section of the questionnaire,
information was also collected on the respondent’s experience with using the method,
their current reproductive intention and current socioeconomic background.
All respondents entered the study only after having provided informed consent.
Respondents were told that the information provided by them would be treated
confidentially and kept in a secure place. Also, at the end of the first and the second
interview, consent was obtained for a re-visit in the future.
Variables
Dependent variables. The three dependent variables used in the study were:
contraceptive use, unintended pregnancy and unwanted birth. Contraceptive use was
measured by whether the woman was using a modern contraceptive method at the
time of the third interview. Researchers have observed that women find it difficult to
label retrospectively some of their living children as being unwanted pregnancies or
births (Bongaarts, 1991; Bankole & Westoff, 1998; Casterline & Sinding, 2000). This
issue of post-birth rationalization was handled to a large degree in this study by using
a prospective design. Unwanted births and unintended pregnancies were created by
linking responses on reproductive intention reported at the beginning of the period
with pregnancies and births that occurred subsequently.
In this study, reproductive intentions were measured by two questions: ‘Do you
want more children?’ and, for those who answered in the affirmative, ‘How long do
you want to wait until your next child?’ This information was used to classify women
with at least one subsequent unwanted live birth and those with at least one
unintended (unwanted or mistimed) pregnancy. Women who wanted no more children
at the first interview and had at least one birth between the first and the third
interview were classified as having an unwanted birth. Women having an unintended
pregnancy include those who have at least one unwanted or mistimed pregnancy
between the first and third interview. Inclusion of reproductive intentions at the
second interview did not make much difference.
Independent variables. All the independent variables included in the analyses were
reported at the time of the first interview. The principal independent variables of
interest were: quality of care received at the time of the first interview and
30 A. K. Jain et al.
membership in the experimental group. Quality of care was measured from women’s
reports at first interview about their experience at the time of adopting a contraceptive method. Information was collected from the respondents on 24 items shown in
Table 3 reflecting five aspects of care: the assessment of her reproductive goals and
prior contraceptive experience (three items), the method choices offered (four items),
the information conveyed (seven items), her perceptions about interaction (eight
items), and whether she was told about follow-up services (two items). Each item for
a woman was scored as 1 for yes and 0 for no. All scores were added to get a
summary score on quality of care for each woman; equal weights to each element
were assigned because there was no empirical evidence to indicate their relative
importance. The total quality of care score was transformed into a three-category
variable: low, medium and high. The medium level was defined as quality within
one-half of a standard deviation of the mean for all women in the study; values falling
below were categorized as low and those falling above the medium were categorized
as high level of quality.
Other independent variables of relevance included are: educational status of
respondent and her spouse; the employment status of the respondent and her spouse,
and ownership of various consumer durables (as proxies for the economic situation
of the household); and other characteristics of the individual and household reflecting
the demographic and social background, such as age of respondent and her spouse,
the number of children they have, and religion.
Analysis
Four sets of analyses were undertaken by using the woman as the unit of analysis:
tests for selectivity bias, for equivalence between the intervention and control, for
effect of the intervention on provider’s knowledge and quality of care received by
clients and whether the quality of care and the intervention had an effect on the
dependent variables. Chi-squared tests and t-tests were performed to test for
statistically significant differences between the groups on their socioeconomic,
demographic and reproductive backgrounds. Bivariate comparisons using chi-squared
tests were performed to examine the effects of the intervention and quality of care on
dependent variables. Logistic regression models were used to predict the effect of
baseline variables on the women followed up at round 3, and to study the effect of
quality after adjusting for the effects of background characteristics.
Results
Is there selectivity between rounds 1 and 3?
At the time of the third and last contact, 1354 or 78% of the original sample of
1728 women were interviewed. The results presented in Table 1 indicate that no
serious selectivity bias was introduced by the attrition of women between the first and
third rounds. The existence of the selectivity bias was checked by comparing those
who were re-interviewed at the third round with those who were not (columns 3 and
4 in Table 1). The two groups are quite similar in many socioeconomic aspects:
Quality family planning care in the Philippines 31
education, marital status, religion, contraceptive used and quality of care received.
