In health care the main objective of quality control is to ensure that all providers consistently offer the same good quality of care to all clients (196, 236). Quality control includes day-to-day supervision and monitoring to confirm that activities are proceeding as planned and staff members are following guidelines (89). It also includes periodic evaluations that measure progress toward program objectives. Good quality control requires that programs develop and maintain:

• Measurable indicators of quality,
• Timely data collection and analysis, and
• Effective supervision.

• Input indicators gauge whether a program has the needed—resources for example, the number of trained providers and the stock of contraceptives.
• Process indicators measure how well program activities are being implemented. Examples include waiting times, the percentage of providers who follow infection-prevention procedures, and the percentage of clients who are informed when to return for resupply or a check-up.
• Output indicators measure results at the program level. Examples include the number of clients served, the percentage of clients who receive an appropriate method, continuation rates, and the percentage of STD cases successfully treated.
• Outcome indicators measure the program's short-term effects and long-term impacts on the general population—for example, contraceptive prevalence, the incidence of sexually transmitted diseases, and the fertility rate (33, 57).

Process indicators began to receive attention more recently. They can be used to pinpoint problems in service delivery and to suggest specific solutions (74, 138). Front-line managers can use process indicators to monitor activity at their facilities and to guide day-to-day decision-making.

Output and outcome measures indicate whether program activities have an impact on their clients or the general population (37). Of course, these indicators may be influenced by factors outside of the program's control, such as the social and economic characteristics of the clientele (74, 93). While donor organizations and government ministries are often interested in output and outcome measures, these measures are difficult to use for quality improvement: They can point out broad areas of unsatisfactory performance, but they seldom specify what needs to change (123, 138). For example, a high contraceptive failure rate might reflect inappropriate method selection, poor counseling, disruptions in contraceptive supplies, poor clinical technique, or even civil unrest (390). By linking process and outcome indicators, however, researchers and managers can document which changes in services improve outcomes.

Devising good indicators of quality is difficult. Indicators must provide reliable, objective, and relevant information about important issues; they must be sensitive to changes in performance; and they must be easy to calculate with available data (59, 322, 386). (For examples of appropriate indicators in Egypt's Gold Star Program)

Measuring quality requires new thinking based on client perspectives. For example, family planning programs conventionally measure discontinuation rates—the percentage of new users who have stopped using their chosen method after a set time period, usually one year. For measuring quality, however, the drop-out ratio is a better indicator because it takes account of clients' reasons for stopping a method. The drop-out ratio is the percentage of new users who are still at risk of pregnancy, do not want to become pregnant, and have quit using any family planning method. Thus it excludes clients whose reasons for discontinuation do not reflect on service quality—for example, women past menopause, who are no longer sexually active, whose pregnancies were planned, or who switched methods (59).

Research efforts have made progress in defining indicators of quality for family planning (33, 64, 184, 261). Most of these new schemes are based on the six elements of quality formulated by Bruce and Jain (see Clients' perspective in Chapter 1.1) or on the IPPF framework: Clients' Rights and Providers' Needs (see sidebar, IPPF Framework: Clients' Rights and Providers' Needs).

The EVALUATION Project has compiled 42 input and process indicators and 6 output indicators of quality for clinic-based programs, based on the Bruce-Jain framework (33). These indicators are measured from three different points of view: the manager's, the provider's, and the client's. Thus quality of care in the choice of a method, for example, can be indicated by:

• The range of contraceptive methods in stock (managerial decision),
• Whether providers offer clients all appropriate methods (provider performance), and
• Whether clients receive the method of their choice (client preference).

In contrast, a comprehensive accreditation system requires a lengthy list of indicators. When the PROQUALI Project began its effort to accredit the reproductive health units of community health centers in Northeast Brazil, the first step was to learn all points of view on quality, including those of the clinic, the health worker, the client, and the community. With this information, planners developed internal and external checklists that cover service delivery, infection prevention, interpersonal communication and counseling, and information, education, and communication (IEC). The most difficult part of the 8-month process was reducing the list to 61 criteria that are considered the minimum needed to monitor the quality of every aspect of services (5, 174).