1. Information about family planning
2. Access to all service delivery systems and health care providers
3. Choice of adopting, switching, or dis-continuing methods
4. Safety in the practice of family planning
5. Privacy during dis-cussions and physical examinations
6. Confidentiality of all personal information
7. To be treated with dignity, courtesy, consideration, and attentiveness
8. Comfort while receiving services
9. Continuity of care for as long as the client desires
10. To express their opinions about the quality of services received

1. Training on technical and communication skills
2. Information on technical issues, updated regularly
3. Infrastructure, including appropriate physical facilities and efficient organization
4. Supplies of contraceptives, equipment, and educational materials
5. Guidance from service guidelines, checklists, supervision
6. Back-up from other providers and levels of care
7. Respect and recognition from co-workers, managers, clients, and community
8. Encouragement to provide good quality of care
9. Feedback from managers, supervisors, other service providers, and clients
10. Self-expression, so that managers consider their views when making decisions

Egypt's Gold Star program, supported by the USAID Population Family Planning III Project, is one of the largest public-sector quality assurance programs for family planning world-wide. Its goal is not only to upgrade the quality of family planning services but also to create new expectations for quality so that the public will request better services. To address both supply and demand, the Ministry of Health and Population (MOHP) and the Ministry of Information have teamed up to improve services, publicize the improvements, and depict for people what they should expect from good-quality care.

Supplying Good-Quality Services

Family planning units that meet all 101 indicators for two quarters in a row are qualified to display a Gold Star—the visible sign of good-quality services. By April 1998, 1,108 units had earned a Gold Star and another 1,450 had achieved 90% to 99% of the indicators for the quarter. Based on the upward trends of the preceding year, as many as half of all MOHP units may reach Gold Star status by the end of 1998.

Creating Demand for Quality

In August 1997, after a substantial number of units had qualified for the Gold Star, the Gold Star emblem moved to the forefront of the campaign, both as a symbol of good services and as a means to locate those services. Messages identified Gold Star clinics and called on the public to visit units displaying the Star. During focus-group pretests of the campaign messages, people were enthusiastic. "This is what I want," said one mother, typical of the middle aged, poorly educated women who make up the majority of public clinic clients, "and if I don't get it, I'll quarrel!" The woman's statement underscores the important responsibility of service providers to meet the demand for good-quality services.

Physicians and nurses are an important secondary audience for the marketing campaign. The messages provide a model of positive client-provider interactions that reinforce the providers' training and high standards of care as an organizational norm. In addition, the campaign motivates providers by publicly recognizing those who consistently meet the standards.

Research and Evaluation

The women were familiar with the campaign's broadcast spots and found their image of high quality both attractive and appealing. Their comments suggest that the campaign is succeeding in its efforts to redefine consumer perceptions of quality and to raise expectations: "We want a clinic like [the one on TV]." "This examination place is clean, and she wears all white." "She treats the patients nicely. We wish to find such doctors."

Meeting the increasing demand for good-quality services will result in greater numbers of satisfied clients, who, in the final analysis, are the most credible spokespersons for Gold Star care. An impact evaluation of the campaign, which is now underway, will assess public understanding of the Gold Star symbol, improvements in service delivery, and changes in clients' perceptions of providers and service delivery.

Dr. Hassan El Gebaly is the Executive Director of the Systems Development Project (SDP) of Egypt's Ministry of Health and Population. Ron Hess is the Resident Communication Specialist for the Gold Star initiative. Carol Brancich was the Resident Management Advisor for the project. Dr. Cynthia Waszak provided technical assistance to the project evaluation.

Nurse's responsibilities:
Reassures client that what is said—and the visit itself—are confidential.

Physician's responsibilities:
Assures that the client makes the choice of a specific method of contraception voluntarily.

Infection prevention:
Use disposable (disinfected/ clean) gloves for vaginal examination, IUD insertion (No-Touch techniques), IUD removal, and handling and cleaning dirty instruments.

Client satisfaction:
Was the staff courteous?

