The right of the child to religious freedom in international law
Background and justification: Yemen is a high-fertility country with elevated levels
of maternal mortality and unmet need for family planning. The government of Yemen
conceived family planning services as an integrated part of the overall reproductive
health services. Yet despite these compelling reasons for family planning services,
and despite the unmet need, the services that do exist are often under-utilized. One
hypothesis explaining this conflict between need and practice is the poor quality of
the services that are offered. Despite the growing body of literature aimed at defining
and measuring quality of care in family planning in recent years, the literature review
reveals a number of gaps and unanswered questions. Among these are the concerns
that the dimensions of quality may be perceived and defined differently by clients
than by the researcher, the need of approach of greater depth that explores the full
range of manifested and latent dimensions of client provider interactions, their
determinants and their consequences and the question of underutilization. Moreover,
the voice and view of clients that are essential aspects in initiatives to improve the
quality of care provided by family planning programmes are often neglected. A
comprehensive acceptable approach for assessing the quality of family planning
services will help in effecting change to improve services delivery and to ensure that
limited and declining resources which are available for health services are utilized in the
most effective and efficient way.
Aims and specific objectives: The study was conducted to develop a systematic
approach for assessment of the quality of family planning services that is
appropriate for Yemen and perhaps for other Middle Eastern countries. This
approach will provide policy and decision makers in Yemen with appropriate
information to improve the quality and utilisation of the services. The study has
five specific objectives:
1. To measure the quality of family planning services provided by service
delivery points (governmental and non-governmental organizations) in Sana'a
city, according to the following six elements of quality in the Bruce-framework:
i) Choice of methods.
ii) Information given to clients.
iii) Technical competence.
iv) Interpersonal relations.
v) Follow-up and continuity mechanisms.
vi) Appropriate constellation of services.
2.To identify whether there are variations in the levels of quality of care related to
the type of service delivery points (governmental and non - governmental
organizations ).3. To study the perception of clients for the quality of care of family planning services.
4. To further develop the Bruce-framework for the assessment of quality of care of
family planning services.
5.To measure utilization of services, in relation to the type of service delivery points
(governmental and non-governmental organizations).
Methods: The study is a descriptive and cross sectional .It includes all service
delivery points (clinics) providing family planning services within the Government
and non-governmental organizations in Sana'a city. The target populations were
clients attending the service delivery points seeking family planning services during
the period of the study. Data collection instrument consisted of: in-depth interviews
with family planning clients, exit interviews with clients, direct observation of clientprovider
interaction and review and analysis of service statistic data. The exit
interview data collection instrument was designed to help in recording what happens
when a provider counsels and examines a family planning client. The observation of
client-provider interactions provided most of the information regarding how a client
is counseled, examined, and provided with a method. From the client perspective the
assessment of quality of care is a complex subject, and concurrent use of additional
data collection method is required to ensure validity. In this respect, in-depth
interviews were used concurrently with a quantitative study. The aim of in-depth
interviewing was to elicit the interviewee's perspective, rather than that imposed upon
by the researcher. Service statistic data were collected to measure the utilization of
services. Data was validated and entered using the SPSS statistical package. The
analysis includes summary statistics, frequency distribution, cross-tabulation, and
measures of associations based on the chi-square test of independence. Multivariate
analysis using logistic regression was applied to the data on client's personal
characteristics. For analysis of the in-depth interview we used content analysis.
Results: Assessment ofthe interpersonal element of quality of care raises a concern
with privacy, as clients needs for privacy is, for most of the time, not considered in
both sectors, although the NGOs give relatively more attention to this aspect. Clients
are not given a chance to express their concerns or to ask questions and most of the
time they are not told in advance about the medical examination they should undergo.
This applies to both sectors, governmental and non-governmental. For the choice of
method aspect of quality the data revealed that both sectors are performing well in
terms of providing clients their preferred method of family planning. Although there
is low information given about condom, in fact condom was also found to be the least
preferred method by clients. Information given to clients is an extremely weak
programme element in both sectors, both in terms of family planning information and
even more so in terms of STD/HIV. The findings on the quality of pelvic
examination and IUD insertion are not encouraging for both sectors. The main
concern found was aseptic procedures, particularly in the use of gloves during pelvic
examinations. STD screening at least through introductory questions on possible
symptoms is not carried out consistently. The NGO providers seem to do better at infonning their clients of the date for their next visit compared to their government
counterparts. However, not many clients are told that they can switch method if they
were not satisfied with their current method, especially within the government setting.
Clients approaching NGOs complained of long waiting hours, which was not the case
for their government counterparts. For most of the clients who responded to the indepth
interview, quality means the way of treatment they encounter. Clients perceive
that good treatment involves staff attitudes, and they also identified staff technical
competence and communication skills as prerequisite for good treatment. Themes
emerging from the analysis of the in-depth interview transcript includes, good treatment,
privacy during examination and consultation, good medical attention, effect of contraceptive
on client health, social and cultural barriers (provider bias, obedience to husband and covert
use of contraceptive), gender role (gender disparities and power imbalance between clients
and their spouses). In general clients tend to focus upon the processes of services of care, as
well as to the outcome of the services, rather than organizational structure or policy. Clients
also focus on the socio-cultural barriers, which hinder their access to quality services and to
comply with provider's recommendations. The three vantage points from which clients view
quality are; the social and cultural barriers, the service -given process itself and the outcome
of care, particularly with respect to individual knowledge and satisfaction with services.
Conclusion and Recommendation: The substantive results from the study suggest
that the quality of care being provided could be improved. The overall weakness of
the programme revolves mainly around family planning counseling, asepsis and
STD/HIV integration. The most important aspect however lies in the poor
interpersonal relations aspect of care, as client needs for privacy are not being taken
into consideration as well as their social context. Without a through understanding of
women's perceptions of family planning in specific contexts, we run the risk of
incorrectly homogenizing and universalizing women and their needs, which would
waken the effectiveness of family planning programmes.
Quality is a broad concept that no single approach adequately and fully measures.
Alone any single approach can address only a piece of the total quality picture.
Improving quality of care for clients means understanding their cultural values,
previous experiences, and perceptions of the role of the health system, and then
bringing service providers and the client's representative together to map out a
shared vision of quality.