Ethical foundations of client-centered care in family planning.

Biomedical ethics provides the foundation for a model of client-centered care that can assure the good quality of family planning and other reproductive health services in developed and developing countries. Client concerns mirror the four ethical principles of autonomy, justice, beneficence, and nonmaleficence. Autonomy reflects clients' desire for full information and respect from providers so that they can exercise their right to make their own informed decisions. Justice, for clients, means fair treatment and ready access to services, regardless of one's socioeconomic status, education, ethnic group, or residence. Beneficence means that providers possess the technical competence and understanding needed to act in the best interest of their clients, as clients expect. Nonmaleficence translates into client concerns about safety--that no harm will come to them as a result of seeking services. Putting these ethical principles into practice requires changing providers' attitudes from paternalistic to client centered. Assessments of client satisfaction can help family planning programs identify and respond to client values and even raise client expectations about the care they should receive. Managers also can contribute to good quality care by meeting providers' professional needs for training, supervision, supplies, record keeping, and so on. Family planning programs around the world are focusing on these ethical concerns to emphasize respect for client values, appropriate decision making, broader access to services, and basic safety issues. Although they use a variety of techniques, all these quality assurance and improvement initiatives share an ethically based, client-centered philosophy.

Family planning programs: improving quality.

PIP: Family planning programs are increasingly making quality of care the highest priority. With improvement in quality of care, contraceptive use is safer and more effective, information and services are more accessible, clients make informed choices and are more satisfied. In addition, family planning providers find their work more rewarding and the general public has a positive view of health care and its providers. Applying the lessons of the quality movement of health care and family planning, programs and providers are finding more creative approaches that suit reproductive health care in developing countries. In addition to adopting a client-centered approach, these efforts suggest that the three sides of the quality triangle are equally essential: quality design, quality control, and quality improvement.^ieng

Population reports. Community-based health and family planning.

PIP: This publication examines existing community-based distribution (CBD) programs for family planning and other health care measures and discusses some principles of organization and management. CBD programs have 4 essential features: community residents who are not health professionals deliver supplies and services, services are delivered to communities or households rather than to clinics, CBD workers operate without day-to-day supervision, and many record keeping, diagnostic, and screening procedures are omitted because they are not practical for community workers. CBD overcomes geographic, cost, bureaucratic, and cultural barriers to health care. The more than 70 existing CBD programs differ in services offered, fees charged, means of delivery, presence of research components, and in whether they are single purpose, integrated, government-sponsored, or private. In designing or expanding CBD programs, the health problems of the community, availability of effective remedies, and ease and safety of services and supplies must be considered. 6 aspects of CBD programs which are likely to be most difficult are discussed: recruiting effective workers, training workers in new skills, providing continued training and supervision, coordinating backup with the existing medical system, keeping supplies flowing, and establishing an evaluation system. Experience in integrated family planning and CBD health programs is inconclusive, but a few lessons are clear: CBD projects should avoid a service overload, new activities should be phased in step-by-step, community participation is desirable, combining family planning with other services is not necessary to make family planning acceptable although it may help meet other primary health care needs, and research on design and implementation of CBD programs is needed. Experiences and problems with CBD programs for health measures in addition to family planning are described, including oral rehydration therapy for diarrhea, malaria treatment, intestinal parasite treatment, nutrition education and supplements, and immunization. A table listing characteristics of selected community-based integrated family planning and health projects is included.^ieng