• Summary
• Credits

1. Understanding the Concept
2. Evidence-Based Practices
3. Adaptability
4. Links with Other Services
5. Minimizing Paperwork
6. Physical Factors
7. Service Hours and Scheduling
8. Client Flow
9. Division of Labor and Job Design
10. Social Factors
11. Implementing the Concept
12. Bibliography

• INFO Project
• Order
• Online Reports
• Upcoming Reports
• POPLINE

This issue was prepared in collaboration with the Maximizing Access and Quality (MAQ) Initiative of the United States Agency for International Development's Office of Population and Reproductive Health. The MAQ Initiative supports research and evidence-based interventions to promote access and quality of reproductive health and family planning services.

Published by the INFO Project, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

Health care programs increasingly use an evidence-based approach—that is, they base guidelines, standards, and practices on scientific evidence of safety, effectiveness, and efficiency (18, 44). Adopting evidence-based procedures and practices can eliminate unnecessary barriers to care and so deliver services better (45, 104).

Use the most up-to-date interventions and approaches. Knowing and using approaches that are based on the best available evidence enable organizations to provide the most effective health care efficiently. Evidence-based guidelines—norms, standards, protocols, and practice recommendations—help health care providers make good decisions about specific aspects of care, such as diagnosing health problems or providing appropriate family planning methods (19).

The World Health Organization (WHO) has developed the Medical Eligibility Criteria, which provide guidance regarding who can safely use contraceptive methods, as well as the Selected Practice Recommendations, which provide guidance regarding how to safely and effectively use methods. This guidance is based on available evidence on the safety and use of contraceptives. It expands access to family planning services by helping ensure that people are not inappropriately denied a full choice of suitable methods. (For more information on WHO Medical Eligibility Criteria and Selected Practice Recommendations, see http://www.who.int/reproductive-health/family_planning/ index.html.) Many organizations and national programs have incorporated this guidance into their standards.

Conclusive scientific studies of efficacy and safety are not always available to justify every health care practice. Organizations can try to stay up-to-date on whatever scientifically valid guidelines are available nationally, and then modify them to suit the local context and resources. In the absence of scientific evidence, organizations should continue to base practices on experience and logical assumptions or adapt practices used elsewhere. For guidance on the best available program practices, Advance Africa provides the Best Practices Compendium —an online database of proven reproductive health and family planning service delivery practices—at http://www.advanceafrica.org/compendium/.

Avoid unproven practices, which waste time and resources, and adopt those that have an impact. Programs that replace outdated guidelines with evidence-based practices can provide services more efficiently (see box right). For instance, current antenatal care practices recommend that women with a normal pregnancy visit a clinic just four times, rather than making more frequent visits routinely. A systematic review of the available evidence has found that frequent visits are unnecessary (20). They often burden the health system and take up providers’ and clients’ time needlessly (79, 124).

Also, new recommended practices call for families to develop birth-preparedness plans—to decide before delivery who will attend the birth, where the mother will deliver, and what to do in the event of complications. The preparedness approach replaces the “risk approach” model, which identified women with high-risk pregnancies so that they could be referred to specialized care. More than 10 years of experience has shown that risk factors fail to distinguish successfully between women who will develop complications and those who will not (102).

By using evidence-based practices, managers can avoid practices that do not work well or create unnecessary costs. For instance, syndromic management of vaginal discharge has been shown to be ineffective for identifying cervical infections such as gonorrhea and chlamydia (24, 106). Syndromic management can, however, still successfully distinguish genital ulcers and, in men, causes of urethral discharge (27, 85, 120).

Remove unnecessary barriers that hinder access to care. Unnecessary medical barriers, such as examinations, standards, eligibility criteria, or practices that have no scientifically demonstrable value, can deny people access to services (8, 21, 54, 82, 104, 108, 110). They can also increase clients’ costs, waste their time, and restrict their options—for example, by needlessly limiting their choice of contraceptive methods (10).

Unnecessary barriers arise for many reasons. Service delivery guidelines that shape provider practices may be outdated. Providers may misinterpret or ignore service delivery guidelines and instead impose barriers of their own. For example, providers may impose barriers based on gender or race or impose inappropriate contraindications to use of a method such as a woman’s young age or low number of children she has (126).

A common unnecessarily restrictive practice is denying a woman access to hormonal contraceptives or the IUD if she is not menstruating (16, 76, 104, 108, 109). Providers want to be sure a woman is not already pregnant when she starts the method. Providers may not know that they can ask other questions to make reasonably sure that a woman is not pregnant. A simple checklist can reduce this common barrier (109) (see diagram at bottom of page).

In Kenya a study to test the effectiveness of the checklist found that it ruled out pregnancy for 88% of 1,800 new, nonmenstruating family planning clients. Comparing the results of the checklist with results from a commercial dipstick pregnancy test, the study found a 99% probability that a woman identified as not pregnant by the checklist is actually not pregnant (35, 109).

Often, providers deny some women access to family planning because they want to protect clients from contraceptive methods that they believe, incorrectly, cause infertility or other health problems (6). Others may be biased against specific methods because of their own experience as a user, the experiences of a few of their own or colleagues’ clients, or circulating rumors. When organizations correct misconceptions and demonstrate in practical terms how incorrect beliefs can limit clients’ choices, providers may be able to overcome such barriers (see box right).

Disclaimer: The information provided on this web site is not official U.S. Government information and does not represent the views or positions of the U.S. Agency for International Development or the U.S. Government.