Front Cover
 The Falmily Panning Association...
 Resume en Francais
 Resume en Espanol
 About the authors
 Back Cover

Group Title: Quality/Calidad
Title: Using COPE to improve quality of care
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088797/00001
 Material Information
Title: Using COPE to improve quality of care the experience of the Family Planning Association of Kenya
Series Title: Quality = Calidad
Physical Description: 24 p. : ill. ; 26 cm.
Language: English
Creator: Bradley, Janet
Family Planning Association of Kenya
Population Council
Publisher: Population Council
Place of Publication: New York
Publication Date: c1998
Subject: Family Planning Services -- organization & administration -- Kenya   ( mesh )
Birth control -- Kenya   ( lcsh )
Birth control clinics -- Kenya   ( lcsh )
Genre: bibliography   ( marcgt )
non-fiction   ( marcgt )
Bibliography: Includes bibliographical references (p. 21).
Statement of Responsibility: by Janet Bradley ; introduction by Judith Bruce, Soledad Diaz, and Carlos Huezo ; afterword by Kalimi Mworia.
General Note: Summary in French and Spanish.
General Note: Caption title.
 Record Information
Bibliographic ID: UF00088797
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 39694728
lccn - 00273655
issn - 1097-8194 ;

Table of Contents
    Front Cover
        Front Cover 1
        Front Cover 2
        Page 1
        Page 2
    The Falmily Panning Association of Kenya
        Page 3
        Page 4
        Page 5
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
        Page 13
        Page 14
        Page 15
        Page 16
        Page 17
        Page 18
        Page 19
        Page 20
        Page 21
        Page 22
    Resume en Francais
        Page 23
    Resume en Espanol
        Page 24
    About the authors
        Page 25
    Back Cover
        Page 26
Full Text

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Quality/Calidad/Qualite, a publication of the Population Council, highlights examples
of family planning and reproductive health programs that are providing unusually high
quality care. This series is part of the Council's Robert H. Ebert Program on Critical
Issues in Reproductive Health which, through scientific and practical efforts, seeks to
improve and expand the scope and quality of reproductive health care. The philosophical
foundation of the program, and of this series, is that women and their partners have a
fundamental right to respectful treatment, information, choice, and follow-up from re-
productive health care providers. The pamphlets reflect one of the four main thrusts of
the program: enhancing the quality of family planning programs.
Projects are selected for documentation in the Quality/Calidad/Qualiti series by an
Advisory Group made up of individuals who have a broad range of experience within the
field of reproductive health and are committed to improving the quality of services. These
projects are making important strides in one or more of the following ways: broadening
the choice of contraceptive methods and technologies available; providing the informa-
tion clients need to make informed choices and better manage their own health care;
strengthening the quality of client/provider interaction and encouraging continued con-
tact between providers and clients; making innovative efforts to increase the management
capacity and broaden the skills of service providers at all levels; expanding the constella-
tion of services and information provided beyond those conventionally defined as "family
planning"; and reaching underserved and disadvantaged groups with reproductive health
care services.
None of the projects documented in the series is being offered as a model for repli-
cation. Rather, each is presented as an unusually creative example of values, objectives,
and implementation. These are "learning experiences" that demonstrate the self-critical
attitude required to anticipate clients' needs and find affordable means to meet them.
This reflective posture is exemplified by a willingness to respond to changes in clients'
needs as well as to the broader social and economic transformations affecting societies.
Documenting the critical choices these programs have made should help to reinforce, in
practical terms, the belief that an individual's satisfaction with reproductive health care
services is strongly related to the achievement of broader health and population goals.

Publication of this edition of Quality/Calidad/Qualite is made possible by support provided by the Ford
Foundation, the John D. and Catherine T. MacArthur Foundation, and the Rockefeller Foundation.
Statements made and views expressed in this publication are solely the responsibility of the au-
thors and not of any organization providing support for Quality/Calidad/Qualitd. Any part of this
document may be reproduced without permission of the authors so long as it is not sold for profit.
Number Nine 1998 ISSN 1097-8194 Copyright 1998 by The Population Council, Inc.

