How Does Quality of Care Relate to a Rights-Based Approach to Family Planning Programs?

...[T]he definition of quality in FP has expanded beyond the attributes of clinical practice, medical supplies, and equipment to include counseling and communications, other dimensions of service delivery, and broader program elements. How quality is defined within and among organizations varies considerably, which hinders prioritization, effective partnerships, and consistent monitoring and measurement within and across health systems."

This paper compares definitions of quality of care in family planning (FP) programmes and contrasts them with the essentials of a right-based approach (RBA). Prepared under the Measuring and Monitoring Quality of Services and Quality of Care project, which was funded by a grant to the Population Council from the David and Lucile Packard Foundation, the paper is grounded in the observed need for common understanding of each construct, of what inputs each entails, and what value it contributes to FP, and indeed all service programmes in the reproductive, maternal, newborn, child and adolescent health (RMNCAH) field. "This would facilitate productive discourse and drive donors' and governments' critical decisions about program investment priorities, program design, resource deployment, monitoring and evaluation plans, and establish a basis for generating evidence about the efficacy and impact of different models and approaches. It would also serve to heighten awareness of individuals' entitlements (as rights holders) and of the roles and responsibilities of those required by international law to respect, protect, and fulfill those entitlements (duty bearers)."

The comparative review revealed that quality of care is essentially a supply-side construct that relates to the conditions and actions programmes should ensure for their clients during service delivery. It is rooted in evidence-based medical science and focuses on the safety and effectiveness of services. Its orientation is primarily around the health system and service provider competencies and behaviours towards those they serve. Table 3 on page 20 provides the elements of quality from 15 different constructs, although with varying terminologies that, in some cases, make intent hard to discern, but every effort has been made to group like elements and distinguish those with distinct meanings. What is clear is that the Judith Bruce framework (1990) and Comment 14, Article 12 of the Right to Health form the foundations of most operational definitions. While Comment 14 cites quality as one of four equally weighted attributes of health care information, services, and commodities to which people are entitled as a human right, several definitions include the other attributes (availability, accessibility, acceptability) as elements of quality. A couple of definitions explicitly include consideration of gender relations as part of quality; a few stipulate effectiveness and efficiency as elements of quality; one framework emphasises prevention and treating the whole individual; and another addresses incentives and disincentives.

In contrast, while it includes quality of care, an RBA is more an ethical model than a medical one. It is a broader programmatic construct, reflecting all components of healthcare systems and programmes, including the policy and cultural context in which they operate and both supply and demand. Unlike quality of care, an RBA applies both to those served and those not served. Commonly accepted rights-related principles are captured in the acronym PANEL - for Participation, Accountability, Non-discrimination and equality (meaning both equal treatment for all those being served, and concerted efforts to reach those not being served), Empowerment, and Links to treaty bodies the government has signed, which makes commitments legally binding and defines international standards. The RBA centres on the dignity, needs, and autonomy of individual clients and potential clients. It is about empowering and engaging people to exercise self-determination for their health and fertility and eliminating policy and programme barriers and practices, including all forms of discrimination, which would block anyone from enjoying their rights. An RBA seeks to ensure no one is pressured or induced into accepting a service they do not want, that everyone has access to the information and services they desire, and that services are of the best possible quality. It is characterised by participation, individual agency, and equity - with special attention to marginalised and vulnerable groups - and it stresses programme accountability. The approach calls for donors and governments to revisit policies that could potentially compromise human rights and involves concerted effort and investment to reach the most vulnerable and marginalised with information and services. It also calls for expanding method choice and supporting effective client counseling to protect clients' free and informed decisions, as well as rights literacy training for providers, supervisors, and community members, along with community engagement.

While an RBA covers quality of care, the inverse is not true, as outlined in this paper. Examples of where the narrow focus on quality fails to address the larger issues of human rights in healthcare include:

• "With a narrow quality focus, the voice and participation of clients and potential clients are often absent in both the planning of new services and the evaluation of existing efforts;
• When the focus is on the medical safety of clients served with little or no attention to the profile of who is and is not being served, the issue of equity is often overlooked. Focusing on quality for clients who avail themselves of services does not protect the rights of those who do not have access to services;
• Quality of services does not address the policy environment in which those services are provided, which could limit method choice and/or create provider bias that compromises clients' full, free and informed choice.
• Access to quality FP services does not in itself redress the problems of gender inequality and lead to women's empowerment; and
• The themes of governance and accountability are poorly understood and often addressed haphazardly at the health systems level. Both are rarely found in the analysis of quality of care, but are necessary for sustainable solutions to shortfalls in quality and for programs that seek to protect and fulfill the rights of all clients and potential clients."

The good news, according to the paper, is that applying an RBA to FP programmes does not require totally overhauling programming; existing efforts to ensure informed and voluntary FP, quality of care and method choice, and efforts to expand access, to serve youth, and to promote gender equality contribute significantly to rights-based FP. For example, participants in a field test of the "Users' Guide for the Voluntary, Rights-based Family Planning Framework" in Kampala, Uganda, in 2014, recognised that the progressive realisation of human rights can be advanced by modifying existing FP programme activities and practices even within existing resources such as by:

• Sharing information about an RBA with colleagues and implementing partners in working group and coordinating committee meetings;
• Adding human rights to the agenda of routine meetings of all FP fora, including District Health Officer meetings;
• Incorporating human rights and health personnel responsibilities into all capacity building, supervision, monitoring, and quality assurance activities;
• Making respect for and protection and fulfillment of clients' human rights an explicit performance expectation and building these behaviours into motivation mechanisms; and
• Reviewing all policies, strategies, guidelines and training materials to identify needs for revision to align them with rights-based principles.

In its conclusion, this paper argues in favour of adopting the broader construct of rights-based programming as a foundation for FP programmes. "It is worth noting that the health and rights communities have traditionally worked on parallel tracks and at times have been at odds with one another, particularly over FP policies and practices that impinge on individual autonomy, equity, free and informed choice, method options, and quality FP information and services....While the goal of the public health system is to achieve the greatest good (i.e. the best quality health outcomes and status) for the greatest number, a rights-based approach focuses on individual dignity, entitlements, and empowerment. Yet the public health approach and the rights approach need not stand in opposition to one another. They share common ground and are actually complementary, rather than contradictory."

What is envisioned is a movement toward thinking in terms of clients, rather than systems, services, or methods, by making people's dignity and needs central to efforts and by engaging clients in programme planning, implementation, and evaluation. In short: "The shift toward rights-based FP programming needs to be bolstered by the systematic application and evaluation of a RBA, plus documentation and dissemination of its results, as priorities on the global research agenda." Should that shift be successful, "[w]e would have reason to expect greater community trust in the healthcare system, increased client satisfaction and use of services, and improved program sustainability." Furthermore, it is argued that there is a strong ethical and legal rationale for taking an explicit and comprehensive RBA. As outlined here, with some modification, the widely accepted Bruce quality framework, which has guided international FP for 25 years could continue to serve us well going forward, provided that we "position quality in the broader human rights context and adopt a full rights-based approach to programs, which orients planning, implementation, monitoring and evaluation in terms of clients, rather than systems, services or providers."

Editor's note: Potentially of interest is this paper, also prepared as part of the Measuring and Monitoring Quality of Services and Quality of Care project: Measuring Quality of Care: A Review of Previously Used Methodologies and Indicators [PDF], by Katherine Tumlinson, March 2016.