Contraceptive commodities:
A 2-month minimum supply of each type of oral contraceptive, based on client load, is in stock.

IEC activity:
Unit has Client Counseling Flip Chart to inform each client before the client chooses a family planning method.

Records and reports:
The unit staff is able to retrieve the medical records of all 5 (or 10) clients selected.

Clinic management:
All supervisory visits in the past three months have been accurately recorded.

Clinic equipment, furnishings, supplies:
Stethoscopes are demonstrated to be functioning properly and clean.

Clinic facilities:
Waiting area has enough chairs or benches to accommodate all waiting clients on busy day.

Recent publications can help programs develop guidelines. Most importantly, as part of the Maximizing Quality and Access (MAQ) initiative (see Chapter 2.3), experts from a wide range of organizations have developed consensus on medical eligibility criteria and practices for providing family planning methods.

Management of sexually transmitted diseases. 1994. Guidance from the Advisory Group Meeting on Sexually Transmitted Diseases Treatment. Revised recommendations for the comprehensive management of patients with STDs. Covers both the syndromic approach to the management of patients with STD symptoms and treatment of specific STD infections. Also provides information on the notification of sexual partners and on STDs in children.
Available from: WHO, Distribution and Sales, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 24 76. Fax: 41 22 791 48 57. E-mail: publications@who.ch Order no. 1930095

Technical Guidance/Competence Working Group. Recommendations for updating selected practices in contraceptive use: Results of a technical meeting. Volumes I and II. 1994 and 1997. Answers important questions about providing various contraceptive methods; also discusses community-based services, STD risk assessment, counseling, dual method use, and other topics (355, 356). Price: US$12 per volume. (The English-language edition will be made available by JHPIEGO in January 1999 on the Internet at: http://www.reproline.jhu.edu/english/6read/6multi/tgwg/6tgwg.htm. The document will be available in French, Spanish, and Portuguese soon after at the same web site.)
Available from: INTRAH, CB# 8100, Chapel Hill, NC 27599-8100, USA. Tel: (919) 966-5636. Fax: (919) 966-6816. E-mail: intrah@med.unc.edu

Both the WHO eligibility criteria and the Technical Guidance/Competence Working Group guidance are condensed in: Population Reports. Family Planning Methods: New Guidance. Series J, No. 44. October 1996. English and French; forthcoming in Spanish. (357) Free to developing countries.
Available from: Population Information Program, Johns Hopkins University School of Public Health, 111 Market Place—Suite 310, Baltimore, MD 21202-4012, USA.Fax: (410) 659-2645.E-mail: PopRepts@jhuccp.org

MAQ checklist for family planning service delivery, with selected linkages to reproductive health. By J. Shelton, S. Davis, and J. Mathis. In checklist format, an annotated "memory-jogger" that directs attention to critical areas of access and quality and asks provocative questions about each. (327) Free to developing countries.
Available from Johns Hopkins Population Information Program; see address above.

No-scalpel vasectomy: an illustrated guide for surgeons. 2nd Edition. 1997. For use in clinical training. English (18). Free to developing countries; otherwise, US$20.
Available from: AVSC Material Resources, 79 Madison Avenue, New York, NY 10016, USA. Tel: (212) 561-8000 Fax: (212) 779-9439. E-mail: info@avsc.org

Family Health International (FHI). Contraceptive technology update series training modules. 35 mm slide presentations designed to update knowledge in seminars, workshops, and training of physicians, nurses, and medical students. Topics available include: oral contraceptives, intrauterine devices (IUDs), injectable contraceptives, barrier methods, postpartum contraception, lactational amenorrhea method (LAM), female and male sterilization, and the reproductive health of young adults. English, French, Spanish. (107) Free to developing countries.
Available from: FHI, P.O. 13950, Research Triangle Park, NC 27709, USA. Tel: (919) 544-7040. Fax: (919) 544-7261. E-mail: publications@fhi.org

International Planned Parenthood Federation (IPPF). Medical and service delivery guidelines in family planning. By C.M. Huezo and C.S. Carignan. 2nd edition, 1997. Guidance on the delivery of good-quality services, covering contraceptive methods, infection prevention, treatment of reproductive tract infections, and diagnosis of pregnancy. English, French, and Spanish. (153) Price: US$20, £12 (UK only), or free to those experiencing difficulties in payment.

