Patients involved in their own care who feel heard have better health outcomes. This research-supported fact represents a broader shift in healthcare philosophy away from paternalistic models that see patients as a body with a particular condition or disease towards now paying attention to the sentient person behind the condition. This wider shift has been reflected in the family planning field as trained and competent providers work to support individuals to interpret and understand their needs and experiences (Sudhinaraset et al., 2018). In this introduction, we trace how ideas about valuing and giving voice to those using services have evolved, drawing on the manuscripts published in Studies in Family Planning. We reflect and celebrate those who initiated this approach in family planning and highlight how thinking and practice has advanced in recent years to encourage and inspire current and future scholars.
In the last thirty years, placing users at the heart of services has played an important role in family planning research, policies, and programs. The 1980s family planning programs focused more on making services available than on the experiences of individuals who used them. The emphasis of family planning programs was on reducing national birth rates and achieving national demographic goals (Jain, 1989). In the 1990s, Judith Bruce identified the neglect of service users’ experience as an important gap in services and introduced the concept of quality of care in family planning (Bruce, 1990). The emphasis on quality of care was innovative because it centered on understanding users’ experiences so family planning programs could respond to them. Initially, quality as a value by itself was not recognized, and it became necessary to demonstrate its value that positive user experiences increase the acceptance and use of contraceptive methods (see Holt et al., 2019). For example, Jain and colleagues (2019) demonstrated that women receiving higher-quality counselling were more likely to continue contraception than those who did not.
The eponymously named Bruce’s quality of care framework identified six key elements that family planning programs needed to focus on so people would have a better experience. This included: (1) technical competence of providers so that services would be safe and effective, (2) a wider choice of contraceptives so that people could decide for themselves which method they wished to use, (3) information provided which was complete and accurate for people to make an informed decision, (4) interpersonal relations so that people felt respected and heard, (5) follow-up of people to ensure that continuing care, and (6) provision of an appropriate array of services to ensure that peoples’ needs are met. Bruce’s six elements provided practical guidance for policymakers and programmers to make services more responsive to users’ experiences. For example, managers could design training curricula to teach providers how to interact with their service users and the types of information they needed to share. Through the 1990s, family planning practitioners and advocates used this framework to innovate “client-centered services” that broadly focused on improved client-provider communication and the readiness of the health system to deliver good quality services (RamaRao and Mohanam, 2004). Family planning managers in the Philippines trained providers to interact with users to identify their self-defined reproductive needs by providing them with relevant and accurate information and quality services (Costello et al., 2001). Similarly, in Pakistan, “client-centered approaches” trained providers to share information and enhance interpersonal communication to acknowledge the wider social pressures that affect users’ engagement (Sathar et al., 2005). Accompanying the piloting of interventions was a greater recognition that successful innovations needed to be scaled up to be beneficial (Simmons et al., 2002).
Quality of care is made up of several dimensions and some of which are not directly observable; this presented a measurement challenge. Along with intervention testing, researchers and program managers began to innovate in measurement methodologies so that changes in quality could be tracked. An important contribution was the Situation Analysis methodology that measured both the readiness of health facilities to provide services as well as the care provided; in other words, it can measure the extent to which health facilities have the necessary infrastructure, equipment, supplies and health personnel; the types of services provided; and the care provided and received by people. For example, findings from Situation Analyses conducted in Nigeria, Tanzania, and Zimbabwe identified factors such as lack of equipment and supplies; inadequate staffing training and poor communication, which hindered the effective functioning of health facilities (Mensch et al., 1994). Consequently, many current routine measures of quality assess facility readiness through facility surveys and audits (e.g., USAID Measure’s Quick Investigation of Quality (QIQ) and Service Provision Assessment (SPA), as well as measures of quality as reported by users through client-exit interviews and other surveys.