1) Population Council
The Population Council is an international, nonprofit, nongovernmental institution that seeks to im-
prove the wellbeing and reproductive health of current and future generations around the world and to
help achieve a humane, equitable, and sustainable balance between people and resources. The Council
conducts biomedical, social science, and public health research and helps build research capacities in
developing countries. Established in 1952, the Council is governed by an international board of trustees.
Its New York headquarters supports a global network of regional and country offices.
Population Council, One Dag Hammarskjold Plaza, New York, New York 10017 USA
tel: (212) 339-0500, fax: (212) 755-6052, e-mail: pubinfo@popcouncil.org, http://www.popcouncil.org

Using COPE to Improve Quality of Care:

The Experience of the

Family Planning Association of Kenya

by Janet Bradley
Introduction by Judith Bruce, Soledad Diaz,
and Carlos Huezo
Afterword by Kalimi Mworia

A Note to the Reader: This is the first of several editions of Quality/Calidad/Qualite
that will describe methodologies designed to assist family planning program managers
and staff to self-assess the quality of services they are providing. These tools give program
sponsors an opportunity to identify shortfalls in their service environment and propose
solutions. In this issue, we focus on AVSC International's COPE (client-oriented, pro-
vider-efficient) methodology, a self-assessment tool that has now been used in 35 countries
around the world.

The 1994 International Conference on Population and Development (ICPD) advocated a cli-
ent-centered approach to the delivery of services-placing individual needs at the center of all family
planning and reproductive health programs. Ultimately, the front-line providers of care are the ones
who bear the responsibility for translating the language of Cairo into action. In adopting a client-
centered approach, providers now need to be aware of their clients' social context and individual
needs, as well as being respectful of their rights and their ability to make informed decisions. How-
ever, more often than not, nothing in the training providers receive, let alone the structure within
which they work, has prepared them to operate in this fashion. Furthermore, when no one is respect-
ful of the providers' capabilities or rights, how can they be expected to relate empathetically to, and
be concerned about the rights of their clients?
Program management bears the responsibility for many of the limitations exhibited by clinic
personnel. Not only do providers receive insufficient or inadequate training and technical guidelines,
but supervisors often take a critical stance, addressing only issues of technical competence and achieve-
ment of quantitative program goals. Clinic staff are routinely excluded from contributing to the defi-
nition of policies and strategies; their opinions and concerns are rarely sought and routinely over-
looked. Yet, at the end of the day, they take the blame for shortfalls in program performance and the
resulting poor quality of care.
AVSC International's COPE methodology, and the bold and sometimes punishing applications
it has been put through by the Family Planning Association of Kenya (FPAK), provide a wonderful
example of what the process of improving care really looks like. It looks like experimentation. It looks
like recognition of past, system-wide failures-without assigning blame. And it looks like a willing-
ness to start over, to try again, and to continue moving ahead.
Although COPE may not be the only way to actively involve providers in determining how care
can be improved, it is an approach that has a demonstrated ability to move individuals and organiza-

tions in the direction of developing practical solutions to a wide range of problems. In the Kenyan
example presented here, COPE has been applied with flexibility and imagination. Top managers
have had to loosen their control of the methodology, with the result that clinic-level staff have come
to see COPE as their own tool, one that they can modify and that they can employ in order to better
serve their clients and increase their own level of job satisfaction.
COPE involves a process that legitimately invests power with providers and clinic-level staff,
and is based on the notion of clients' rights. It gives providers more control over their environment,
more scope to take initiative, and more authority over logistics such as supplies and key aspects of
finances. In sum, it allows them to make judgments and take responsibility outside of strict hierarchi-
cal boundaries. Second, it allows providers to feel a natural identification with their clients, to under-
stand their sense of powerlessness, exclusion, and frustration. Providers are sometimes clients them-
selves, and many have chosen to work in a service profession because they want to help others.
Unfortunately, to date, few management techniques have recognized or built upon this natural affin-
ity. The use of COPE has also fostered a willingness to talk openly about several former "unmention-
ables": for example, the poor levels of protection against infection found in many family planning
clinics and program emphasis on longer-term, often invasive modern methods such as the IUD,
injectables, and permanent voluntary surgical contraception, in an environment of increasing levels
of sexually transmitted infections (STIs) including HIV/AIDS.
On paper, COPE appears to be clinic-centered, thus leading to the question, how can COPE
exercises, which are conducted in individual clinics, bring about systematic change? Use of COPE is
nevertheless validating the rhetoric of ICPD, reinforcing messages that are starting to seep out across
the landscape: the importance of method choice, the importance of offering more complete informa-
tion, the importance of confidentiality and the individual's right to privacy, and the fundamental
importance of safe care. In Kenya, this process is exemplified by close cooperation between FPAK
and the Ministry of Health and the generally comfortable association between government and non-
governmental organizations in an atmosphere conducive to experimentation. (Kenya was also the
country where the first situation analysis study was carried out.) The result is that these self-assess-
ment exercises are, in fact, resulting in system-wide quality improvement. The commitment and
enthusiasm of the sponsoring organization to allow the process of change to move forward, and its
enthusiasm for the COPE process has allowed a potentially limited self-assessment exercise to be-
come a dynamic force of change affecting the entire health system. Today, quality improvement is
not only a key element in FPAK's strategic plan, but also in the 1995 National Implementation Plan
for Family Planning of the Kenyan Ministry of Health (MOH).
Ultimately, the strength of the process is a testimony to the honesty of service providers and their
capacity to become the engines of change. Long after the impact studies of quality of care are finished,
the priorities of donors have shifted, and the conclusions of international conferences are forgotten, the
enduring focal point for change will remain the providers themselves. These are people who simply
want to wake up in the morning and feel good about going to work and doing a job that they know is
useful and appreciated. Thus COPE is hitting just the right pitch in terms of mobilizing clinic staff as a
constituency for improved care and for a more humane and responsive health system.

