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Analyzing the Organizational Context for a Positive Client-Provider Interaction : A Leadership Challenge for Reproductive Health |
Efforts to improve quality of care in family planning, including efforts concerned with CPI, generally have focused on specific interventions such as training, supervision, or management improvement. There is increasing recognition, however, that sustainable quality improvement requires a more comprehensive systems approach.
The importance of using a systems model is highlighted in Townsend's description of the integrated operation of program components and their concerted effect on service quality. It is confirmed by Schuler and Hossain, who state, based on their observational research in Bangladesh: "More than counseling training, clinic staff need to hear from the institutions that employ them that they are there to serve all women equitably. This concept probably cannot be conveyed through a single training course and must be embedded in the broader vision as well as institutional policies, management systems, norms, and incentives."
Similarly, Huezo and Díaz identify the institutional structure and support that providers need in order to offer the quality services to which clients are entitled. These include training, information, infrastructure, supplies, guidance, backup, respect, encouragement, feedback, and self-expression. In an issues paper prepared for the 1994 International Conference on Population and Development, Bruce and Bongaarts point out that "while most providers want to have positive relationships with their clients, they are not always trained or rewarded for doing so." They also note that time pressure places a further limitation on providers’ ability to ensure positive CPI. Clearly, a great many organizational issues contribute to CPI quality.
A systems approach can address the full range of issues affecting CPI. This type of approach views the organization as a dynamic system, consisting of interconnected and interacting elements. As such, positive and sustainable changes in one element of the system require—and indeed create—changes in other elements. This approach also views the organization as an open system, in active exchange with its environment and influenced by such external factors as donor priorities, the political climate, and the sociocultural context of the local community.
The framework presented here uses a systems approach to assess the different organizational elements that create the context for client-provider interactions. Since the aim is to improve the context that supports good CPI, the paper focuses on the organization at the point where the interaction takes place: the local service delivery point (SDP). An SDP typically includes staff members working in a clinic setting as well as affiliated community workers who support clinic activities and meet client needs through referral, follow-up, and community education. It is understood that the SDP with its clinic and community activities is part of a larger organization, and that the organization itself is also part of a bigger picture. As such, changes at the SDP level of an organization may require changes at the community, regional, national, or even international level. The concepts outlined in this paper apply to the larger system as well as to the local service site.
A useful framework for conceptualizing an organization as a system is Marvin Weisbord’s "Six-Box Model" for organizational diagnosis. This model has been used widely and successfully in the field of organizational development. The model is applied here to the field of reproductive health. The only adaptations are to the terms used for the different boxes, or elements, of the framework; the terms used below reflect current terminology in reproductive health.
This model views the organizational context in which CPI occurs as a system, in which internal organizational elements interact with one another while influencing and being influenced by the outside environment. Balancing the internal and external factors is the great challenge to meeting clients’ needs. Successful organizations—and their clients—require skilled, dedicated leaders who can strike the right balance. Leadership is the key.
The framework can be used to assess a reproductive health organization with regard to its CPI climate. For each element of the framework, this section discusses its function within the organization, identifies the characteristics that have been found to foster positive CPI, and provides a set of guiding questions to use in the assessment. The questions can be used and adapted by the organization’s leaders (or others) to guide a process of reflection on how to improve the organizational context for CPI. Some questions may require interviews or document review, but most serve to identify areas for improvement. In addition to an overarching discussion on leadership and trends in the outside environment, the five key internal organizational elements discussed here are:
An organization’s mission serves to set the stage for all the organization’s programs, internal functioning, and external relationships. This mission statement summarizes the organization’s purpose and provides the rationale for defining goals and objectives. It usually is communicated in annual reports, personnel policies, information brochures provided to donors or community members, and other documents.
Sound CPI can be better promoted if the organization’s explicit mission is client-focused, with an emphasis on meeting individuals’ needs and empowering clients to make decisions and engage in behaviors that enhance their reproductive health. An organization with a client-focused, community-oriented mission—well understood and accepted by all staff members, clients, and the community—facilitates informed choice of family planning methods and an appropriate concern for reproductive health needs. The client-focused mission is reflected throughout the organization: in the organization’s structure, its approach to rewarding staff members, its community outreach efforts, etc.
The organization’s goals describe the concrete expectations for achieving the mission and set the framework for developing strategies, staff members, and all management systems. Goals may influence CPI either by stating clear and measurable client-centered objectives or by suggesting priorities that may support or impede positive CPI.
