In quality design the participation of front-line service providers, field supervisors, and clients is crucial. Top decision-makers rarely have direct experience with day-to-day service delivery (124, 244, 344). Without insights from providers and clients, intended improvements may not be meaningful to the staff who must implement them and may not attract clients or meet people's reproductive health needs (6).

Services should be planned realistically, considering program resources (88, 139). Safe and effective care demands a minimum level of resources (117, 375). Lack of adequate resources forces planners to make difficult choices as part of the quality design process—for example, whether to limit the number of services or else to reduce the number of people who can be served.

Quality design decisions often involve weighing the costs, risks, and benefits of different services and modes of service delivery. This is the approach to contraceptive introduction taken by the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (338). The first step in the process is to examine clients' needs and the capacity of the service delivery system to offer proposed new methods safely and effectively. Such an assessment led the government of Vietnam to postpone widespread introduction of Norplant® implants until technical quality of care and counseling could be improved (333).

In projecting costs, managers must plan for the unexpected and protect the quality of services by budgeting for it. Building in this "organizational slack" allows managers to respond to unanticipated events (such as an epidemic or a shortage of contraceptive supplies) without cutting into routine services or overloading the staff (181). Studies show that effective and innovative organizations consistently have uncommitted resources available (308). Estimating how much slack to include is a matter of experience, but the less predictable the environment, the more slack is needed. Where funding agencies do not allow budgeting for contingencies, budget line-item flexibility helps when emergencies or opportunities arise.

The Cost Revenue (CORE) Analysis Tool, developed by the Family Planning Management Development project, helps managers analyze various mixes of staff, services, equipment, and supplies so that they can anticipate costs and allocate resources more efficiently (226). The Marie Stopes program in Tanzania, for example, used the CORE spreadsheet to control costs, rationalize fees, and still improve the quality of services (218).