The two groups were significantly different on other characteristics: ownership of
consumer durables, employment, age, number of living children, age of the youngest
child and reproductive intentions. However, there were no significant differences
between those re-interviewed at round 3 and those lost to follow-up between the first
and third rounds in the crucial variables of interest: the quality of care they reported
receiving at the time of their first facility visit, and membership status in the
intervention group. These findings are similar to those found by comparing those
re-interviewed at the second contact and those who were not (RamaRao et al., 2003).
The existence of the selectivity bias was further tested by running a logistic regression
on being interviewed in the last round and controlling for the set of characteristics at
the first round. The results of this regression analysis showed that those who were
interviewed at the third round were significantly different from those who were not
interviewed on the ownership of the modern durables, husband’s employment and the
age of the youngest child (data not shown).
Did the randomization work?
The results presented in Table 2 indicate that the randomization of facilities in
experimental and control groups was largely successful in achieving two equivalent
groups of clients. In round 1 respondents in the experimental and control groups
shared similar socioeconomic and demographic characteristics differing only in that
the experimental group had a higher percentage of employed and greater ownership
of consumer durables than those in the control group (also see Costello et al., 2001).
The same minor differences between experimental and control group respondents is
noted by comparing round 3 data, with the addition of the lower age of the youngest
child in the control group becoming significant. Also, the proportion of respondents
who reported wanting to limit childbearing had increased in both groups over time
(from 63% to 76% in experimental; 67% to 74% in control).
Did the intervention improve providers’ knowledge and quality of care received by
clients?
The intervention significantly improved providers’ knowledge and the quality of
care received by clients (see Costello et al., 2001 for details). The training intervention
improved the knowledge of service providers in the experimental group in comparison
with their pre-intervention levels as well as in comparison with providers in the
control group. Most of the increases occurred in specific aspects of contraceptive
knowledge such as side-effects or warning signs. For example, the average score for
number of side-effects and warning signs known for oral contraceptives rose
significantly from 3.0 to 5.6 among providers in the experimental group compared
with an increase from 2.9 to 3.4 in the control group.
The intervention also improved the quality of care received by clients. Respondents in the experimental group reported receiving significantly higher levels of care
than those in the control (see Table 3). There were statistically significant differences
between intervention and control groups on 18 out of 24 elements of care after
32 A. K. Jain et al.
Table 1. Socioeconomic and demographic characteristics at round 1 of women
interviewed at rounds 1 and 3 and those who were lost to follow-up between these
rounds
Characteristic at round 1
Interviewed
at round 1
(N=1728)
Lost to
follow-up
between
rounds 1 & 3
(N=374)
Interviewed
at round 3
(N=1354)
2 testa
p
Socioeconomic
Education (mean) 8.5 8.3 8.5 ns
Husband’s education (mean) 8.2 8.2 8.2 ns
Ownership (mean) 2.0 1.7 2.1 0.005
Employed (%) 15.8 12.3 16.8 0.036
Husband is employed (%) 97.5 95.7 98.0 0.012
Demographic
Age (mean) 31.2 30.0 31.6 <0.001
Husband’s age (mean) 34.9 33.7 35.2 <0.001
Married (%) 99.9 100.0 99.9 ns
Christian (%) 82.2 80.4 82.7 ns
Reproductive
Age of youngest child (mean years) 1.7 1.3 1.8 <0.001
No. living children (mean) 3.0 2.7 3.1 0.002
Ever pregnant (%) 100 100 100 —
Reproductive intention – limit (%) 65.3 59.4 66.9 0.007
Reproductive intention – space (%) 34.7 40.6 33.1 0.007
For less than 2 years 17.0 12.5 18.5 ns
For 2 years or more 83.0 87.5 81.5 ns
Method accepted
Pill (%) 39.1 41.7 38.4 ns
DMPA (%) 35.5 28.9 37.3 0.003
IUD (%) 14.0 18.7 12.7 0.003
Condom (%) 10.2 9.4 10.4 ns
Sterilization (%) — — — —
Other (%) 1.2 1.3 1.2 ns
Quality
Low (score, 0–16) 26.4 26.7 26.3 ns
Medium (score, 17–20) 37.8 38.2 37.7 ns
High (score, 21–24) 35.8 35.0 36.0 ns
Mean 18.5 18.4 18.5 ns
Mean (normative 0–5) 3.0 3.0 3.0 ns
Area
Intervention 50.3 52.9 49.6 ns
a
2 tests assessing whether the round 1 characteristic of women interviewed at round 3 are
statistically different from round 1 characteristic of those who were not interviewed at round
3.