The questions that follow can help assess how the organization’s mission and goals directly or indirectly influence CPI.
What steps are needed to ensure that the mission and goals are stated and communicated in support of good CPI?
The organization’s structure refers to how the responsibilities, tasks, and functions are allocated among staff members. The structure serves to define the reporting relationships and the lines of authority for different levels of the staff. The structure is usually outlined in an organizational chart and in job descriptions.
CPI can be positive whether the organization’s structure is hierarchical or flat, whether it is based on functions (e.g., training, counseling, clinical services, administration, development) or projects (e.g., an adolescent project, a breastfeeding support project). What matters is that all individuals in the organization have client service as a central component of both their formal job description and their actual responsibilities. Even those whose responsibilities do not involve direct client contact (such as personnel involved in logistics management or facility maintenance) are carrying out tasks that can be defined in client-service terms. All staff members should be able to identify how their responsibilities - whether related to community-based education, performance of surgical procedures, or data entry - enhance appropriate CPI.
The benefit of broad involvement of all staff members is demonstrated through the results of a quality improvement project in Latin America. The International Planned Parenthood Federation/Western Hemisphere Region reports major system-wide impact on positive CPI in three family planning associations that trained all staff members—including drivers, sweepers, receptionists, and others—in quality improvement.
The questions that follow can help assess the ways in which the organization’s structure influences CPI.
What steps are needed to adapt the structure in support of good CPI?
The concept of relationships refers to how all levels of the staff interact with one another and how decisions are made and communicated. Many aspects of organizational relationships are determined by the organization’s structure (as described on the previous pages). Relationships serve the functions of collaboration, communication, and supervision, allowing work to be carried out toward the mission and goals. Relationships also serve to build the organizational culture. For example, relationships may help create a client-centered organization or a donor-centered organization.
Staff members who have contact with clients are often the best source of information about client needs and experiences; they should be a resource for managers and others involved in making changes to enhance CPI practices. Studies show that staff members have stronger, more positive contacts with clients when they themselves participate in decision-making and are valued by the organization.
The questions that follow can help assess the influence of organizational relationships on CPI.
What steps are needed to improve the existing relationships in support of good CPI?
Rewards serve to recognize good performance. Rewards include both financial compensation - the basis on which an organization pays its employees - and non-financial compensation, such as promotions, titles, authority, status in the community, opportunities for personal growth, and recognition of contributions. Incentives serve to motivate staff members’ performance. Incentives can include giving staff members time for consulting outside the organization, providing training aimed at improving or developing skills, recognizing excellent programming, and ensuring strong organizational support for any new initiative.
An organization may have a client-focused and community-oriented mission and goals, a structure in which all staff members are expected to address clients’ needs, and relationships that emphasize integrated services. But if the organization’s reward system does not encourage positive CPI, it is unlikely that clients will be well served. In some organizations, the reward system encourages staff members to provide contraceptive methods that yield high numbers of couple-years of protection (CYP), rather than to help clients select the method that best meets their individual needs and circumstances. In other organizations, the reward system distributes recognition equally to all providers - those who practice positive CPI as well as those who arrive late at the clinic, are rude to clients, and violate client confidentiality. In such organizations as these, staff members are unlikely to perceive any reason to improve CPI. On the other hand, if staff members are praised, given bonuses or promotions, or otherwise rewarded for being sensitive to and responding to clients’ needs, they are more likely to carry out positive CPI.
Traditionally, reward systems have targeted mid- and upper-level managers. To have an impact on CPI, rewards also need to focus on the front-line workers—those who interact directly with clients, deliver services to clients, and gather information and opinions from clients about services. Rewarding these staff members requires a fair and objective performance evaluation system.
As an example, the Government of Bangladesh makes annual awards to lower-level family planning workers (including community-based volunteers) who have made significant achievements during the year. These awards are given by the Prime Minister and receive wide media coverage. Other international organizations such as PROFAMILIA (Colombia) and PROSALUD (Bolivia) have long recognized the importance of incentives—including creative non-monetary rewards—in attracting and maintaining high-quality employees who are dedicated to client-centered programs.
The questions that follow can help assess the influence of the organization’s reward system on CPI.
What steps are needed to improve the reward system in support of good CPI?
