Adapting Service Delivery to Continuing Clients
Programs can adapt and improve service delivery to ensure that it responds to continuing clients. Supplying a range of contraceptive methods supported by effective logistics systems encourages continuous use of family planning. Training providers strengthens their ability to counsel and support continuing contraceptive users. Often, reorganizing clinic procedures can serve continuing clients better and more efficiently, in particular streamlining client flow—the way in which family planning clients move through clinics—and developing a good client record-keeping system that enables programs to maintain contact with continuing contraceptive users.
Offer a Continuous Supply of a Range of Methods
People are more likely to continue to use contraception when many contraceptive methods are readily available, because they have more options to meet their changing reproductive health needs. No single family planning method works for everyone, and seldom does one method suit anyone for a lifetime. If the right method is not available when needed, some clients abandon contraception altogether (84).
Experience in Bangladesh demonstrates that providing a range of methods, coupled with offering client-centered care, can dramatically improve contraceptive continuation. In the mid-1980s a program approach that offered only OCs, with condoms as a second choice, gave way to a new client-centered approach, with better trained providers and seven different contraceptive methods. In the first approach 40% of family planning clients continued to use family planning at 12 months. In contrast, in the second approach continuation was twice as high—80% of clients were still using a family planning method at 12 months (17, 20, 95).
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People are more likely to continue to use contraception when many contraceptive methods are readily available.
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Strong logistics systems help ensure continuous supply. To offer a range of contraceptives without interruption, programs need efficient logistics systems. Failure of the contraceptive supply chain leads to erratic supply or stockouts (41, 111). The effects on clients can be severe: widespread discontinuation, loss of confidence and trust in services, an increase in unintended pregnancies, and more exposure to the risk of STIs, including HIV/AIDS (23, 41, 111).
A family planning logistics management information system (LMIS) can help programs support the continuous delivery of supplies to clients (23, 31, 53, 111). After building a comprehensive LMIS, Nicaragua's national family planning program substantially improved access to contraception and increased continuation rates. Since 2001, the percentage of health facilities adequately stocked to meet client demand has risen from 8% to 94% (32, 119).
Alternative family planning methods can help fill gaps. Programs also can help meet the needs of continuing clients by including family planning methods that do not require either supplies or a medical procedure. Such alternatives include the Lactational Amenorrhea Method (LAM)1 for postpartum women, fertility awareness methods, and withdrawal (125). Particularly in countries where supplies of modern methods are scarce and stock-outs are common, these alternatives to supply and clinical methods can encourage continued contraceptive use (51, 52, 125).
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Here Now!
This new book revises and improves on its predecessor, The Essentials of Contraceptive Technology, to provide evidence-based family planning guidance developed through a global concensus process. See http://www.fphandbook.org
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Offering alternatives to modern supply or clinical methods also helps programs attract and serve more clients. Some people prefer a family planning method that they can be sure will not have side effects or potential health risks, while others avoid modern methods because of religious or cultural beliefs (38, 115).
Help Providers Respond to Individual Needs
Providers can be more effective within a continuing-client strategy when they understand how new clients differ from continuing clients and know how to counsel each client based on individual circumstances. Counseling new clients is essential for successful continued use of contraception. After providers discuss the most important aspects of a method and its proper use, they should also cover common side effects and health risks of the method and should be sure that clients are aware that they can switch methods at any time. (For more on the advice that providers can give to new clients, see Help New Clients Choose an Appropriate Contraceptive Method.)
When clients return for a follow-up visit, providers should determine whether they are satisfied with their chosen method, or whether they are having problems. If a client is having problems with a method, the provider can address the client's concerns, or suggest switching to a different method, if appropriate. (For more on how to advise clients at the return visit, see Counsel Clients Based on Their Reasons for Returning.)
Providers often require training to improve their ability to help new clients choose an appropriate method, to counsel continuing clients on problems with using their methods, and to help clients switch methods if necessary (42, 104).
Providers can benefit from expert guidance that specifies what topics to cover at clients' initial and continuing visits, including handbooks and job aids that help them identify client concerns and answer questions about contraceptive use and side effects (66, 68, 74, 104).
Training providers in counseling helps establish a positive interpersonal relationship between providers and clients. When providers treat clients as valued customers and give them good service—by listening to, understanding, and responding to their needs—their clients are more likely to be satisfied and to keep coming back (104, 117). When clients are satisfied with their treatment at a clinic, they will tell their friends and relatives about their good experience (and conversely, if they are unsatisfied they will pass along their bad experience, too).
Satisfied clients are the best word-of-mouth marketing a program can have (80, 117). In an assessment of a Norplant® program in Egypt, for example, more than half of new Norplant users received their information through word of mouth from satisfied continuing users, including relatives, friends, and neighbors (35).
Guidance tools can improve counseling. Handbooks and other reference materials can give providers access to key information, provide treatment recommendations for common side effects, and also supply answers to commonly asked questions about side effects and other health concerns. Although side effects are a major reason for discontinuation, providers often lack guidance on what to do to help clients deal with them.
The most recent evidence-based expert guidance on contraceptive methods is contained in the forthcoming handbook "Family Planning: A Global Handbook for Providers." The Global Handbook can help family planning providers assist clients in choosing a family planning method, support effective use, and solve clients' problems with contraceptive use. The Handbook also contains specific information on how to help continuing users of each contraceptive method. (For ordering information, see Table 2, Key Resources for Developing and Maintaining a Continuing-Client Strategy.)
