Conceptual Framework

Bruce’s quality of care framework was developed in response to the need to

operationalize a more “client-centered” approach to family planning service delivery with the expectation that improved quality of care would increase client satisfaction and enable clients to exercise control over their fertility and achieve their reproductive goals. However, many proponents have argued that in addition to these individual-level benefits, on the macro-level, high-quality reproductive health services may contribute significantly to increases in

contraceptive prevalence and lower levels of fertility (Bruce, 1990; Arends-Kuenning & Kessy, 2007). Anrudh Jain (1989), a senior researcher at The Population Council, developed the conceptual model displayed in Figure 2.1, which demonstrates the hypothesized

mechanism by which quality may affect contraceptive behavior. Simply put, improvements in quality may increase both acceptance and continuation of contraception which will, in turn, reduce fertility (Jain et al., 1992).

Efforts to improve quality of care, much like efforts to increase geographic and financial accessibility, are typically classified as supply-side family planning interventions because they facilitate a couple’s ability to use family planning, responding to an existing demand for services. In contrast, demand-side interventions, such as interventions to

influence a couple’s desired family size or their motivation to prevent unintended pregnancy, work to generate additional demand for contraceptive services and supplies. A wealth of demographic literature discusses the ability of demand- and supply-side interventions to increase contraceptive prevalence and reduce fertility (Mwaikambo et al., 2011; Jain, 1989).

Jain, however, has suggested that improvements in quality may straddle these two categories given the powerful role of word-of-mouth communication in many communities of interest. Therefore, in addition to the direct relationship displayed in Figure 2.1, Jain hypothesizes that clients well-satisfied by high quality services are likely to influence other members of their community, helping transform latent demand for services into actual contraceptive use (Jain, 1989). Although researchers have looked extensively at demand-side factors such as

demographic characteristics and cultural values, relatively little is known about how supply- side factors such as quality of care affect contraceptive use (Arends-Kuenning & Kessy, 2007).

Figure 2.1. Conceptual model demonstrating the known and hypothesized relationships between quality of family planning services, contraceptive uptake and continuation, and fertility. Anrudh Jain, The Population Council, 1989 (Jain, 1989).

In the interpretation of Figure 2.1, Jain also points out that ‘motivation’ plays an important role in the relationship between service quality and contraceptive prevalence. According to Jain, those couples strongly motivated to avoid unintended pregnancy will overcome the hardships imposed by poor quality services to achieve their reproductive goals. Conversely, those with little to no motivation to prevent pregnancy will not become

Contraceptive Acceptance (Outcome of interest) Quality of Services: (Main

Exposure) A. Choice of Methods B. Information to users C. Provider competence D. Client/Provider relations E. Follow-up mechanisms

F. Appropriate constellation of services

Contraceptive Prevalence

Fertility Other proximate determinants

Contraceptive Continuation

Other factors

Known Effects Hypothesized Effects

contraceptive adopters even if excellent services are available. For these two extreme groups, the quality of family planning service delivery is unlikely to have much impact on

contraceptive use and continuation. However, for clients whose level of motivation and corresponding demand for services falls somewhere between these two extremes, quality is expected to have a significant impact (Jain et al., 1992; RamaRao et al., 2003).

In preparing to assess the relationship between quality and contraceptive use, some researchers have suggested that achieving a high level of service quality may not be realistic in the absence of adequate service infrastructure (Tuoane et al., 2004). In other words, those with direct client contact—the service providers—need support in the form of training, guidance, supplies, and educational materials to do their job well (Huezo & Diaz, 1993). RamaRao and Mohanam (2003) note that program managers have cited deficiencies in the service infrastructure as a key barrier to providing good quality services. As such, the term “quality” can be expanded to include not only the dynamics of the interaction between the provider and client but also the degree to which facilities are prepared to offer services. The quality of service infrastructure is commonly referred to as a facility’s “readiness” and this concept draws attention to factors that may impede the provision of high quality services (RamaRao & Mohanam, 2003). In comparing the concept of readiness and Bruce’s quality framework to Donabedian’s three-pronged approach to measuring quality (structure, process, and outcome), readiness could be considered to map to Donabedian’s “structure” while Bruce’s framework aligns closely with “process.”

Several researchers have considered as well the possibility that perceptions of quality may be more closely related to contraceptive behavior than actual quality as measured by more objective means (Koenig et al., 1997; Speizer & Bollen, 2000; Veney et al., 1993). For

example, a study using 1989–1991 data from rural Bangladesh looked at the relationship between perceived quality and subsequent adoption or continuation of a contraceptive method, using prospective data from 7,800 women (Koenig et al., 1997). According to their perceptions, 28% of women received good quality of care most or all of the time and these women were significantly more likely to adopt a method (risk ratio: 1.27, p≤0.05) or to continue use (risk ratio: 1.41, p≤0.001), after controlling for other factors. A subsequent study in Tanzania considered whether perceptions of quality from knowledgeable informants were correlated with objective measures of quality and found that though a few objective traits were associated with perceptions of quality, many were not (Speizer & Bollen, 2000). As a result, some researchers have concluded that even when perceived quality is

significantly associated with contraceptive use and continuation, little is known about how family planning programs can influence these perceptions, for example improving

availability of methods or ensuring privacy (Arends-Kuenning & Kessy, 2007).

Not all researchers agree with the theory that high fertility rates are the result of an unmet need for high-quality family planning services. Pritchett (1994) offers a contrasting point of view by arguing that high rates of fertility reflect the desire for large families. Pritchett’s interpretation of household data from several developing countries indicates that the cost of contraception is not a strong factor in decisions regarding the number and spacing of children. Pritchett states that even the poorest families spend between 1% and 3% of household income on tobacco, a luxury item, and could therefore easily afford contraception. Based on these observations, Pritchett recommends policies and programs that focus on changing women’s desires rather than increasing contraceptive supply. To this end, Pritchett recommends raising the educational and income levels of women and working to improve

their status within their community (Pritchett, 1994). Bongaarts (1994) took issue with Pritchett’s view that “excess fertility” was not a matter of great importance, citing the hazards to both women’s health and the planet of unchecked population growth and stating, “Helping women (and men) to implement their reproductive preferences is an obvious place to start if one wants to reduce fertility and future population growth” (Bongaarts, 1994). Although Bongaarts recognized the important role of economic development in achieving fertility reductions, he pointed out the critical ability of family planning programs to address established barriers to contraceptive use, namely fear of side effects and cultural disapproval, thereby reducing the “non-economic” costs of using family planning methods (Bongaarts, 1994).