• 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

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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 organizations should consider both clients’ and providers’ needs when setting schedules for service delivery. Clients can obtain services more easily when offered convenient hours, flexible scheduling, and follow-up that ensures continuity of care (17). Providers can do their work better when given sufficient time during the day to perform responsibilities other than seeing clients—such as completing paperwork—and when given adequate breaks.

Base service hours and scheduling on both clients’ and providers’ needs. Both clients and providers benefit when service hours and scheduling take their needs into consideration. Clinic hours can inadvertently limit clients’ access (48, 78, 100). For instance, male clients can be discouraged by daytime clinic hours that conflict with their work schedules and thus force them to choose between seeking care and losing a day’s wages (119).

Clients have better access to health services when clinics announce their hours of operation and adhere to them (75). Clients also want adequate time to talk with providers. They are more satisfied and more likely to return for follow-up care when they get that time (5, 56). With adequate time, providers can encourage clients’ questions and ensure that clients understand instructions (59, 118).

Accounting for providers’ situations is as important as scheduling to meet clients’ needs. Providers may not be able to see clients during certain times of the day because they must do paperwork, or they necessarily spend less time with each client because their caseloads are too heavy (66, 67, 86). Providers may have to delay seeing clients in the morning because they are preparing for the day’s work. In such cases clinics can change their procedures—for example, scheduling service preparation activities before the clinic officially opens its doors to clients or after it closes (75).

Convey guidelines for follow-up clearly. Clinics should have an organized system in place to help clients return to the clinic as needed (see box right). Family planning providers can explain routine reasons for return, such as contraceptive resupply or a next injection, and discuss how often the client should come back. Providers also need to ensure that follow-up is appropriate to the contraceptive method and that excessive follow-up requirements do not discourage continued use. For instance, providers can give women up to a year’s supply of oral contraceptives. They do not need to return to the clinic sooner unless they have problems (125).

Telling clients when and where to return for a visit makes it clear whether follow-up care is necessary—a point that many clients may otherwise not know. Providers need to distinguish between routine care and emergency care and to explain separately the reasons to see a doctor or nurse immediately, such as signs of possible complications associated with the client’s family planning method (46). Studies find that many providers discuss the return visit and track when clients return, but that others do not do so consistently (6, 58, 75, 112).

Scheduling appointments in advance encourages clients to return for follow-up visits. Programs with community-based links can maintain relationships with clients through health workers’ home visits, rather than requiring trips to a clinic (113). Even follow-up after female sterilization or vasectomy can be handled in a home visit (46).

Make gatekeeping appropriate to the need. The provider’s role as gatekeeper often affects how and when clients receive services and even whether clients receive services at all (103). Providers are gatekeepers in the sense that they manage the client’s treatment plan. They have the authority to decide on a course of care and either to provide care themselves or to refer clients elsewhere. Providers must ensure that in their role as gate-keepers they do not impose unnecessary medical barriers to care (see Remove unnecessary barriers that hinder access to care in chapter 2.). Since clients know their own needs for such services as family planning, client preferences, not provider preferences, should guide health care decisions to the extent possible (118).

Service providers are not the only gatekeepers at a clinic. Receptionists, clinic guards, and anyone else who affects clients’ access to services are gatekeepers. Clinic guards, for example, can prevent some people seeking care from entering the clinic, while receptionists can control the order in which clients are seen. Managers can ensure that these gatekeepers make it as easy as possible for clients to obtain services. They can inform staff about the location and hours of all services offered, establish and display client check-in procedures, and require that guards keep the clinic open to all during clinic hours.

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