The Family Planning Association of

The Family Planning Association of Kenya
(FPAK) began in 1961 as a group of volunteers
seeking to raise awareness about family planning
within the government and the community. That
year, FPAK became the first family planning as-
sociation in Africa to join the International
Planned Parenthood Federation (IPPF). By 1969,
FPAK opened its first model clinic and began
recruiting staff. Progress was slow: Throughout
the 1970s, the focus of activities was on educat-
ing and motivating women to use contraceptives.
By the end of the 1970s, an increasing num-
ber of women began using family planning meth-
ods and, during the 1980s, the role and coverage
of government and mission hospitals increased
substantially. FPAK was able, therefore, to diver-
sify its activities, and experiment with specific pro-
gram components such as services for youth and
for men; community-based distribution (CBD)
programs; development of information, educa-
tion, and communication (IEC) strategies; im-
provement of service quality; and expansion of
reproductive health programming. These activi-

ties, as well as the subsequent introduction of
COPE, were frequently undertaken with the sup-
port of the Kenyan Ministry of Health (MOH).
"FPAK is independent, but is seen as a sort of
arm of the Ministry of Health," says Jane Asila,
Senior Trainer in the MOH Division of Family
Health. "If we want to explore new areas, then
FPAK is always willing to pilot-test for us, to try
new things, and to evaluate new strategies."
FPAK now operates with an annual budget
of more than 300 million Kenya shillings (US$5
million) and a full-time paid staff of 250 (most of
whom support the CBD program in the field; 100
work in the clinics). FPAK has a varied program,
yet more than 50 percent of its budget is still re-
served for family planning services. The organi-
zation supports 14 reproductive health clinics that
offer family planning, Pap smear screening, preg-
nancy testing, breast examination, and screening
(including laboratory testing) and treatment of
sexually transmitted infections (STIs). In addition,
three new clinics funded under the IPPF's Vision
2000 program are offering services exclusively for
men. FPAK offers CBD services through a net-
work of over 1,000 volunteers working in 21 sites
throughout the country and manages two advice


centers for young people. A recent initiative is
the gender project through which FPAK, together
with Plan International, is developing an advo-
cacy program to address such issues as early mar-
riage and female genital mutilation. Efforts to
develop a postabortion care program within the
organization are also under way.
During the 1980s, FPAK forged an alliance
with the New York-based nongovernmental or-
ganization (NGO), AVSC International, to intro-
duce such clinical innovations as minilaparotomy
under local anesthesia. In time, FPAK became a
key clinical training center for the introduction
of new technologies, including Norplant contra-
ceptive implants. Subsequent FPAK and AVSC
evaluations of the care offered in delivery of these
new technologies, however, revealed shortfalls in
both technical and interpersonal aspects of care.
This evaluation took place during a time when
criteria for program success were beginning to
be defined in terms of what clients were actually
receiving rather than in terms of the range of tech-
nologies offered. Clearly, there was a need to train
both a wider range of practitioners and expand
the content of the training itself to include more
than technical skills.

Early Attempts At Improving Quality
of Care

"I think we first started talking about qual-
ity of care in the mid-1980s," says Godwin Mzen-
ge, Executive Director of FPAK in Nairobi. "We
had always prided ourselves on providing high-
quality services, but we realized that there were
gaps: We were not fully prepared for dealing with
the HIV epidemic and related safety concerns;
we did not have defined basic standards of care;
we didn't do enough quality counseling; clients
were waiting a long time in the clinics; we real-
ized that there were many medical barriers. We
knew we needed to do something, but what?"
One of the first attempts to improve quality
was to look at client waiting times, using a client
flow analysis (CFA) in five FPAK clinics. "We used
the Centers for Disease Control (CDC) computer
program and indeed identified waiting times as a
major problem," says Dr. Isaac Achwal, Senior Pro-
gram Manager with FPAK. "However, as we didn't
have a computer and, as the process was so com-
plex, we couldn't repeat the CFA widely and had
to abandon it. We needed something simpler that

