With a population almost half that of the United States in an area less than 2% the size, Bangladesh relies heavily on family planning services to enable men and women to limit family size. Yet use of clinical contraceptives has been declining, in part because the quality of services is often inadequate.

As part of a Bangladeshi government initiative to address these problems, AVSC implemented a project from July 1995 to March 1997 in five thanas, or counties, in Sylhet and Jhenaidah districts. Its goal was to improve the quality of family planning services and the variety of contraceptive methods available by strengthening four components of the family planning system: planning at the local (thana) level, supervision, training, and referral services.

Approaching Quality Improvement

To get started, meetings were held with key health and family planning officials at the local, district, and national levels to orient them to local planning issues. Then AVSC engaged over 200 providers, supervisors, and support staff at all three levels in COPE, AVSC's self-assessment technique used to identify and solve problems in service-delivery settings.

Through COPE exercises, staff identified several factors hindering service quality.

Routine examinations were not being performed due to lack of laboratory facilities. Sterilization services were offered in few locations and at limited times, owing to staff vacancies and insufficient numbers of staff trained in the procedures. Norplant implant services were not available at all in the thanas.

Clients had limited access to information about clinic services, schedules, and service charges. In addition, there was no regularly scheduled pre- and post-natal counseling, no counseling arranged for male clients, and often no separate room available for counseling.

Provider supervision and training were insufficient, as was providers' knowledge about sexually transmitted infections and infection prevention procedures. Linkages between services were also lacking.

Strategies Implemented

To solve these problems, local staff developed and implemented action plans. Implementation strategies were reviewed at monthly meetings.

Training courses were attended by 183 service providers. Refresher courses were given on all contraceptive methods, counseling, and infection prevention, with comprehensive training given in sterilization, Norplant implants, and injectable contraception.

Through facilitative supervision workshops, the supervisors learned new approaches to supporting providers in improving quality.

Responding to Client and Staff Needs

Providers who participated in the COPE exercises and trainings indicated overwhelmingly that they were becoming more aware of and responsive to clients' needs and rights. They also paid greater attention to counseling, client screening, and infection prevention procedures, reporting that the clinics had become cleaner than before. And client referrals and coordination between sites increased substantially.

In addition, supervisors found that after participating in the workshops, they were better able to identify staff training needs, and their supervisory style became less directive and more helpful. They also gained a better understanding of what was expected of them, and since supervision became easier to perform, they provided it more systematically.

Rise in Service Use

During the project period, there were no dramatic changes in the mix of contraceptive methods used. However, more clients started using clinical contraceptive services than before.

Just as important, client exit interviews indicated high levels of satisfaction with the services received during the project period. Almost all clients said that the problem that had brought them to the clinic had been resolved, and all said they felt comfortable discussing the problem with the provider. The clients also believed that they had been treated well by the provider, and said they would recommend the services to friends and relatives.

Of those clients who had also received services within the past year, many noted such improvements in the clinics as the addition of partitions for client privacy, a much-needed fan, greater cleanliness, and better lighting.

Three-Year Extension

Due to the project's success, the interagency evaluation team has recommended extending it for another three years. Ultimately, it is expected that these improvements in quality will result in more individuals and couples requesting clinical contraceptive services.

Karen Landovitz is an editor and writer for AVSC International.