Assessing all dimensions of quality of care is resource-intensive and not feasible for facilities in resource-restricted settings. More recently there has been innovation in the measurement of specific domains of quality of care. For example, the Method Information Index (MII) focused on capturing the quality of contraceptive counselling based on users’ responses to three questions about the information they received during counselling – whether they had been informed about (1) methods other than what they received, (2) side effects, and (3) actions to take if they experienced side-effects (Jain et al., 2019). The MII has also been assessed if these three questions truly capture the content of the interaction. Using data from Pakistan and Uganda, Chang et al (2019) reported that the MII tends to overestimate the quality of counseling; their research documents how MII consistency can be assessed by comparing responses to additional questions (e.g., specific method the user was told about, method-specific side-effects, and specific actions to take in case of side-effects) with the method she received.
As the quality-of-care framework specific to family planning took hold, ideas about person-centered care were developing in the health sector more broadly. In 2001, the Institute of Medicine (IOM) began to emphasize the importance of person-centered approaches e.g. care that respects and responds to individual preferences, needs, and values, recognizing the growing evidence that health outcomes improve with patients’ satisfaction and involvement in their care. This suggests something more than providing accurate information during a counselling session but rather a model of shared decision-making that accounts for the whole person. Several studies have developed a person-centered approach to quality contraceptive counseling that encompasses more than just providing tailored information. This approach emphasizes understanding each individual’s unique circumstances, preferences, and reproductive goals, ensuring that counseling is respectful, nonjudgmental, and responsive to their needs. This includes: (1) Dignity and Respect (i.e., the ability for people to receive care in a respectful and caring manner); (2) Autonomy (i.e., the health system supports people, their family, and companion of choice to make informed choices, including consented care); (3) Privacy/Confidentiality; (4) Health Communication (i.e., provider clearly explains all procedures, details of treatment, and treatment options to people and the extent to which woman understand these explanations); (5) Social Support (i.e., companion of choice during care); (6) Supportive Care (i.e., timely, compassionate care); (7) Trust (i.e., the extent that people feel providers tell them the truth about their care and have confidence in their providers); and (8) Health Facility Environment (i.e., a fully enabled environment, including clean surroundings, space, etc.) (Sudhinaraset et al., 2018). Components s of person-centered care are not captured through a Situational Analysis such as people’s involvement in care, needs and preferences related to care, and the extent to which people understood the instructions they have received (Sudhinaraset et al., 2018). As such, new metrics were developed to fill this gap like the Quality of Contraceptive Counseling scale (Sudhinaraset et al 2018; Karp et al 2023; Holt et al 2019).
As part of the shift to person-centered approaches, there has been a move away from assessing facility readiness and content of information provided to users towards unpacking and interrogating what we mean when we are talking about users’ needs and preferences. We need more direct measures of access to and/or desire for contraception, for example, around people’s intention to use contraception (Boydell and Galavotti, 2022). A more person-centered approach has also uprooted the field’s grounding in ideas about fertility intention. A growing literature asks people about their contraceptive preferences instead of assuming this preference is based on the highly problematic notion of fertility intentions (Mocheraud et al., 2024; Burke and Potter 2023; Cardona et al., 2024; Harrington et al., 2025). Holt et al (2023) have radically reconceptualized how we think about preferences with the idea of preference-aligned fertility management (PFM), defined as the degree to which individuals act in line with their preferences. PFM aims to directly assess whether individuals’ self-defined needs are met and importantly recognizes the desire not to use contraception as a legitimate outcome, a counterpoint to presenting contraceptive use as universally positive (Holt et al., 2023; Fabic et al., 2023).
Putting service users at the center of family planning services is not as tidy a story as portrayed here; there are overlaps, contestations, ambiguities and ambivalences. These selected papers are curated in the spirit of gratitude for the progress made in the field, acknowledging over thirty-five years of work with many ebbs and flows. Studies in Family Planning is honored to have published much vital and rigorously reviewed research on quality of care and its related topics.
Saumya RamaRao, Population Council
Victoria Boydell, University College London