By Poonam Muttreja & Dr Aparajita Gogoi
Ensuring universal access to quality health services is indeed an imperative, while designing and implementing effective sexual and reproductive health and family planning programmes. “Quality of Care” gained prominence at the International Conference on Population and Development (ICPD) in 1994. The ICPD Programme of Action emphasized the interdependence between the provision of quality of services and improved health and fertility outcomes. Respectful care is an integral part of quality, which maintains that high coverage alone is not enough to result in better outcomes and that increased coverage should be accompanied by improved quality throughout the continuum of care.
The World Health Organization (WHO) defines quality of care as “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.” Individuals wanting to exercise choice about their family size need to be assisted and enabled to make informed choices. This includes informing them clearly about all available family planning methods even if they appear to have their mind made up on a specific method. It means ensuring technical competence of health service providers and treating clients with respect. It is also about the provider-client relationship. A woman’s relationship with care providers and the health system when accessing reproductive health services, including family planning, pregnancy and childbirth, is vitally important – her experiences at a health facility may influence her future decision to avail services at that or any other facility.
In 2016, the landmark verdict in the Devika Biswas versus Union of India case was a significant move in advancing quality of care in family planning service provision and women’s reproductive rights in the last several decades. It took cognisance of the “The Robbed of Choice and Dignity” report of the multiorganizational fact-finding mission led by Population Foundation of India (PFI) on the tragic deaths of 16 women in a botched sterilisation camp in Bilaspur in Chhattisgarh in 2014. It made specific recommendations to the government to improve the quality of services being provided under the family planning programme. However, just last month when the Chhattisgarh health department reportedly carried out tubectomy surgeries on 101 women within 7-8 hours, it was like revisiting that dreadful situation from seven years ago. What makes things worse is that the most affected are nearly always the most vulnerable. Tribal women were those affected in both the cases.
The truth, as tragedies in Chhattisgarh have drummed home, is that quality of care standards in family planning and reproductive health services need to be far more strongly implemented. Research by the Centre for Catalyzing Change and the White Ribbon Alliance India found that mistreatment of women while availing reproductive health services is not exclusive to high load facilities. This finding counters the claim that high patient load and poor infrastructure leads to disrespect and abuse. Evidence shows that disrespect and abuse are often “normalized” in the healthcare system. This is further exacerbated by a lack of awareness of patients’ rights, gender sensitivity, clinical empathy skills and a humane attitude among providers. Surprisingly, clients availing of services often consider this disrespect routine in exchange for availing services. Not surprisingly, this mistreatment is closely linked to discrimination based on caste, race, tribe, ethnic group, education and/or poverty. Poor schedule caste and tribal women who usually did not avail of ante-natal care (ANC) services faced the highest disrespect and abuse in health facilities.
The stigma and shame associated with contraception and a lack of awareness on the part of women accessing family planning services, often leads clients to maintain silence if they encounter provider bias or coercion. Women are either not aware of the contraceptive options available to them or of any grievance redressal mechanisms. Grievance mechanisms, for example, being set up under the flagship SUMAN program, will help in enabling client feedback and resolution of grievances.
Improving quality of care requires investments and a systematic approach that focus on the promotion of respectful care, patient needs and satisfaction with services, sensitizing service providers, reduction of abusive and negative behaviour. It is imperative that successful responses cross sectors and include social accountability, provider training, health systems strengthening, and grassroots awareness to empower women as rights bearers.
Incorporation of respectful care into global, national, and sub-national laws, policies, quality assurance guidelines, monitoring framework, and building a robust accountability framework to oversee the implementation of these is a must to institutionalize it as a standard practice across all health services. Provision of respectful care also demands an adequate budgetary allocation.
Most importantly, women’s voices must be central to policies that advance respectful and quality care. Approaches and policies to promote it must be contextual and involve women and the community. This is no doubt, the hardest yet most sustainable way forward. Women who are informed and find themselves respected are bound to lead to healthier and happier families, enabling the achievement of all goals that India has set to meet. On World Contraception Day this year, let us commit to ensure equitable access to quality sexual and reproductive health and family planning services so that no one is left behind.
(The authors – Poonam Muttreja is Executive Director, Population Foundation of India and Dr Aparajita Gogoi is Executive Director, Centre for Catalyzing Change. The article is for informational purposes only. Please consult medical experts and health professionals before starting any therapy, medication and/or remedy. Views expressed are personal and do not reflect the official position or policy of the Financial Express Online.)