Family planning handbook for health professionals: The sexual and reproductive health approach. Edited by I. Evans and C. Huezo. 1997. The companion volume to Medical and service delivery guidelines provides in-depth explanations of background, methods, and techniques for service providers. (105). Price: US$24, £12 (UK only), or free to those experiencing difficulties in payment.
Available from: IPPF Distribution Unit, Regent's College, Inner Circle, Regent's Park, London NW1 4NS, UK. Tel: 44 (0) 171 487 7900. Fax: 44 (0) 171 487 7897. E-mail: info@ippf.org

John Snow, Inc. (JSI) and AVSC International. SEATS II clinical protocols for family planning programs: A resource book. 1995. By C. Carignan, L. Ippolito, and P. Neresesian. An overview of the process of developing clinical protocols. Includes documents on technical and programmatic issues that can be used as resources. Also presents a representative case study in protocol development. (66)
Available from: SEATS II, JSI, 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, USA. Tel: (703) 528-7474. Fax: (703) 528-7480. E-mail: seats_project@jsi.com

Johns Hopkins Population Information Program (JHU/PIP). The essentials of contraceptive technology: a handbook for clinic staff. By R. Hatcher, W. Rinehart, R. Blackburn, J. Geller, and J.D. Shelton. 1997. English, Spanish; forthcoming in French. Practical information for clinic-based providers about the major family planning methods. (136) Free to developing countries; otherwise, US$5.
Available from: Johns Hopkins Population Information Program, 111 Market Place, Suite 310, Baltimore, MD 21202, USA. Tel: (410) 659-6300. Fax: (410) 659-2645. E-mail: PopRepts@jhuccp.org

Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO). Service delivery guidelines for family planning programs. 1996. Edited by N. McIntosh and E. Oliveras. Current information on family planning services, including counseling, client assessment, contraceptive methods, infection prevention, STDs, and postabortion care. English, French. (240) Price: US$5.

PocketGuide for family planning service providers. 2nd edition, 1996. By P.D. Blumenthal and N. McIntosh. Clinically oriented reference guide on family planning service provision. English, French, Russian. (40) Price: US$15.

IUD guidelines for family planning service programs. 2nd edition, 1993. Edited by N. McIntosh, B. Kinzie, and A. Blouse. Essential information for clinicians on how to provide IUD services (specifically the Copper T-380A IUD). English, Portuguese, Russian, Spanish. (239) Price: US$15.

Norplant implants guidelines for family planning service programs. 2nd edition, 1995. Edited by N. McIntosh, A. Blouse, and L. Schaefer. Essential information for clinicians on how to insert and remove Norplant implants. English, Russian. (238) Price: US$15.

Infection prevention for family planning service programs. 1992. By L. Tietjen, W. Cronin, and N. McIntosh. Designed to help develop uniform infection prevention (IP) standards for use in any type or size of family planning service program. Covers basic IP principles, practical and easy-to-do IP practices for each surgical contraceptive method, and "how to" instructions for using the recommended procedures. English, French, Portuguese, Russian, Spanish. (363) Price: US$15.
Available from: JHPIEGO Corporation, 1615 Thames Street, Suite 200, Baltimore, Maryland 21231-3447, USA. Tel: (410) 614-3206. Fax: (410) 614-0586. E-mail: info@jhpiego.org

Other publications. For results of a POPLINE database search for additional publications, contact the Johns Hopkins Population Information Program at the address at left.

