Service protocols give providers step-by-step instructions for performing tasks, such as inserting an IUD or counseling a client to make an informed choice among contraceptives (292, 392). Good protocols standardize treatment, designate practices that are appropriate based on scientific evidence, and guide training and supervision (63, 205, 277). Providers appreciate protocols because they offer comprehensive guidance, a review of medical research findings, knowledge of how other providers work, and reassurance that they are delivering good care (21, 28, 63).

In a parallel fashion, management procedures offer detailed instructions on nonmedical tasks, such as ordering and distributing contraceptive supplies, filing client records, and managing client flow. They contribute to the quality of care by standardizing and strengthening support services.

In family planning programs the most extensive work on guidelines has focused on the medical and technical aspects of quality of care, aided by recent scientific consensus. Guidelines are equally important for other aspects of quality, however, such as interpersonal communication and privacy. No matter what their subject matter, guidelines should have clear objectives related to quality of care, be based on scientific evidence and client concerns, be accepted by consensus, and be achievable (137).

A May 1998 survey identified 54 countries that have planned to update or draft national or regional guidelines on family planning and other reproductive health services. Some 38 of these 54 had finished writing new guidelines, and 26 also had disseminated them (230).

Developing guidelines. By inviting all interested groups to participate in guidelines development, programs can build a broad commitment to the changes that new or revised guidelines will require (21, 205). Consensus fosters the use of guidelines by providers and their acceptance by policy-makers (372). Interested parties often include service organizations, professional associations, teaching institutions, women's advocacy groups or other client representatives, as well as medical experts (187). When service providers and their supervisors help to write and field-test guidelines, they can assure that the guidelines will be feasible, readily understood, and acceptable to providers (205, 344).

Clients also should have a voice to help ensure that guidelines reflect their concerns and needs (205). For example, in Kenya managers added the subject of condom disposal to the guidelines because it was a frequent concern of clients and one that providers did not address consistently (224).

Various organizations have published reference materials to help programs develop family planning service guidelines. These materials summarize the current clinical and epidemiological findings that provide the scientific foundation for clinical guidelines (see sidebar, Sources of Guidance on Clinical Care in Reproductive Health). Each program must adapt this guidance to specific settings, particularly to the training and skill level of providers, to the resources available, to national and program goals, and to the social setting (167, 246, 352, 355, 388).

Guidelines must be reviewed and updated often (131, 135, 187, 291). Updates should take account of:

• New research findings on the risks and benefits of contraceptive methods;
• Technological developments, such as changes in the formulation of hormonal contraceptives;
• Emerging public health problems, such as HIV/AIDS;
• Social changes—for instance, shifting attitudes toward contraceptive use by unmarried women;
• Programmatic changes, such as the addition of community-based providers or a new method; and
• Feedback from providers and clients.

Choosing the level of care. Guidelines may be more or less stringent, depending on their objectives. Minimum standards of care define the lowest acceptable level of care; their goal is to eliminate substandard care and ensure safety. Higher standards of care foster excellence by demanding better care and aiming towards a so-called gold standard.

Sometimes the setting dictates the level of care. For example, pelvic exams, lab tests for STDs, and cervical cancer screening are preventive health measures that add to the quality of care received by family planning clients who adopt the Pill, injectable, or implants. Because these procedures are not necessary for safe use of these methods, however, family planning programs with limited resources can meet minimum standards of care without offering them (136, 355).

Planners balance risks and costs against potential benefits when they decide what level of care a program will offer (21, 131). In Ecuador, for example, the Céntros Médicos de Orientación y Planifacación Familiar (CEMOPLAF) calculated that reducing the specified number of scheduled IUD revisits from four to one would reduce the actual number of revisits—and their cost to the agency and to clients—by 36%, while decreasing the number of serious medical problems detected by 7%. (The decrease in revisits was limited because women were taught the signs of possible IUD problems and encouraged to return if a problem arose, and because many women did not return for scheduled appointments.) After weighing the costs and benefits, CEMOPLAF decided in 1993 to change its IUD revisit policy, thus freeing 1,800 hours of provider time per year for other essential services, such as gynecological visits (47).