Quality family planning care in the Philippines 33
Table 2. Socioeconomic and demographic characteristics of women at rounds 1 and 3 by study group
Characteristic
Experimental
group
(N=869)
Control group
(N=859)
2 test
pa
Experimental
group (N=671)
Control group
(N=683)
2 test
pa
Socioeconomic
Education (mean) 8.5 8.4 ns 8.6 8.4 ns
Husband’s education (mean) 8.3 8.2 ns 8.2 8.2 ns
Employed (%) 18.9 12.7 <0.001 20.6 13.0 <0.001
Husband is employed (%) 97.2 97.8 ns 97.9 98.1 ns
Ownership (mean) 2.1 1.9 0.008 2.2 1.9 0.014
Demographic
Age (mean) 31.4 31.1 ns 31.9 31.3 ns
Husband’s age (mean) 35.0 34.7 ns 35.5 34.9 ns
Ever pregnant 100.0 100.0 — 100.0 100.0 —
No. living children (mean) 3.0 3.0 ns 3.1 3.0 ns
Age of youngest child (mean years) 1.7 1.6 ns 1.9 1.6 0.029
Reproductive intentions at interview
Wants to limit (%) 63.3 67.3 ns 76.2 73.5 ns
Wants to space (%)
For less than 2 years 16.0 18.1 ns 24.4 19.9 ns
For 2 years or more 84.0 81.8 ns 75.6 80.1 ns
Quality at round 1
Mean score (0–24) 19.2 17.7 <0.001 19.2 17.8 <0.001
Low (ref., score, 0–16) 18.2 34.7 <0.001 18.9 33.5 <0.001
Medium (score, 17–20) 39.6 36.0 ns 39.0 36.3 ns
High (score, 21–24) 42.2 29.3 <0.001 42.0 30.2 <0.001
ap is the probability that the characteristics of women between experimental and control areas are different.
34 A. K. Jain et al.
controlling for the effects of background characteristics. Clients in the experimental
and control groups received similar care on such aspect of choice as being told about
other methods and such aspect of care as being satisfied with the services. Clients in
the experimental group received better care on such aspects as assessing client needs,
providing information and informing about return dates. For example, respondents in
the experimental group were more likely to be asked about their reproductive
intentions than those in the control group (73% versus 59%); they were more likely
to be told of side-effects (83% versus 62%) and also about warning signs (80% versus
56%). Further improvements are still possible on some elements: for example,
information on other methods (64% versus 68%), and other sources of supply (23%
versus 33%). Without this information, switching of contraceptive method or current
source of supply would be difficult if either became problematic.
Did the quality of care and intervention affect contraceptive use and reproductive
behaviour?
Table 4 presents the results for contraceptive use and reproductive behaviour
between rounds 1 and 3 by quality of care received at round 1, separately for
intervention and control groups of clients. The level of contraceptive use increases
with the level of quality received for women in both groups and achieves statistical
significance for the control group. The level of unintended pregnancy decreases with
improved quality and the relationship was almost statistically significant (p=0.056) in
the intervention group. A similar statistically significant and negative association is
observed between quality and unwanted births, both in the intervention and control
groups, with a weaker effect in the control group (p=0.067). Once the two groups are
pooled, quality of care received at the time of initial adoption of a method is found
to increase the likelihood of using contraception at the third interview from 53% at
low levels of quality to 55% at medium levels, and 63% at high levels. Quality of care
received at initial visit decreased the likelihood of subsequently having an unintended
pregnancy from 28% to 22% and also decreased the likelihood of subsequently having
an unwanted birth from 16% to 8%. Multivariate regression analysis using controls
for social, economic, demographic and cultural factors confirmed the effects of
improved quality on subsequent contraceptive use and reproductive behaviour (data
not shown).
