Interviews in Nigeria also reveal the drawing power of good quality. Nearly 40% of women interviewed did not attend the closest clinic. Among women using more distant clinics, 9 of every 10 said the reason was better services at the more distant clinics (249). Similarly, rural women in Peru reported switching from public- to private-sector providers for better care (110).

How do clients judge the quality of family planning and other health services? A growing body of research is discovering what clients want and how to measure client satisfaction. In both developed and developing countries, clients share seven major concerns (6, 8, 10, 22, 110, 111, 185, 198, 212, 229, 262, 267, 268, 316, 317, 319, 341, 351, 354, 365, 376, 400). These are:

1. Respect. Clients want to be treated with respect and friendliness. Clients interpret courtesy, confidentiality, and privacy as signs that providers are treating them as equals. In Bolivia, for example, when a doctor apologized to a roomful of waiting women for a delay and explained its cause, she reversed the clients' negative perceptions of the clinic (316). Dealing with providers who treat them badly is more than some people are willing to tolerate.
2. Understanding. Clients value individualized service and prefer providers who make the effort to understand their particular situation and needs. They want providers to listen to them, to explain options in terms that they understand, and to assure them that problems can and will be taken care of. When providers are unresponsive, frustrated clients may simply drop out. "I took the pills for a year. I felt dizzy and lost my appetite. I told the [field workers] about it, but they didn't say anything," explained a client of a community-based program in Bangladesh. "So I stopped taking it, and then I felt better. Then I got pregnant for the third time" (317).
3. Complete and accurate information. Clients value information. They worry that family planning providers are not telling them all the facts, especially negative information about contraceptive methods. In Indonesia, for example, clients commonly believed that they could get the truth about side effects only from friends or relatives and that midwives would discuss only advantages of a method (351).
4. Technical competence. Clients can and do judge the technical competence of the services they receive, although they may not use the same criteria as providers and they may not be technically accurate. For example, clients surveyed in Chile based their judgments on the cleanliness of the clinic (376); in Kenya and Zambia, on how thoroughly they were examined (267, 268); and in Indonesia, on what types of medicine they received (351). Ultimately, clients judge technical competence by whether their needs are met or their problems are resolved.
5. Access. Family planning clients want ready access to contraceptive services and supplies. A convenient location and prompt service are important, but access also means that services are reliable, affordable, and without barriers. For example, access is compromised when CBD workers fail to return as scheduled, facilities run out of supplies, or providers turn people away without counseling or care (317, 341).
6. Fairness. Clients want providers to offer thorough explanations and examinations to everyone alike. They complain that providers offer preferential treatment to friends, relatives, those from a higher social class or certain ethnic group, those with political connections, or those who offer bribes (22, 110, 351). Studies in Bangladesh and Nepal found that providers gave less information and the most disrespectful treatment to the poorest, least educated clients (318, 319).
7. Results. Clients come for services for a specific purpose. They are dissatisfied when told to come back another day or to go to a different facility, or when providers dismiss their complaints as unimportant (267). For women in northeastern Brazil, getting the results they wanted outweighed virtually all other factors in judging quality of care, including long waiting times and brusque treatment (174).