staff could use themselves on an ongoing basis."
In 1986, FPAK organized its first quality
improvement meeting for program officers and
service providers, but the outcome was less than
encouraging. "We decided to start to look at our
problems, but all we achieved was everyone blam-
ing everyone else. The supervisors blamed the
clinics, the clinics blamed the supplies depart-
ment, the supplies department blamed the area
managers, the area managers blamed the doctors,
and the doctors blamed the nurses. Everyone had
a story about someone else and nobody had any-
thing constructive to say or understood anyone
else's constraints." The search for someone to
blame made staff defensive, and it quickly became
clear that there was a basic lack of trust among
them; people were afraid to make decisions or
take responsibility.
Other early attempts at a solution revolved
around developing guidelines and basic standards
for clinical practice, developing counseling cur-
ricula, training staff, and developing supervisory
checklists. Around this time, FPAK also devel-
oped a logo stating that "A client is always right,"
but the effort remained rhetorical and mechani-
cal. FPAK annual meetings duly focused on qual-
ity yet, despite initial enthusiasm among the staff,
no one could agree upon a definition of "quality
improvement" and no sense of collective effort
emerged. Dr. Achwal and his colleagues realized
that they needed to rethink their approach and
develop a nonthreatening framework for the dis-
cussion of problems. Dr. Achwal now recalls that
they were, in fact, "trying to legislate quality."
"The area managers (regional supervisors)
were not even invited to the annual planning
meetings at first," says Godwin Mzenge. "They
felt left out and were unsupportive of the changes
that clinic staff were trying to make. Besides, the
idea of focusing everything on the client ignored
the needs of the providers; in effect, [this focus]
continued to 'blame' the providers for the inad-
equacies of the program." This divisiveness was
inadvertently fueled by a decision to use staff from
"good" clinics to help other clinics. It was at this
point that FPAK began to realize that people were
not the problem. Rather, the problem was the
unsupportive, overly centralized and sometimes
punitive system in which they worked which cre-
ated an atmosphere in which issues could not be
frankly discussed nor could imaginative changes
be proposed.


* g


I 'i





Up until this time, FPAK's activities were
highly centralized. Literally each and every letter
sent by the organization had to pass through the
Executive Director's office. When a nurse from
any FPAK clinic applied for leave-no matter how
distant she might be from headquarters-only the
Executive Director could approve it, in consulta-
tion with the Finance Manager and the Medical
Director! All new supplies and purchases had to
be authorized by headquarters, so inevitably long
delays occurred and staff experienced much frus-
tration. "We began to realize," says Mr. Mzenge,
"that we had to let go .. Nothing would change
unless we were prepared to trust our employees
to make decisions for themselves."
On the other hand, clinic staff had never
been delegated much authority before, had never
been encouraged to assess themselves and the
quality of their services, and had never felt in-
clined to admit their mistakes for fear of retribu-
tion. Senior staff realized that delegation of re-
sponsibility for improving quality meant more
than decentralization, that it would not be fea-
sible without a parallel process of empowerment
of the clinic staff.

COPE: A Self-Assessment Technique
for Improving Family Planning

It was at about this time that AVSC Inter-
national was experimenting with a new tool called
COPE (client-oriented, provider-efficient), de-
signed to help personnel evaluate their own ser-
vices and identify ways to make improvements.
The COPE technique consists of four main com-
Self-assessment. This is primarily per-
formed with the aid of guides.' Staff use them (1)
to evaluate and define their own need for infor-
mation, training, management and supervisory
input, supplies, and a good working environment;
(2) to evaluate whether their services address their
clients' rights to information, access, method
choice, safety, privacy, confidentiality, dignity,
comfort, expression, and continuity.
Client interviews. Staff interview 10 clinic
clients, asking their opinions about services and
what suggestions they have for improvements.

1. Initially these were called checklists; they were redesigned
in 1993 and renamed guides.

Usually those interviewed are selected from
among clients waiting for services or, occasion-
ally, women are approached just before they leave
the clinic. The questions asked relate to clients'
overall impression of services at the clinic and not
just their own experience on this particular visit.
Client flow analysis. This is a method of
tracking clients during their clinic visit. It enables
providers to determine how long clients spend
waiting for services, where bottlenecks occur, and
whether staff time could be used more efficiently.
The plan of action. This is a summary of
the other three COPE assessment tools in the
form of a written plan. Developed by staff on the
last day of COPE, it lists actions to be taken to
solve identified problems, persons responsible,
and target dates for accomplishment.
Originally COPE was primarily a set of
checklists. However, over time it has evolved into
a process for change and quality improvement.
FPAK's experience using COPE, described be-
low, was an important factor contributing to that