For further information on quality control tools and techniques, you may request the following materials from their publishers:

Electronic Resource Center. The health and family planning manager's toolkit. 1998. Internet website with management tools developed by a number of organizations. Available at: http://erc.msh.org/toolkit/

Facilitative Supervision. Facilitative supervision: A vital link in quality reproductive health service delivery. By B. Ben Salem and K. Beattie. 1996. (25) and Facilitative supervision guide, by AVSC International (forthcoming) (17). Available free from: AVSC International, 79 Madison Avenue, New York, NY 10016, USA. Tel: (212) 561-8000. Fax: (212) 779-9489. E-mail: info@avsc.org

Indicators. Handbook of indicators for family planning program evaluation. By J. Bertrand et al. 1994. (33) Available from: University of North Carolina/EVALUATION Project, 123 W. Franklin Street, Suite 304, Chapel Hill, NC 27516-2524, USA. Tel: (919) 966-7482. Fax: (919) 966-2391. E-mail: eval.cpc@unc.edu

Operations Research. The Handbook for family planning operations research (2nd ed., 1991) is available free from The Population Council, One Dag Hammarskjld Plaza, New York, NY 10017. Tel: (212) 339-0500. Fax: (212) 755-6052. E-mail: pubinfo@popcouncil.org)

Rapid Evaluation Method (REM). Rapid Evaluation Method guidelines for maternal and child health, family planning and other health services. 1993. (389) and Use of the Rapid Evaluation Method for evaluation of maternal and child health and family planning services. 1992. (391) Available free from: Unit for Strengthening Country Health Information, Family and Health Services, WHO, 20 Ave. Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 23 82. Fax: 41 22 791 41 94. E-Mail: info@who.ch

Situation Analysis. The Situation Analysis approach to assessing family planning and reproductive health services: A handbook. By R. Miller et al. 1997. (258) Available free from: The Population Council, One Dag Hammarskjöld Plaza, New York, NY 10017, USA. Tel: (212) 339-0500. Fax: (212) 755-6052. E-mail: pubinfo@popcouncil.org

The following team-based quality improvement approaches have been developed for family planning and other health programs in developing countries:

Quality Assurance. The Quality Assurance Project (QAP) is implemented by the Center for Human Services, a nonprofit affiliate of the University Research Corporation, working with the Joint Commission International and the Johns Hopkins Center for Communication Programs. QAP takes a comprehensive approach to quality management, combining quality design, monitoring, and improvement activities into large-scale quality assurance programs, often at the national level (89). QAP employs a 6-step problem-solving methodology using analytical tools developed in industry (113). QAP currently offers technical assistance to health and family planning organizations in 15 countries.

Client-Oriented and Provider-Efficient (COPE). Developed by AVSC International, the COPE approach uses a set of simple self-assessment tools developed for front-line workers at family planning clinics and for regional, district, and site supervisors. Staff members conduct client interviews, analyze the flow of clients through the clinic, and complete questionnaires on every aspect of service delivery, following the IPPF framework, "Clients' Rights and Providers' Needs" (16, 219). AVSC and its local partners have used COPE at numerous sites in over 35 countries (90), and other organizations have adapted COPE for their QI programs (174).

Continuous Quality Improvement (CQI). The Family Planning Management Development (FPMD) project hasinvestigated various quality improvement methodologies to strengthen family planning management (61, 132). CQI tools and techniques promoted by FPMD have been applied in eight Latin American programs, including MEXFAM and APROFAM, the IPPF affiliates in Mexico and Guatemala, respectively, and government health programs in Bolivia, Guatemala, Mexico, and Peru (184, 266). FPMD also has applied accreditation and self-assessment strategies in Brazil, Madagascar, and elsewhere (82).

Expanded Quality Improvement (EQI). The Family Planning Service Expansion and Technical Support Project (SEATS) has taken a flexible approach to quality improvement, selecting tools and tailoring techniques to fit specific projects (165, 184). Based on its experience in West Africa, SEATS has developed EQI (known as EQUIPE in French), which expands improvement teams to include representatives from the community and from referral sites as well as from service sites. EQI teams are trained in both problem-solving techniques and quality monitoring (162).

