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HOME: STATE OF WORLD POPULATION 2004: Reproductive Health and Family Planning
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Reproductive Health and Family Planning

Family Planning and Sexual Health
Contraceptive Access and Use
Unmet Need
Choice of Methods
Sexually Transmitted Infections
Quality of Care
Stronger Voices for Reproductive Health
Securing the Supplies
Men and Reproductive Health

Quality of Care

The ICPD Programme of Action recognized that in addition to making reproductive health services universal, “family planning programmes must make significant efforts to improve quality of care” (para. 7.23). The aim should be to “ensure informed choices and make available a full range of safe and effective methods” (para. 7.12).

Since 1994, services in many countries have been reoriented to improve their quality and better meet clients’ needs and wishes—through a wider choice of contraceptive methods, better follow-up and improved training of staff to provide information and counselling (with an emphasis on sensitivity, privacy, confidentiality and informed choice). Improving services for poor populations is another global priority.(36)

The publication in 1990 of a quality of care framework(37) established the components of good reproductive health care. Clients need a choice of contraceptive methods, accurate and complete information, technically competent care, good interaction with providers, continuity of care, and a constellation of related services. Another framework detailed the support, tools and resources that providers need to offer quality care.(38)

Efforts to improve quality focus on improving the service environment to meet clients’ needs by involving all levels of staff in identifying problems and suggesting solutions. After the ICPD, approaches that were already widely used in developed countries were translated for use in international family planning programmes.(39)


Clients assess the quality of the services they receive. If given a choice, they will use facilities and providers that offer the best care as they perceive it. Studies around the world suggest that clients want:

  • Respect, friendliness and courtesy;
  • Confidentiality and privacy;
  • Providers who understand each client’s situation and needs;
  • Complete and accurate information, including full disclosure about contraceptives’ side-effects;
  • Technical competence;
  • Continuous access to supplies and services that are reliable, affordable and without barriers;
  • Fairness. Information and services should be offered to everyone regardless of age, marital status, sex, sexual orientation, class or ethnicity;
  • Results. Clients are frustrated when they are told to wait or come back.
See Sources

CONCRETE ACTIONS. The 2003 UNFPA global survey found that 143 countries had taken steps to improve access to quality reproductive health services, with 115 reporting multiple actions. These include increasing staff and training (77 countries); introducing quality standards (45), and improvements in management and logistics (36). In Bangladesh, the Democratic People’s Republic of Korea and Mongolia, for example, protocols and quality control measures are now in place for a wide range of reproductive health services. Indonesia is updating existing protocols. Jamaica is establishing indicators for assessing and monitoring the quality of care.

Public sector, family planning association and women’s health NGO programmes in Guatemala, India and Kenya all include providing quality care as part of their goals and objectives.(40)

IMPACTS OF QUALITY. Quality care can increase demand for services by helping clients select an appropriate contraceptive method and continue using family planning if they wish to limit or space their pregnancies. Women and men in communities with quality services are more likely to use family planning than those who are not, as a study in Peru showed.(41) In rural areas of the United Republic of Tanzania, perceptions of a family planning facility’s quality of care have a significant impact on community members’ contraceptive use.(42)

Being able to choose a contraceptive method matters to clients. In Indonesia, 91 per cent of women who were given the method they wanted continued to use it after one year, compared to 38 per cent of those who had not been given their method of choice.(43) In Gambia and the Niger, new users who received good counselling on side-effects were one third to half as likely to discontinue contraceptive use after eight months as those who perceived such counselling to be inadequate.(44)

EMPOWERING THE POOR. Better treatment particularly makes a difference to poor women. In a recent Bangladesh study, women who felt they had received good care(45) from fieldworkers were 60 per cent more likely to adopt contraception and 34 per cent more likely to continue its use than those who perceived they had received poor care.(46) While service quality affected contraceptive adoption for all women, it was far more important as a determinant for continued use among poor and uneducated women.

TRAINING EFFORTS. Interaction between clients and providers is critical to good care. Providers need to explore clients’ thinking about health decisions, address their concerns about side-effects and encourage them to play an active role in consultations. Providers’ knowledge and interpersonal skills can be improved by defining clear expectations for interaction with clients, giving feedback on their performance and making training more effective. It is also important to provide adequate compensation, space, supplies and time; and to match workers with jobs for which they have the skills.(47)

Countries as diverse as Senegal, Turkey and the United Republic of Tanzania have, since the ICPD, undertaken system-wide reforms to provide quality care to clients. They have strengthened training, expanded educational activities, upgraded infrastructure and equipment, updated policies and procedural guidelines, and strengthened management systems.(48)

Many other countries have strengthened staff training and supervision and improved method availability and choice.(49)

Many countries have worked to upgrade their reproductive health facilities. Measures taken include: certification or accreditation of facilities (Mozambique); strengthening infrastructure and ensuring that specialized follow-up care is available (Brazil); piloting mobile health units (Armenia and El Salvador); and providing free or low-cost services for slums and urban squatter settlements (148 countries).


The ICPD stressed the importance of involving the beneficiaries of reproductive health programmes in planning, implementation and monitoring. The 2003 UNFPA global survey found that 124 countries reported having taken key measures in this area, with 48 reporting multiple measures. Some have conducted public hearings or consumer surveys and involved communities in developing programmes that reflect the needs and opinions of the population.

Kenya has included village chiefs and traditional healers as community resource persons. Malaysia has organized dialogues between service providers and clients. Brazil has set up national, regional and municipal health councils. Honduras has used questionnaires, focus groups and in-depth interviews to elicit feedback on all health systems. Latvia has created a “Patients Rights Bureau” that conducts surveys of patient satisfaction with health care.

A number of donors and international organizations have launched activities to promote civil society participation in meeting reproductive health needs. Thirty-four national family planning associations of the International Planned Parenthood Federation are undertaking a five-year initiative to identify and correct deficiencies in quality. See Sources

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