Using COPE at FPAK: The First
Time Around

When they first heard about COPE, FPAK
staff were keen to try it out. So, between 1987
and 1990, they worked with the MOH and AVSC
to test it in a few sites. However, the early version
of COPE proved to be too focused on the tools
themselves and too centered around specific clinic
services rather than on staff or client needs. It
quickly became apparent that, to be effective, the
tools must first work to open up an ongoing dia-
logue about quality of care, to reallocate decis-
ionmaking power among staff, and to change pro-
vider attitudes toward clients. For example,
initially all COPE reports had to be sent to head-
quarters and, because everything was still going
to the Executive Director's office, the arrival of
these daunting compilations of problems caused
great consternation among FPAK management.
"Headquarters (HQ) staff wondered why clinics
were having so many problems all at once," says
Dr. Achwal. "HQ staff would write to the clinics
and demand an explanation, even send warning
letters that these issues should be resolved at once.
The so-called self-assessment exercise was clearly
being used in a punitive way."
When it became obvious that this approach

had failed, FPAK next tried using staff from one
clinic to carry out the COPE exercise in another
clinic. "This didn't work either; staff felt that they
were being spied on, divided, and used," recalls
Jane Magu, a receptionist at Phoenix House
Clinic. "We did it on the second of January. We
found so many problems. It showed us up to be
doing a terrible job, very inefficient.... We thought
this had been brought to provide evidence that
we should be sacked!"
"We felt very threatened," Alice Ngugi, a
nurse at the clinic agrees, "especially as we did it
on the second of January. We thought it very in-
auspicious-what a bad start to the year!"
Along with COPE, FPAK also introduced
supervisory checklists and client suggestion boxes.
During supervisory visits, staff and supervisors
would discuss the supervisor's findings, the COPE
results, and the clients' complaints. But no mat-
ter how hard supervisors tried to be positive, the
discussions still suggested that staff were falling
short of the mark.
"The problem was that the staff were still
seen as the problem, rather than the solution,"
says Joseph Dwyer, Africa Regional Director of
AVSC International. "A new approach had to be
developed, one which really empowered and sup-
ported rather than blamed staff, which involved

a greater understanding of the quality improve-
ment process by supervisors and HQ staff which
sought to emphasize positive rather than nega-
tive aspects, and which stressed ownership of the
quality improvement tools by the site, not the

Using COPE at FPAK: Starting Over

In 1993, FPAK and AVSC decided to start
over.2 They took to heart the comments made by
Carlos Huezo and Soledad Diaz in an article in
Advances in Contraception.3
A strategy for quality of care cannot be
realistic without recognizing that service
providers have their own needs which can
be outlined as: training, information, infra-
structure, supplies, guidance, back-up, re-
spect, encouragement, feedback, and self-
Their message was an important one. Clear-
ly staff needs were not being fully explored and
personnel were not being encouraged or sup-
ported by a facilitative supervisory structure; they
did not enjoy the best possible working environ-
ment. In other words, staff were expected to pro-
vide for clients what they did not have themselves.

By 1993, international attention began to
focus on the notion of clients' rights to quality
services. IPPF's poster defining the rights of cli-
ents was circulated widely and began to appear
on clinic walls around the world, including in
Kenya. Almost immediately FPAK staff could re-
late to these ideas in terms of their own situation.
They began to think about their clients as "cus-
tomers" who came to the clinic to be served. Ex-
plains AVSC International's Grace Wambwa:
"How could [the staff] provide information to the
clients on a new method if they themselves had
never been updated? How could we expect them
to provide safe services, decontaminate instru-
ments, and the like, if the need had never been
explained and the lotions for decontamination and
sterilization were not provided?"
As a result of this new emphasis, AVSC and
their Kenyan partners rearranged the COPE self-
assessment checklists. Formerly they had been or-
ganized functionally around different areas of ser-
vice provision; now they were reframed as 10
guides, seven devoted to clients' rights and three
devoted to provider needs. The self-assessment
guides were also made modular in form so that
they may be used selectively, their simplicity al-
lowing them to be used routinely and at low-cost.
The way COPE exercises are carried out
also changed at this point with local staff being
trained to perform the exercises themselves.
Completion of a COPE exercise requires that staff
divide into groups, each taking responsibility for
one of the guides. Each group develops a draft
action plan that is brought before the full group
for discussion.
When the tools themselves were under re-
view, AVSC found that while the client flow analy-
sis was perceived as useful, it was also considered
by staff to be time-consuming and to hold the
potential for assigning blame to individuals for the
problems that were identified. "We didn't like the
CFA at first," says Rebecca Isiche, nurse/midwife
at Eastleigh Clinic, "It was too personalized. The
exercise shows an individual service provider's
contact with clients throughout the day. What it
doesn't show is that when you were not with a
client, you were sterilizing instruments or sorting
out records, or doing other important work."
Neither did it improve the quality of the consul-
tations: "We were too concerned with rushing cli-
ents in and out so it didn't look as if they had
waited too long." Ultimately AVSC suggested that