Accelerated Quality Improvement (AQI). SEATS also has developed AQI, which is based on an approach of the Institute of Health Care in the US. AQI accelerates quality improvement cycles by focusing on a single topic, using simple measures, relying on existing knowledge of best practices, and working with interested staff members (171). The ACQUIS (Accelerating Access to Contraceptives and Quality to Increase and Improve Services) Project has applied AQI at 39 sites in Burkina Faso, Cameroon, Cte d'Ivoire, and Togo (204).

District Team Problem-Solving (DTPS). The World Health Organization (WHO) developed this one-year structured analysis and planning process to strengthen lower-level management in decentralizing health care systems (361). Top managers assign a high-priority health problem to a team of five to seven district-level managers, who become responsible for analyzing and solving it. DTPS has been applied in more than a dozen countries (313, 362).

Service Quality Improvement (SQI). Developed by Family Health International (FHI), SQI integrates the Bruce-Jain framework on quality of care with CQI principles and analytical tools. SQI's 9-step improvement process involves staff members but is directed by managers (129). While it has not been applied, the approach has influenced other family planning quality improvement initiatives.

QAP: Quality assurance of health care in developing countries, by L. DiPrete Brown et al. 1993. (89), and Achieving quality through problem solving and process improvement, by L. Franco et al. 1995. (113) Free to developing countries from: Center for Human Services, 7200 Wisconsin Avenue, Suite 600, Bethesda, MD 20814, USA. Tel: (301) 654-8338. Fax: (301) 941-8427. E-mail: cmadubuike@urc-chs.com

COPE: COPE: Client-Oriented Provider-Efficient services: A process and tools for quality improvement in family planning and other reproductive health services, by AVSC International. 1995. (16), and COPE: A self-assessment technique for improving family planning services, by J. Dwyer et al. 1991. (97) Free to developing countries from: AVSC International, 79 Madison Avenue, New York, NY 10016, USA. Tel: (212) 561-8000. Fax: (212) 779-9439. E-mail: info@avsc.org

CQI: "Using CQI to strengthen family planning programs" (61) and "Manager's toolbox for CQI" (132) in Family Planning Manager, Vol. 2, No.1, and Supplement. 1993. Available in English, French, and Spanish. Free to developing countries from: FPMD Project, Management Sciences for Health, 165 Allandale Road, Boston, MA 02130-3400, USA. Tel: (617) 524-7799. Fax: (617) 524-2825. E-mail: fpmd@msh.org

EQI: Various country reports and descriptions of basic methodology. Request reports on region of interest from: SEATS II, JSI, 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, USA. Tel: (703) 528-7474. Fax: (703) 528-7480. E-mail: jsinfo@jsi.com

DTPS: District Team Problem-Solving guidelines for maternal and child health, family planning and other public health services. 1993. By M. Thorne et al. (361). Available from: Unit for Strengthening Country Health Information, Family and Health Services, World Health Organization, 20 Ave. Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 23 82. Fax: 41 22 791 41 94. E-mail: info@who.ch Also available on the Internet at: http://www.who.int/hst/sci/b/b1/dtps/dtps.htm

Long waits are so common in family planning and other health care facilities that some quality improvement approaches routinely analyze client flow (16, 96, 113). AVSC International has developed a simple form of client flow analysis that records each client's arrival time and length of time spent with staff (221). With the help of graphs and summary sheets, staff members then calculate how long clients spend waiting, how long they spend in direct contact with staff members, and where the greatest delays occur. The results surprise many providers and motivate them to make changes (219).

Causes of long waits, and their solutions, vary from one place to another. In two Kenyan clinics studied, problems started at the beginning of each day, when care was delayed while providers prepared the clinic and conducted group talks (221). Completing paperwork after seeing each client added to delays. Part of the solution was to reorganize the clinic schedule to match the flow of clients, which was heaviest early in the morning and slowed dramatically in the afternoon. Changes included preparing the clinic at the end of the day, excusing continuing clients and most providers from attending group talks, and saving paperwork for the afternoon. Waiting times of more than two hours were cut by almost two-thirds in one clinic and by one-third in the other (95).