The ACQUIRE Project has also developed a forthcoming curriculum for providers, "Counseling for Effective Family Planning Use: A Curriculum," in an effort to address discontinuation of family planning use and encourage continuation. This curriculum stresses the importance of preparing new clients for the possibility of side effects, and provides specific guidance about meeting the needs of continuing clients, whose counseling needs are often overlooked. (For ordering information, see Table 2, Key Resources for Developing and Maintaining a Continuing-Client Strategy.)
Using job aids such as flipcharts can help providers translate their knowledge and skills into positive interactions with clients and to tailor information to clients' individual situations at initial and return visits (65, 66, 74). A successful example is the "Decision-Making Tool for Family Planning Clients and Providers" (DMT), a two-sided flipchart developed by the World Health Organization (WHO) and the Johns Hopkins INFO Project to assist both clients and providers with decision-making about family planning methods. The DMT also contains a counseling section focused on continuing clients. Similarly, the Population Council has developed the Balanced Counseling Strategy, a decision tree to be used in combination with several job aids, or visual memory aids (74). (For more information on the DMT and the Balanced Counseling Strategy, see Table 2, Key Resources for Developing and Maintaining a Continuing-Client Strategy.)
Checklists can be a useful screening tool for reproductive health care providers in resource-poor settings, including physicians, pharmacists, and CBD workers. Checklists improve the quality of care by helping providers accurately screen clients for safe contraceptive use. Increasing a program's ability to provide contraceptives safely at the community level helps to overcome unnecessary medical barriers for contraceptive use (for example, requiring a visit to a medical doctor before providing supply methods) (40). Checklists also help programs offer services in rural areas with little access to clinics. (For more information on provider checklists for reproductive health services, see http://www.fhi.org/en/RH/Pubs/servdelivery/checklists/index.htm)
Organize Client Flow to Encourage Continuation
Improving client flow—that is, how clients move through a clinic—can remove obstacles such as long waits that can discourage continuing clients from returning. By developing a fast, specialized service for resupplying continuing clients who have no problems with their methods, the clinic can increase efficiency, decrease waiting times for everyone, and improve satisfaction—without adding staff or expanding clinic hours (81, 112).
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Improving client flow can remove obstacles that can discourage continuing clients from returning.
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Express lanes for continuing clients are a good way to help improve client flow. When clients come into the clinic, the receptionist can identify those who can be served quickly and separate them from others who will require more time. Providers without extensive training can resupply clients who do not have other concerns. In turn, highly trained staff members can spend more time with clients—new or continuing—who need more help. Alternatively, clinics can set up separate registration areas for new clients and continuing clients.
In smaller clinics where there are just one or two providers, having express lanes or separate registration areas can be difficult. In such cases, managing provider and clinic schedules is an alternative, in which specific days are assigned for continuing clients versus new clients (77).
Often, client flow can be improved by listing clinic hours clearly and informing clients when they can expect to be seen by a service provider. For example, in a family planning clinic in Peru, when clinic staff began to explain to walk-in clients who were waiting that clients with appointments received priority, more continuing clients started to make appointments rather than walking into the clinic and then having to wait (109).
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Clinics can make productive use of waiting time to refresh clients' knowledge about contraceptive options, including by displaying posters, distributing pamphlets and giving informational talks in the waiting room. Illustration: Rafael Avila/CCP
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Continuing clients who have problems or questions about their method and need to see a provider often will have to wait. Clinics can make productive use of the waiting time to refresh clients' knowledge about contraceptives. Clinics can give informational talks in the waiting room, display posters, distribute pamphlets, and play recorded tapes available for clients to consult while they wait (81).
Client-flow analysis can improve efficiency. A client-flow analysis can help managers assess how much time clients spend waiting compared with seeing providers and can identify the bottlenecks in client flow. Clinics can track client flow by taking a sample of clients' arrival and departure times and recording how much time was spent waiting versus meeting with clinic staff members (81, 112).
COPE® (client-oriented, provider-efficient services), a self-assessment method developed by EngenderHealth, includes a client-flow analysis tool, which can help providers examine how clients spend and staff use their time in the clinic, and then use the COPE method to determine how to improve client flow and other service delivery (36, 78).
Focus Record Keeping on Continuing Clients
A good client record-keeping system can make sure that providers have ready access to each client's medical history, clinical information, and family planning experience for every return visit. Keeping accurate records on continuing clients promotes better continuity of care for returning clients and also helps identify clients who do not return to the clinic for supplies or a follow-up visit. For clients who do not return for their regular checkups, an outreach worker can provide follow-up (82, 88).
Record-keeping forms can include: date of visit, client's name (or a number for confidentiality), essential personal information (age, address, number of children), type of client (whether new or continuing), medical history, special health considerations, reproductive intentions, contraceptive method selected, side effects experienced, reason for discontinuation if applicable and whether they switched to another method, and date scheduled for next follow-up visit (135). (For a sample record form used for initial and return visits in clinics in Kenya, see Figure 1, Visit/Revisit Card, Ministry of Health, Kenya.)
When a client returns to the clinic, the provider should be able to look at the client's record, determine what methods she has used in the past, what problems the client may have experienced, and what help (if any) she received to manage side effects. Making note of problems a client is having with her method can help the provider who sees her next time know what to follow up on. Similarly, making a note of the client's reproductive intentions can help a provider counsel a returning client on method choice.
Managers can periodically test records for accuracy and completeness, giving providers feedback (9). When providers understand how keeping careful records can identify problems and improve services, they are more likely to collect and use the data (76).
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A sample record-keeping form used in Kenya by family planning providers at initial and return visits. The form includes essential information such as medical history, contraceptive method selection, reasons for discontinuation, and date for next visit. Credit: 2007 Courtesy Kenya Ministry of Health and JHPIEGO
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