the CFA be given less emphasis, used only when
waiting times (or other serious bottlenecks) are
perceived to be a problem. However, if a deci-
sion is made within a clinic to use the client-flow
analysis, it too has been made more user-friendly;
data can now be computed locally, as part of the
exercise, and then presented to the entire group
along with the other information.
In all likelihood, the tools of the exercise
will continue to change; supplemental guides
dealing with abortion complications, maternity
ward issues, breast examinations, Pap smears, and
reproductive tract infections are already available.
Kalimi Mworia, Associate Regional Director for
IPPF and a former Executive Director of FPAK,
sums up COPE's appropriateness: "COPE is truly
an African invention, molded by people at the
cutting edge of service delivery issues. That's why
it works." However, the process of implementing
COPE has made it clear to FPAK and AVSC that
tools alone are not enough. Without change in
attitude and a supportive system within which to
use them, the tools will be useless. Thus COPE
has evolved into a process that now includes many
other important elements.

A New Approach to Supervision

For one thing, the COPE process revealed
major problems in the way supervisors' roles were
configured. AVSC International's Joseph Dwyer
observes, "Services in Kenya were expanding at
such a rate that quality improvement and quality
assurance could not be the purview of a few su-
pervisors." Supervisors had to learn to be the
guides, the motivators, and the facilitators of the
process, not the custodians.
My role has changed, says Njagi Muchiri,
Area Managerfor Nairobi. I have more aut-
onomy than before and that has given me
more confidence to support the clinics rather
than check up on them. I used to only go to
the clinics to find faults, but now I go to
support them. My job is to make sure that
the clinics have enough supplies, to help
them maintain equipment, to troubleshoot,
to help with recordkeeping, and to train staff
on the job where I can. I feel that they like
me more in my new role and that makes my
job more rewarding.
While problems still arise as the provider/



- I
j '

; lUL




vey family planning client has the right to:

i To Icarn about the
benefits and availability of family

0 To decide freely whether
to practise family planning and
which method to use.

5 0 To have u private
environment during counselling
or services.

7 Dignity
STo be treated u ith
courtesy, consideration and

9 0 1o receive contraceptive
services and supplies for as long
us needed.

2 Access
0 10 obtain services
regardless of sex, creed, colour.
marital status or locution.

4 Safety
0O lo he abcll to practise
safe and effective family

0 To be assured that any
personal information s ill remain

0 To feel comfortable
when receiving services.

1 O TI o express viecs on the
services offered.

P..i PP F......

~s=~_';h"-f"-*'~-F-~ F:







supervisor relationship is being redefined, ulti-
mately most supervisors feel that the role of fa-
cilitator is more worthwhile and satisfying than
that of inspector.

On-the-job Training

In carrying out the COPE exercises, poor
skill levels were frequently identified as problem-
atic among providers. Up until this point, like most
institutions in Kenya, FPAK had relied upon the
use of periodic formal, centralized training pro-
grams usually held at an off-site location. But
FPAK is now convinced that in most cases on-
the-job training is a faster, more effective, and less
costly means of improving provider skills. Nzioka
Kingola, Area Manager for Nyeri, observes: "We
have realized that training is not about getting a
certificate, but about acquiring knowledge and
skills to do a job. Most of that knowledge and skill
exists right here-we just need to learn to tap it."
What has been most encouraging is the way
in which clinic staff themselves have become avid
learners and trainers as well. At FPAK's Nyeri
Clinic, the nursing staff (supported by a well-
trained supervisor) have trained each other in
contraceptive technology, including permanent
methods, and in counseling, infection prevention,
logistics management, and recordkeeping. Using
up-to-date information, they organized all the
sessions themselves and the only new cost in-
curred was for paper. At Phoenix House Clinic,
staff have oriented each other to all available fam-
ily planning methods. They take turns reading the
literature about a particular method and present-
ing their findings to the others. FPAK has facili-
tated this process by providing some training for