In contrast, in Aguascalientes, Mexico, waits were long at primary health care facilities because of the lack of an appointment system, inappropriate scheduling of personnel, poor handling of medical files—and a social norm that considered up to 150 minutes of waiting time to be acceptable (95). In this case the quality improvement team not only had to reorganize the health centers but also deal with the social norm. Their actions, which included setting up an appointment system and an incentive plan for health personnel, cut the average wait from 139 to 70 minutes. Because quality improvement is a Ministry of Health initiative, the new systems will be adopted at government health centers throughout the state of Aguascalientes.

In-service training is seen as the remedy for many quality problems. Before turning to training, however, managers should analyze the causes of poor staff performance, which often lie with systems that discourage providers from applying their knowledge and skills effectively (53, 121, 384). Common obstacles to good performance include inadequate equipment and supplies, little supervisory support, few rewards, inappropriate evaluation, limited opportunities to practice skills, and flawed recruitment or job assignments (311, 384).

A performance needs assessment is a key step in the Performance Improvement Approach (PIA), which applies industrial experience with performance improvement to reproductive health care (288, 311). For example, a recent PIA needs assessment in Burkina Faso identified six organizational problems that hindered the performance of community-based distributors. While these workers also needed new knowledge and skills, the PNA team recommended that training be postponed until the organizational issues were resolved (270).

Training Alternatives

Formal training, in which staff members attend a workshop or course at an off-site training center, may not be the best option. Many formal training programs fail to change trainees' everyday practices (48). It can be difficult to transfer skills and concepts learned in the artificial setting of a training center to the job (101, 114, 350). In the US, performance experts estimate that 10% or less of employee training results in new skills that are applied on the job (306).

Effective, less expensive, and less disruptive alternatives to formal training are supportive supervision, informal on-the-job training, coaching, and job aids such as wall charts, flip charts, and checklists (164, 350, 384). When supervisors or co-workers instruct providers on the job, they can tailor their advice to the individual needs of each provider and to the setting, and they can offer immediate feedback. Supervisors and co-workers, however, do not always offer correct or complete training (45).

On-the-job training is a common way to refresh, update, and expand providers' knowledge as well as to orient new staff (98, 219). For example, a quality improvement team at a Bangladesh hospital asked supervisors to orient new staff to infection prevention procedures, while trained family planning counselors updated nurses and supervisors on contraceptive information and counseling approaches (23).

Whole-site training, pioneered by AVSC International, broadens the concept of on-the-job training. Staff members are trained on site, if possible, as a service delivery team, so that staff members understand their roles on the team and can support one another (98, 101). For example, when nurses are trained to insert Norplant implants, family planning counselors also learn about the method, and receptionists and other support staff receive an orientation so that they can answer clients' basic questions (45).

Whole-site training is more efficient than formal classroom training. Using the whole-site approach, the Family Planning Association of Kenya and the Christian Health Association of Kenya provided skills training for 596 staff, updates for 532 staff, and 834 orientations for new staff over a 2-year period at a cost of US$228,000. By comparison, the two organizations had spent almost as much—$213,000—over the preceding two years on centralized training for just 143 staff members (45).

Distance education offers another alternative to off-site training. It can bring a standardized curriculum to scattered and isolated workers. For example, the Nepal Radio Communication Project used distance education to improve the counseling skills of community health workers. Listening to a 15-minute educational radio program twice a week for six months improved observed counseling skills better than a 3-day workshop, and without taking providers away from their jobs (346, 347).

The Case for Formal Training

Managers must ensure that staff returning from training find support to apply their new skills (11, 114, 193). Supervisors should know the content of training so that they can foster trainees' new skills. Lack of support from supervisors and co-workers explains why much formal training is never applied on the job (271). To ensure appropriate supervision, both the Young Women's Christian Association of Uganda and FPAK have trained supervisors and providers together (60). An Operations Research project in Indonesia has found that structured self-assessment and peer review can help providers maintain newly learned communication and counseling skills when supervision is not feasible (191).