Quality in health care and family planning has been defined in many ways (39). From a public health perspective, quality means offering the greatest health benefits, with the least health risks, to the greatest number of people, given the available resources (148). For others, quality means offering an appropriate array of services—for example, integrating sexually transmitted disease (STD) services and maternal and child health (MCH) care with family planning services. Still others define quality largely as satisfying the clients' wishes.

Also, good quality may mean either meeting minimal standards for adequate care or achieving high standards of excellence. Quality can refer to the technical quality of care, to nontechnical aspects of service delivery such as clients' waiting time and staff's attitudes, and to programmatic elements such as policies, infrastructure, access, and management (53, 76, 91). Quality is sometimes contrasted with access. In fact, it is difficult to draw a line between them.

Clients, providers, managers, policy-makers, and donors all have differing but legitimate perspectives on what constitutes good-quality care (89):

Providers' perspective. Historically, for health care providers quality has meant clinical quality of care offering technically competent, effective, safe care that contributes to an individual's well-being (89). For their part, program managers recognize that support services—for example, logistics and record-keeping—also are important to the quality of service delivery. For policy-makers and donors, additional key elements of quality include cost, efficiency, and outcomes for populations as a whole (154, 269). The World Health Organization (WHO) definition of quality encompasses the perspectives of all these groups:

Quality of health care consists of the proper performance (according to standards) of interventions that are known to be safe, that are affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability, and malnutrition. (307)

• Choice of methods,
• Information given to clients,
• Technical competence,
• Interpersonal relations,
• Mechanisms to encourage continuity, and
• Appropriate constellation of services.

With growing recognition of the clients' perspective, quality in family planning and health care is being redefined as "the way clients are treated by the system" (154). When health care systems—and those who work in them—put clients first, they offer services that not only meet technical standards of quality but also satisfy clients' need for other aspects of quality, such as respect, relevant information, access, and fairness (53, 91, 92, 262).