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staff in educational techniques and by setting up
a small library at each site.
Another benefit of this approach is that it
has broken down internal hierarchies. At Ribeiro
Clinic, the nurse in charge taught the cleaner/mes-
senger about infection prevention; she showed him
how to clean the clinic properly and to autoclave
instruments, oriented him to male family plan-
ning methods, and encouraged him to talk to cli-
ents. "I thought my job here would be just to clean
up, but now I have been given confidence to do
all sorts of jobs," says Francis Ndungu. In fact,
Francis has become so confident that he has led
some of the training sessions himself, teaching
others about infection prevention, how to use the
autoclave, and proper waste disposal. Although
incorporation of on-the-job strategies will take a
long time to be fully accepted in Kenya-more
support from the MOH (and donors) is required
so that they become nationally legitimized-
FPAK is convinced they are headed in the right

Ceding Control to the Clinics

Probably the most significant contribution
of FPAK headquarters to the whole COPE pro-
cess has been decentralized decisionmaking. Staff
can now buy equipment locally when they need
it instead of having to apply to headquarters for
permission. "I still have to account," says Ednah
Namiti, "but I'm more able to decide what the
money will be spent on. It's much better; I feel
that I'm trusted more to do the right thing."
"Decentralization was a gradual process but
staff started to work together as teams just as
headquarters learned to stop watching over
everyone's shoulders," notes Kalimi Mworia. "We
had to have the confidence to let go, to change a
whole mind-set of control and a feeling that we
in HQ were the only ones who knew anything.
We had to let them manage the process of change
themselves and not force it upon them. I never
thought we could do this in Africa, but we did."
With this shift in the locus of control, service pro-
viders not only began to feel more comfortable
with the quality-improvement strategies but also
began to feel more valued by the organization.
The data generated through use of the
COPE exercises are sensitive. Recognizing this,
one of the most important changes FPAK made
was to stop insisting that COPE reports always

come to headquarters for review. Now these find-
ings are the property of the clinic staff. Similarly,
client suggestions are now discussed by clinic staff
with their supervisor and staff have been given
more responsibility for taking action to solve the
problems they identify.
Today FPAK providers at each site conduct
quality-improvement meetings, including under-
taking a COPE exercise, every three months. They
enjoy using COPE because it belongs to them.
"Of course, some things keep appearing on our
'to do' list every quarter; for example, we keep
asking headquarters to advertise our clinic more
widely," says Rebecca Isiche, a nurse at FPAK's
Phoenix House Clinic. "That's frustrating, but you
should have seen the long list of problems we had
at first and how many we've solved!"

Now We All Work Together as a

Use of COPE encourages all staff to attend
and participate in problem-solving sessions. For
many, this is the first time they have ever commu-
nicated directly with senior staff. "Junior staff feel
very privileged and excited to be involved," says
Jane Asila of the Ministry of Health. "As we never

sat down together and discouraged the clients from
complaining, we just carried on in the same way.
Even if we thought something was wrong, we were
never encouraged to air our views," says Florence
Githera of Eastleigh Clinic. "We were losing cli-
ents and not even trying to figure out why! And
senior staff, although a little resistant at first, soon
realized that involving everyone makes their job
easier. Where staff have been difficult or uncoop-
erative in the past, they are now starting to plan
and work together. Because it's their plan and not
the bosses', things start to improve. Then they feel
able to support the process!" At Ribeiro Clinic,
staff members take turns facilitating the quarterly
COPE exercises so that they feel truly involved
and free to express themselves.
The COPE approach encourages all staff to
attend meetings; it also encourages true involve-
ment and teamwork. "The COPE approach has
changed the traditional chain of command," ex-
plains Jane Asila. A government hospital for years
had experienced water shortages that threatened
the safety of services. After a COPE exercise, the
nurses organized a walk through the town where
they collected enough funds to sink a new bore-
hole. Now they have enough water to provide safe,
clean services, and an operating theater that had

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been closed for many years has been reopened.
At Thika Clinic, teamwork has improved
noticeably. "Before we adopted this new ap-
proach, staff morale was very low, said one staff
member. "We didn't even want to see each other.
Now we have improved relations so that if, for
example, the records clerk is overloaded, other
staff come to the rescue to help out." Staff at
Eldoret Clinic were surprised at first when it was
suggested that drivers and cleaners come to staff
meetings. "No one ever asked me before what I
thought about services, and I do have ideas," says
one of the cleaners. At Nyeri Clinic, gardeners
and askaris (watchmen) are also involved and have
been given an orientation to family planning. All
staff agree this is important, because clients are
often given directions by staff working outside.
Now, even on weekends, clients can be advised
about when to come for services.
The quality-improvement process also
seems to have helped staff understand one an-
other and ultimately their clients. As staff at Phoe-
nix House Clinic report:

We realize that we need each other and that
we are all individuals with our own feelings
and behaviors that others need to under-


stand. ... We all need to help to build each
other's confidence and to be friendly to each
other. We are doing that at Phoenix House,
and it has made a tremendous difference in
the way we relate to each other and in the
way we treat clients. How can we be civil to
clients if we are not, as providers, civil to
each other?