A comparison of women in the experimental group with those in the control
group, however, did not show a significant effect of the provider-level training
intervention on any of the three client-level outcome variables: contraceptive use,
unintended pregnancy or unwanted birth (Column 6, Table 4). For example, 58% of
the respondents in the experimental group were using a modern method at the time
of the third interview as compared with 56% in the control group. One-quarter of the
women in both experimental and control groups reported having an unintended
pregnancy by the time of the third interview, and about 11% of women in both
groups reported having an unwanted birth (11.2% in experimental group and 10.8%
in control). This set of results indicates that the effect of the training intervention on
women’s subsequent contraceptive use and reproductive behaviour was extremely
weak.
Quality family planning care in the Philippines 35
Table 3. Percentage of women by quality of care they received at the time of initiation of a contraceptive method by study
group
Elements and measure of quality of care received Control Experimental Adjusted odds ratio
Needs assessed
Asked whether she desired another child 59 73 1.9**
Asked how long she wanted to wait before next child 85 90 2.4**
Asked about previous family planning experience 84 89 1.5*
Method choice
Asked type of method she preferred 91 95 1.6*
Told about other methods 68 64 0.9
Received information without any method being promoted 89 92 1.4*
Received chosen method 98 100 3.9*
Information received
How her chosen method works 76 89 2.6**
How to use the chosen method 88 91 1.4*
Side-effects of the chosen method 62 83 3.0**
How to manage problems that arise 66 85 2.9**
Warning signs associated with method 56 80 3.0**
Possibility of switching to another method 85 85 1.0
Methods that protect against STDs 32 43 1.7**
Interpersonal relations
Client allowed to ask questions 85 93 2.5**
Her questions were answered to her satisfaction 84 93 2.4**
36 A. K. Jain et al.
Table 3. Continued
Elements and measure of quality of care received Control Experimental Adjusted odds ratio
Client felt that her privacy was maintained 68 86 2.6**
Facility was clean 97 99 1.7
Client satisfied with services 98 99 1.5
Provider used IEC material 47 52 1.2
Client felt she was treated well 30 42 1.6**
Continuity of care
Client was told timing of next visit 88 93 1.7**
Client was told of other sources of supply 33 23 0.6**
Client was given an appointment card for follow-up visit 30 31 1.0
Index of quality
Low quality (score 0–16) 34.7 18.2
Medium quality (score 17–20) 36.0 39.6
High quality (score 21–24) 29.3 42.2
Total 100.0 100.0
Average quality score 17.7 19.2
Number of women 859 869
Adjusted odds ratios measure the effect of intervention after controlling for all background variables.
*p%0.05; **p%0.01 (show the probabilities that these adjusted odds ratios are significantly different from one).
Source: Costello et al. (2001).
Quality family planning care in the Philippines 37
Homework help – Discussion
This paper presents the results of a training intervention study conducted in the
province of Davao del Norte in the Philippines. The intervention aimed to improve
client–provider interactions in public sector facilities by focusing on the information
exchanged between the two parties.
The principal hypothesis tested in this study was that the provider-level training
intervention would improve client-level outcomes in terms of their contraceptive use
and reproductive behaviour. The results from the Philippines study could not
demonstrate a statistically significant effect of the provider-level training intervention
on the client-level impact indicators. In other words, the intervention may not have
been powerful enough to improve continuation of contraception or to reduce
unwanted fertility among women in the experimental group in comparison with those
in the control group.
This is a conundrum because the study demonstrated the validity of all the
causal links in the chain. For example, the training intervention significantly improved
the knowledge of providers; it also improved the quality of client–provider interactions in the experimental group, compared with the control group (Costello et al.,
2001). Furthermore, the study results also demonstrated and confirmed the existence
of a link between quality of care received by women and their subsequent
Table 4. Contraceptive use, unintended pregnancies and unwanted births by quality of
care separately for intervention and control groups
Quality of care 2 test Total
Dependent variable Low Medium High p
Percentage of women using modern method at round 3
Intervention group 55.1 55.7 61.7 ns 58.1
Control group 51.5 54.0 64.6 0.015 56.4
p-value (t-test) ns ns ns ns
Total 52.8 54.9 62.9 0.006
Percentage of women with at least one unintended pregnancy between rounds 1 and 3