Avoiding unnecessary medical barriers. Guidelines sometimes inappropriately and unnecessarily restrict access to contraceptives without scientific justification (326, 328). Typical unnecessary medical barriers found in guidelines include requiring women to return more often than necessary for check-ups or supplies; making age, parity, marital status, or spouse's consent a prerequisite for a method; and requiring women to be menstruating, as proof that they are not pregnant, in order to start hormonal methods or IUDs (72, 187, 211, 329, 339, 340, 370).

Unnecessary medical barriers reduce access to services, increase costs, and limit choices. For example, a recent review found that one-fourth to one-half of new clients in Cameroon, Ghana, Kenya, and Jamaica were turned away without another method because they were not menstruating at the time of the visit. The results were unwanted pregnancies, unnecessary costs to clients who had to return later, and pressure on clients to lie about their menstrual status (340).

Revising guidelines sometimes can reduce unnecessary barriers, increase the number of clients served, and improve quality of care (187, 291). For example, in 1996 the Ghanaian Ministry of Health adopted new service policies based on WHO medical eligibility criteria and eliminated age restrictions and parity requirements for injectables and female sterilization. A subsequent evaluation at two urban service sites found a 130% increase in the number of injectable users and a 99% increase in the number of women choosing sterilization (115).

Sometimes unnecessary medical barriers are not written into a program's guidelines but instead exist unofficially as practice norms or individual provider's biases (32, 131, 291, 328). Indonesian providers, for example, often ask a woman seeking an IUD whether she has her husband's consent, even though official policy requires spousal consent only for sterilization (192). Interviews with providers in five sub- Saharan African countries found that providers consistently imposed more restrictions on contraceptive methods, based on the client's age, parity, marital status, and spousal consent, than government service protocols required (256).

Communicating guidelines. For guidelines to be followed, they must be communicated to every staff member, and their use must be supported and rewarded throughout the organization (21, 63, 131, 187, 263). The guidelines must be consistently reflected throughout a program, including accreditation systems, service manuals, preservice and in-service training curricula, job descriptions, job aids, supervision and monitoring tools, and client materials (75, 205).

Without dissemination of new guidelines, providers may ignore them. In Malawi, for example, a study found that one-fourth of providers had not read the new "Child Spacing Policy and Contraceptive Guidelines," and two-fifths felt uncomfortable with new policies that lifted restrictions based on age and marital status. Most did not consider the guidelines a true call for change since they were not accompanied by the informational materials, contraceptive supplies, training, support, and supervision needed to implement them (354).

To disseminate guidelines, managers must develop a variety of materials that are appropriate for different staff levels and categories (205). Posters, checklists, and other job aids may suit front-line providers, for example, while reference manuals may be more useful for supervisors (372). In Turkey the 1994 national family planning guidelines were disseminated to providers in a user-friendly Clinician's Handbook and a series of method checklists. These materials did not try to summarize the guidelines but instead applied them to daily practice (187).

Special training and staff discussions can help workers understand why and how to apply new guidelines. In Mexico, for example, the Ministry of Health held a series of workshops in 1994 at the district, state, and regional levels to introduce new guidelines. At the workshops, staff members at every level could ask questions, express doubts, and discuss interpretations (187).

It is also important to tell providers what not to do (274). In Cameroon providers' attitudes and practices did not improve after new guidelines were disseminated, partly because the guidelines did not discuss the inappropriate medical barriers or highlight the desired changes in practice (130, 340).

Organizational structures and processes, such as equipment and supplies, training, supervision, performance assessment, and rewards, must support the new guidelines (131, 372). For example, if supplies are not available, providers cannot be expected to follow guidelines that call for a broad choice of methods. Also, supervisors can reinforce new guidelines by checking whether staff members follow them (205).

Revising the curriculum in pre-service training institutions is especially important so that new providers begin their jobs understanding the guidelines (75). Also, job aids, such as wall charts, cue cards, flip charts, and checklists, can remind staff to follow program policies, guidelines, and procedures (187). They can guide workers systematically through counseling, diagnosis, treatment, or the supervision process (108, 209). Providers and supervisors like job aids and, with their help, often improve performance (215, 225, 374).

For example, in Paraguay the Centro Paraguayo de Estudios de Población has written a "Provider's ABC" that tells rural family planning promoters how to counsel family planning clients depending on their individual reproductive needs, contraceptive history, and other factors (67). Using the guide has improved quality of care as assessed by clients' knowledge of contraceptive methods and checklists completed by simulated clients (325).