Support functions are systems and activities that facilitate the organization’s work. Although these functions are often administrative, they not only support but also help create the organizational context for CPI. As such, it is important to ensure that they are efficient and that their standards and protocols are client-focused. The following support functions that have the most significant effect on CPI are discussed below:
The way in which service fees are structured and communicated can enhance or detract from the quality of the client-provider interaction. For example, fees may have a negative effect on client choice of method if sterilization is free of charge while pills and condoms are relatively expensive, or if the organization does not promote natural methods of family planning simply because there is no commodity to sell. Optimally, fees for service should reflect the client’s ability to pay and should not influence the client’s choice of method. Communication with the client about payment should be confidential and respectful.
What steps are needed to improve the financial systems in support of good CPI?
Logistics systems can also enhance or detract from CPI. For example, a wider range of methods carried may reflect attention to client needs, while a smaller range of methods may reflect provider preferences. An adequate range and supply of family planning methods, educational materials, and other supplies (antibiotics, disposable needles and gloves, iron tablets, etc.) should be available, dated, stored, and distributed appropriately.
From the client’s point of view, logistics systems also involve location and operation of service delivery facilities. Facilities should be located so that clients can walk or take convenient public transportation to receive services. Similarly, hours of operation should reflect clients’ needs rather than the needs of the clinic staff.
What steps are needed to improve the logistics system in support of good CPI?
A client’s path from the moment of arrival at the SDP through registration, waiting, seeing a provider, receiving supplies, and setting up a new appointment can be complicated and time-consuming. An effective client-flow process optimizes the efficiency of both the client’s and the provider’s time, minimizes waiting, and allows sufficient opportunity for interaction to meet the client’s needs.
The client-flow process should be based on client needs rather than provider convenience. Analyzing the client-flow process from the client’s perspective can provide useful information about how to accommodate the clients’ needs. For example, the SDP should ensure that there is a process to serve clients efficiently in the following cases:
What steps are needed to improve the client-flow process in support of good CPI?
Supervision involves performance evaluation, staff management, and technical assistance to staff members: all of these can be used to strengthen CPI. Supervision can be an important tool to increase staff members’ awareness and competencies in CPI. A collegial, constructive supervision style - one that emphasizes facilitation and respect for staff members’ opinions, experience, and knowledge - can serve as an effective model for providers’ interpersonal relations with clients.
To affirm the importance of CPI, performance evaluations should incorporate an assessment of how each staff member interacts with clients. There should be consequences (whether positive or corrective) associated with the evaluation findings. Supervisors should also provide constructive feedback to staff members and should coach the staff members - or arrange for CPI training - in areas needing improvement.
What steps are needed to improve supervision in support of good CPI?
Training can improve the competency of the staff at all levels to provide client-centered services. Training is more effective when the importance of CPI is woven throughout the process, starting with the training needs assessment and continuing with the training objectives, curriculum development, follow-up support, and evaluation. The focal areas to include in the training depend on the role staff members play with regard to CPI, but they may include:
CPI philosophy and skills should be incorporated into pre-service training wherever possible, in order to ensure the broad-based sustainability of CPI among health professionals. Service delivery organizations may be able to encourage pre-service training programs to incorporate CPI in their curricula in two ways: by placing a strong and visible emphasis on CPI within their own programs, and by including pre-service trainers in workshops.
CPI training may be conducted through courses for selected staff members or through the whole-site training method. It may be provided in-service or pre-service, formally or informally. In all cases, it is essential that training cover specific CPI competencies and that trainers receiving ongoing support for practicing their CPI skills in their work.
What steps are needed to improve training in support of good CPI?
Clients can benefit from written, visual, or audiovisual materials that provide accurate and appropriate information related to their reproductive health concerns. Educational materials can encourage clients to ask questions and to provide information through interactive communication with the provider. Materials can increase clients’ understanding of various family planning methods or other reproductive health issues, which in turn allows the client-provider interaction to be more focused, effective, and brief.
IEC mechanisms include training the staff in the effective use of educational materials and ensuring sufficient supplies of materials to distribute.
All staff members who engage in interpersonal communication with clients should have positive CPI skills, such as asking and listening skills. Appropriate and pre-tested IEC materials should be available to all clients so that they may be optimally prepared for the client-provider interaction.
What steps are needed to improve IEC in support of good CPI?