Intervention group 32.2 26.0 21.3 ns 25.2
Control group 26.2 27.0 21.8 ns 25.2
p-value (t-test) ns ns ns ns
Total 28.4 26.5 21.5 ns
Percentage of women with at least one unwanted birth between rounds 1 and 3
Intervention group 19.7 9.9 8.5 0.003 11.1
Control group 13.5 11.7 6.8 ns 10.8
p-value (t-test) ns ns ns ns
Total 15.7 10.8 7.8 0.001
Number of women
Intervention 127 262 282 671
Control 229 248 206 683
Total 356 510 488 1354
38 A. K. Jain et al.
contraceptive and reproductive behaviour; receiving better quality care at the time of
initial adoption increased contraceptive continuation and reduced both unintended
pregnancies and unwanted births.
So, what explains the lack of significant differences in the observed levels of
contraceptive continuation, unintended pregnancies and unwanted births between the
experimental and control groups? The answer seems to be a combination of two
factors: women in the control clinics received a fairly good quality of care and the
effect of the training intervention on improved quality, while statistically significant,
was not large enough. Facilities in Davao surprisingly did not start from a very low
or abysmal level of care. In fact, in the control group of facilities, 29% and 36% of
clients received a high or medium level of care, respectively, and only 35% received
a low level of care (Table 2). The average level of care received by all clients in the
control clinics on a 24-point scale was as high as 17.7 points. Consequently, the
potential for improving quality through an intervention was reduced due to the ceiling
effect. Nevertheless, the intervention – training of providers – indeed shifted the
distribution of women in the experimental group in the right direction. Only 18% of
the clients in the experimental group received low level of care and as many as 42%
received high level care. The average level of care also increased to 19.2 points. While
this improvement in quality was significant statistically, the difference of 1.5 points
was not large enough to produce significant differences in contraceptive continuation
and unwanted childbearing among women between the two groups. Increasing the
divergence when the base (i.e. control) level is not poor is a difficult task as most
programme managers and field practitioners will attest; it is easier to move from low
levels and becomes increasingly harder at higher levels.
Implications
The absence of straightforward and uncomplicated results of this study may be
interpreted by some key stakeholders as a lack of rationale to invest in approaches
that are client oriented and that promote good quality services. Such a conclusion,
however, is not warranted because women’s reproductive behaviour is influenced not
only by service environment but also by a combination of contextual and individual
factors not under the control of service providers. The effect of provider-level
intervention must be interpreted within this context.
To begin with, quality along with accessibility and cost are three dimensions of
services, and information exchange is one of the six elements of quality. Moreover,
the contribution of side-effects to discontinuation may be overestimated from
retrospective studies that ascertain causes of high discontinuation only by interviewing
those who discontinue. It is quite possible that these responses are proxies for more
intimate and personal reasons for discontinuation that women may not want to share
with interviewers. An accurate estimation of the probability of discontinuing
contraception among those who experience side-effects would require that the study
also ascertain the extent to which women continue to use contraception even though
they experience similar side-effects. The results of this study, while disappointing, do
not negate the significant effect of quality of care received by women on their
Quality family planning care in the Philippines 39
subsequent behaviour observed in this study and many other studies mentioned in the
Introduction section.
The main reason for continuing efforts to improve the nature and the content of
client–provider interactions, however, remains intuitively simple: as long as there are
programmes that intend to serve their beneficiaries, there will be points of contact
between providers and clients, resulting in interactions between them. In many
settings, these interactions may be the only source for receiving accurate information
about contraceptive methods. Providing accurate information to clients through these
interactions becomes crucial in these circumstances. The nature and the content of
these interactions, however, need to be defined explicitly within the local contexts in
terms of such topics as: assessing clients’ reproductive goals, helping them to select a
method appropriate to achieve those goals, informing them how to use the method
selected, what to expect in terms of side-effects, how to manage these side-effects, and
treating them decently. Moreover, this type of orientation could easily be incorporated without too much additional cost in the ongoing training programmes for
providers. In addition to monitoring progress in improving client–provider interactions, future studies could also focus on identifying clients that consistently receive
poor quality care or providers that consistently offer poor quality care to all or certain
group of clients. Remedial actions to improve quality could then focus on these
groups.
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Quality family planning care in the Philippines 41
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