In fact, ample resources alone do not guarantee high quality. Research in the United States, for example, has revealed high error rates in the delivery of health services (49, 206). US health care clients share many of the same causes for dissatisfaction as clients where resources are scarcer, including poor interpersonal relations with physicians and inadequate information (31, 85, 212, 304).

Efficiencies and allocation. By deploying existing equipment, staff, and facilities more efficiently, managers often can increase the number of people served without additional funds (109, 375). For example, a health directorate in Jordan was able to increase the number of vaccinations administered by 5% at the same time that it cut the amount of vaccine ordered by 25%, after a quality assurance team reduced the amounts of vaccine that were wasted (87).

Some improvements in quality even pay for themselves in the long run (42, 73, 243). The Central Asian Infectious Disease Program trained health workers to treat acute respiratory illness (ARI) and diarrheal disease appropriately. When these health workers returned to the field, drug costs declined as they prescribed fewer drugs per case, fewer unnecessary antibiotics, and fewer injections. For example, among trained providers in Kyrgyzstan the average cost of treating a case fell 78% for pneumonia, 59% for other ARIs, and 64% for diarrhea—even though the cost of the drugs increased sharply over the same time period (158).

Sometimes resources at the service site are not fully used. For example, assessments in five African countries found that available communication materials were used with fewer than one-quarter of all clients, and most facilities had a light family planning and MCH client load that did not keep providers busy (125). In these facilities there were opportunities to improve services without additional costs (257).

Low-cost improvements. A change in providers' attitudes or reorganization of service delivery can improve quality at relatively little cost, without additional staff or equipment (336). For example, it costs no more for providers to treat clients with respect (154, 185) or for clerks to administer an efficient registration and payment process (60). Such changes do require training and supervision, but health care programs already pay for training and supervision as part of the basic costs of doing business.

Sometimes, affordable good-quality care means choosing appropriate technology. For example, programs that cannot afford disposable syringes or autoclaves for steam sterilization can still prevent infection by rigorous hand washing, high-level disinfection of instruments, and steaming surgical gloves in a rice cooker (241).

Avoiding unnecessary costs. By preventing injuries, infections, and unwanted pregnancies, good-quality care eliminates costly follow-ups to treat clients who have been harmed (109, 269). In Oyo State, Nigeria, for example, lapses in counseling, screening, and infection prevention sent many IUD clients back to clinics to have side effects explained, infections treated with antibiotics and pain relievers, and expelled IUDs reinserted (293). Such avoidable repeat visits are costly both for programs and for clients, who may have to take time off from work and pay for transportation (275). Poor care also can exact a human toll of anxiety, pain, and suffering.

Even if any harm done does not incur follow-up costs, inappropriate care amounts to a waste of money (293). For example, a 1995 cost analysis of oral contraceptive use in Brazil estimated that cost per appropriately served client was less at a clinic than in pharmacies, even though cost per client overall was higher—US$34 versus $24 per year. Many pharmacy clients were not medically eligible to use the Pill, and most did not feel satisfactorily informed. In contrast, at the So Paulo Feminist Sexuality and Health Collective, all Pill clients were appropriate users and three-quarters felt satisfactorily informed. If ill-informed or inappropriate Pill clients are excluded, the annual cost of serving a well-informed, clinically appropriate Pill user at the clinic was $46 a year compared with $200 at the pharmacies (83).

Quality attracts revenue. Improving quality can attract more clients, help programs raise revenue, and attract donor support. Offering good-quality services allows some programs to charge or raise user fees (7). Clients often are willing and able to pay more than they already do for services—but only for services that they consider are of good quality (7, 275, 299, 394, 396, 397). In contrast, when service quality is poor and clients have other options (which may include foregoing care), clients stay away, and financial support dwindles, which often reduces quality even further (157).

Whether or not programs charge fees for services, better quality that attracts more clients can lower per-client costs. For example, the Bangladesh Women's Health Coalition attracted many clients by offering good-quality services. The high volume of clients allowed the program to spread its fixed costs over a greater number of clients, and the lower cost per client made serving more people affordable (185).