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Focused Assessment Should Be Made To Ensure Quality In Family Planning

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Family Planning plays an important role in achieving multiple development targets and goals set under the development agenda. Goal 3 – Good health and well-being and Goal 5 – Gender equality, call for reduced maternal mortality, reduced premature, neo-natal and child deaths and universal access to sexual and reproductive health care and rights, including family planning information and education.

In 2012, the ‘London Summit on Family Planning’ was held to bring the focus on family planning globally. It was a watershed event in the history of family planning worldwide wherein countries and donors pledged around $2 billion (INR 12,000 crores) annually and all-round efforts to reach 120 million (12 crores) women with lifesaving family planning information, services and supplies, a sizeable 48 million (4.8 crores) of whom are resident in India. Needless to emphasise that the London Summit on Family Planning provided a much-needed impetus to the national agenda in order to revolutionize the vision of protecting children and mothers dying due to unhealthy spacing and lack of access to family planning choices.

Recognising the urgency and importance of family planning from a rights-based framework, the government announced the expansion of the basket of contraceptive choices for women with the introduction of injectables, and improved quality health care in the country. India is also the country with very high unmet needs. Approximately 13 percent of currently married women between the ages of 15 and 49 in India have an total unmet need for contraception (NFHS 4) and 5.7 % have unmet need of spacing method and only 47.8 % of currently married women are using any modern contraceptive method (NFHS4).  India is committed to increase demand satisfied by modern contraceptives to 74% by 2020 (Vision FP 2020).

Improving Quality Of Care

Improving the quality of care in family planning services is key to improve use of family planning services in India, both by attracting new contraceptive users and by maintaining existing users (i.e. ensuring continued engagement with services)]. Quality improvement is an unending process. Monitoring and constant assessment is very essential for providing quality services which is also a major thrust area under National Health Mission. The basket of choices under family planning program has extended beyond sterilisation but sterilisation continues to be the preferred and widely accepted method amongst couples adopting family planning methods. The government has been actively pursuing improvement in quality of sterilisation services provided through the states’ fixed day static centres as well as camp outlets.

The need to strengthen infrastructure, human resources management, accountability and governance of the public health system has been repeatedly emphasised (Pachauri, Sexual and reproductive health services: Priorities for South and East Asia, 2011) as these are major impediments to the effective delivery of health and family planning services ((UNDP), 2014). But it is not enough to only ensure availability and geographical and economic access to family planning services. Quality of services (perceived or real) strongly predicts choice of provider as well as the decision to use family planning. At other times, poor quality may lead to loss of return to follow-up or even discontinuation of use of family planning.

Methods for measuring Family Planning quality of care have generally been built upon the six part framework initially outlined by Bruce. Ensuring quality of family planning services includes a number of elements such as

  • Choice: Clients must be offered all the choices legally available in a non-judgemental manner. Provider discretion and biases (“conscientious objection”) should not be allowed to impact the clients’ decision to either use or not to use family planning or the method of choice.
  • Information: To enable clients to make a choice that is right for them, complete information regarding method effectiveness and the advantages and disadvantages of each should be shared with them. Once the client has made a decision about the method s/he would like to opt for, information on correct usage, potential side effects, follow-up requirements etc. should be clearly explained. This reduces the chances of discontinuation and/or failure due to incorrect usage.
  • Client-provider relationship: Respect should be the basis of the client-provider relationship. A listening and guiding attitude on the part of the provider leads to increased acceptance of, and satisfaction with, family planning methods. Both auditory and visual privacy are important, during client-provider interactions as well as during provision of services. This will make the client feel more comfortable discussing her/his individual needs and increase follow-up rates. Information shared by the client during her/his interaction with the provider should be kept confidential.
  • Technical competence of provider: The provider needs to be trained in the appropriate medical and surgical skills (as required for the cadre) and also in counselling skills. Provision of skilful services prevents potential complications and reduces failure and discontinuation rates.
  • Constellation of services: The acceptance and uptake of family planning services is best when provided as a component of a constellation of services, such as services for maternal and child health.

Focused and frequent quality assessments will provide actionable data to program managers. Identifying, and then acting upon, systematic barriers to low FP service quality will decrease the unmet need for contraception and lead to important gains in women’s health. There is also need to have standardized Family Planning assessment tools, quality indicators and methodologies for data analyses to help identify gaps in service provision, community barriers as well as potential points for intervention.

Moreover, family planning programs function not in isolation but within the broader context of social relations in a setting. Within India, these relations are determined largely on the basis of caste, social class, and gender. Within such systems, the poor, especially poor women, have traditionally been accorded few rights—including the right to receive sympathetic and respectful treatment. It is essential to focus attention on strengthening the health system’s capacity to reach the poor and unreached. Also, the integration of men into the ambit of family planning is essential. The decreased contribution of men in availing contraception and sterilisation has lead the responsibility of contraception been born by women.

To realise SDGs and India’s commitment to FP2020 goals of reaching to 48 million additional users of modern family planning methods by 2020 (compared to 2012) and increased financial commitment on family planning to more than US $2 billion (Rs. 13,000 crores) from 2012 to2020, it becomes imperative to work on quality of care.


Authored by Dr. Rita Prasad, Technical Specialist, Health, CARE India

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