Elevating the client’s voice in quality of care

By Christine Bixiones, Senior Technical Advisor, SRH

PSI and Abt Associates recently shared lessons learned in the IBP network-hosted webinar, “Elevating Quality of Care (Q0C) in Voluntary Family Planning Services.” Dr. Eva Lathrop, PSI’s Global Medical Director, opened the webinar reminding practitioners of the Lancet Commission’s finding in 2018 that in low- and middle-income countries, poor quality health care is now a bigger obstacle to reducing mortality than lack of access to care, making quality a fundamental issue in serving the most vulnerable.

Within this global context, PSI shared insights into ensuring quality of care from its experiences implementing the USAID-funded Strengthening International Family Planning and Health Organizations 2 (SIFPO2) Sustainable Networks project in over 30 countries across 6 years. As a result of key project learnings, PSI shifted to a stronger focus on client-centered care practices and the client experience as a key measure of quality of care.

What We Learned:

SIFPO2 support enabled PSI to expand its prioritization from clinical adherence to an equal focus on systematically capturing and evaluating the client’s experience of care across its family planning (FP) programs. Transformations in digital health and their adoption by consumers and providers have played a critical role elevating the consumer voice in health services supported by PSI.  In 2019, PSI analyzed data from 15 country client exit interviews where clients were asked how they experienced their care. The following visualization demonstrates these data: Green represents “pleased with the care,” orange represents “neutral” and blue represents “displeased with care.”

The data showed consistently high scores in client experience; albeit, when asked about their wait times, close to 5% of clients globally said they were displeased. While these appeared to be largely positive results, these data fail to indicate where PSI could make substantive changes to improve the client’s experience, a finding in line with evidence suggesting that reported client satisfaction tends to be biased towards higher quality, particularly when asked subjective questions, such as evaluating treatment by staff. This response bias, or “courtesy bias,” along with expectations for care that are sometimes low, could potentially mask deficiencies that affect a client’s experience with the care they receive.

Adopting Actionable Client-Centered Metrics

To identify more meaningful insights into a client’s experience of care, PSI initiated work in 2019 to select and test client-centered metrics that can be added to or take the place of what PSI programs currently use to evaluate quality of care from a client’s perspective.

After conducting a desk review of all validated scales that measure client-centered care in the family planning field, PSI developed criteria to ensure that all metrics selected to test would yield deep insights and actionable data that are best measured from a client’s perspective. The metrics fall within categories such as “trust”, “respect and dignity,” and “decision-support” and help to evaluate if care adheres to standards within PSI’s global quality of care domains “Interpersonal Connection & Choice” and “Information Exchange.”

While many QoC measures exist in the field, the goal is to focus on a set that do a better job of revealing gaps in the client experience. In 2021, following cognitive interviewing and field testing of the indicators, PSI will consult with the global FP community of practice on the selected metrics and make them available as a global good.

QoC Self-Care Framework

Another key output discussed during the recent webinar was the QoC Framework for Self-Care. Self-Care is an essential component of a voluntary and comprehensive FP program that responds to a client’s preferences and choices. In order to ensure the highest standards of QoC in self-care, PSI, in collaboration with the Self Care Trailblazers Group, developed a QoC Framework for Self-Care for use among implementers, Ministries of Health, researchers, policy makers and donors. Inspired by the WHO Consolidated Guideline on Self-Care Interventions, the framework is aligned to PSI’s five domains of QoC (based on the Bruce-Jain framework) and adheres to the principles of rights-based FP.

This global good is not intended to replace any current quality of care systems, but rather expand and reorient what exists to ensure both people-centered and health-system centered approaches. It is designed to apply to a range of self-care interventions and behaviors, not limited to FP, such as HIV self-testing, HPV self-sampling and diet and lifestyle adjustments. The framework is currently being incorporated into QoC systems at the country level.

Looking Forward

PSI’s six years of SIFPO2 implementation catalyzed several client-centered approaches that support PSI, partners, and national health systems in their important efforts to make health care more responsive to clients’ needs, preferences and choices. As the SIFPO2 project draws to a close, these inputs will continue to support global efforts to bring high-quality, client-centered care to different settings around the world. To learn more, please watch the recording of the recent Webinar that covers these topics, and more, at the follow link: “Elevating Quality of Care (Q0C) in Voluntary Family Planning Services” webinar.

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