Evaluations of all sorts can provide useful information on the quality of client-provider interactions. Evaluations of program quality and impact should be conducted from a systems perspective, focusing on the multiple factors that affect CPI. The "Checklist for Family Planning Service Delivery, with Selected Linkages to Reproductive Health" is a tool that identifies many of the relevant issues. These issues include the appropriateness of information given to clients; the characteristics of CPI (e.g., interactive communication, minimizing social distance, showing respect for clients' rights); and client satisfaction.
Similarly, all program evaluations should include CPI indicators. A number of in-country organizations and international health agencies have developed and are testing or using indicators for CPI. In particular, several indicators in the comprehensive handbook prepared by Bertrand et al. may be helpful in assessing CPI.
What steps are needed to improve evaluation in support of good CPI?
The physical infrastructure of the SDP can enhance CPI by creating an environment that fosters privacy, confidentiality, efficiency, and client comfort. Designing the facility with the client’s privacy and comfort in mind is one way to support positive CPI. Even in low-resource settings, it is possible to provide a physical space and equipment that are conducive to positive CPI.
There should be adequate equipment for the lab and a comfortable setting for physical exams, delivery of family planning methods, and treatment of sexually transmitted diseases. Clients will feel more comfortable if there is a private place to change their clothes as well as to be examined.
What steps are needed to improve the physical infrastructure in support of good CPI?
At the center of the framework, leadership is the key element that brings together the other organizational elements. The leadership element is also responsible for recognizing and managing influences stemming from organizations, communities, or trends in the outside environment. Successful leaders are those who:
Successful leaders should recognize the importance of positive client-provider interactions for their organization. They should be committed to improving CPI in their organization, understand the interrelationships of the elements influencing CPI, and recognize the influence of the external environment. As they focus on improving CPI, leaders can ask themselves the following questions to assess the strengths, commitment, and challenges facing them personally as well as their organization:
What steps are needed to improve leadership in support of good CPI?
At present, the donor community as well as the broader reproductive health field are becoming increasingly aware of the importance of the client-provider interaction. This growing awareness stems from several factors:
These trends may significantly affect the context in which client-provider interactions take place. Possible effects include:
As these trends unfold nationally and within institutions, leaders will have to pay attention to the consequent impact on caregiving. They will have to maximize their opportunities to rethink and realign other elements to enhance positive CPI.
Finally, donors’ funding priorities are a critical means of changing CPI. Encouraging trends include the increasing number of bilateral agencies committed to a broader vision of reproductive health focused on client needs; the endorsement by important donor governments of the agreements reached at the International Conference on Population and Development and in Beijing; and increased collaboration among donors, including coordination of their policies. Trends to watch include attrition of support for some countries, regions, or programs whose efforts to improve CPI have not yet been fully institutionalized; declining levels of support may undercut CPI.
This paper has focused on identifying the many interrelated and dynamic factors that contribute to the quality of the client-provider interaction. It has shown that CPI quality is a product of the characteristics of the clients, the service providers, the organization offering the services, the donors supporting the organization, and the cultural setting—not the responsibility of providers alone. Sustainable improvements in CPI therefore require broad changes; training of service providers alone, while important, is unlikely to result in long-term change.
Such changes do not occur in a vacuum. Sustainable improvements require strong, creative leaders who can clearly articulate goals, engender shared commitment among staff members, and develop and implement practical and measurable plans that realign services and contacts to be as helpful as possible to clients. Leaders who are committed to quality of care and to meeting their clients’ needs will recognize that positive CPI needs nurturing at all levels.
Victoria Jennings, Georgetown University Medical Center
Institute for Reproductive Health
Elaine Murphy, PATH
Cynthia Steele, AVSC International
Ellen Eiseman, Pathfinder International
Sallie Craig Huber, Management Sciences for Health, FPMD Project
Ann Lion-Coleman, INTRAH, Project Prime
Sharon Rudy, INTRAH, Project Prime
Anne Wilson, PATH
This paper is a publication of the Maximizing Access and Quality (MAQ) Initiative - an initiative of the United States Agency for International Development (USAID), collaborating agencies, country partners, and other collaborators to apply state-of-the-art methods to maximize access to and the quality of family planning and other selected reproductive health services.
The development of this paper was supported by the Center for Population, Health, and Nutrition of USAID. This paper does not represent official statements of policy by USAID, or the position of the organizations represented by the authors. This MAQPaper was produced for the MAQ Initiative by the Family Planning Management Development Project of Management Sciences for Health.