The major areas of providers' needs, first
described by Huezo and Diaz, were grouped by
AVSC into three major categories in the self-as-
sessment guides: (1) good management and su-
pervision; (2) information, training, and develop-
ment; and (3) supplies and a good working envi-
ronment. As we have already seen, positive
changes are clearly taking place in all three cat-
egories. Similarly, clients' rights have been orga-
nized into seven major groupings: information,
access, choice, safety, privacy and confidentiality,
dignity, opinion, comfort, and continuity.

Viewing Clients as "Customers" and
Involving Them in the Process

Involving clients in the process of improv-
ing the quality of care has been an interesting and

important part of FPAK's program. At FPAK clin-
ics today, service providers talk about their de-
sire to relate better to clients, about wanting to
hear clients' views, and about creating the sort of
services clients will want to recommend to their
friends. "I think we needed to start to see the cli-
ents as our customers," says Patricia Muiko, a
nurse/midwife at the Phoenix House Clinic.
Use of COPE stimulated FPAK to review
previous efforts to seek client feedback. Under
the old scheme, suggestion boxes had been placed
in waiting areas at all the clinics. However, as Dr.
Achwal reports, "Clients weren't told about the
suggestion boxes, so we didn't get many sugges-
tions." He adds, "We also used to leave the key
with the supervisor, so that he or she, in a sense,
controlled things. The boxes would be opened
when the supervisor visited and would be used to
criticize staff."
Now, after COPE, clients are not only more
aware of their rights but also are encouraged to
comment on clinic services. A questionnaire has
been designed that offers the opportunity for
praise as well as criticism. In addition, staff mem-
bers themselves have become the "owners" of this
information; they now hold the key to the sug-
gestion box! As a result, staff are now more open
to clients' comments and more willing to make
necessary changes.
In addition to written suggestions, as part
of quarterly COPE exercises, staff conduct face-
to-face interviews with clients. Of course, the re-
sults of these interviews are often more positive
than negative because of courtesy bias, but the
exercise does serve an important purpose. "Our
clients feel accepted and treated respectfully here,
and they like being given the opportunity to speak
their minds freely," says Ednah Namiti at Phoe-
nix House. "Clients tell us that they have noticed
improvements," adds another nurse. "They say
'thank you' for safe and quick services; they com-
ment on cleanliness and fresh needles and sy-
ringes. It inspires me to greater things!"
The client's right to information. FPAK
clinics have always led the way in information,
education, and communication work in Kenya.
But in recent years, Kenyan women have started
to want more information. "They want to know
their options; they want to know about infection-
prevention practices," says a nurse in Thika. "They
come here these days asking how we sterilize our
speculums before they'll agree to a Pap smear.

We've educated them to question and to be aware,
and that's good."
The range of information provided to cli-
ents has also been widened. All FPAK clinics now
give talks on breast examination, the importance
of Pap smears, sexually transmitted infections,
HIV and AIDS, as well as the usual family plan-
ning talks. Clinics are quite well supplied with a
broad range of client leaflets and posters, although
a better requisition system for IEC (similar to that
for other equipment) needs to be in place. Many
clinics now display the dates of forthcoming talks
and they stick to the established schedule. "That
way," says Ednah Namiti, "if clients want infor-
mation on a certain topic, they can arrange which
day to come for services." Staff have also come to
realize that clients are often too shy to ask direct
questions, so staff must initiate the discussion.
The client's right to access and timely
service. Before COPE, most of the clinics were
only open during weekdays, and then only until 5
p.m., so services were not readily accessible to
working women. When staff in Nyeri interviewed
clients, they found that many were in favor of the
clinics being open on Saturday, so now they are
open six days a week, and staff have posted signs
all over town advertising the new hours. At



Ribeiro Clinic, near a transportation hub in cen-
tral Nairobi, staff now keep the clinic open week-
days until 7:00 p.m. and on Saturday mornings.
This revised schedule is not only important for
working women but also for those rural women
who want to combine a trip to the market with a
family planning visit.
COPE exercises (particularly the client-flow
analysis) also revealed that clients often had to
wait for services while staff took lunch breaks.
Therefore, at Eastleigh Clinic, staff decided to
stagger their lunches rather than stop providing
services entirely. Subsequent interviews with cli-
ents have shown that this change has been greatly
appreciated. In Eldoret, the first time the analy-
sis was conducted, it showed (to the providers'
surprise) that clients waited an average of 57 min-
utes for service. After a few months, the staff had
reduced waiting time to eight minutes-a year
later, waiting times were holding steady at about
eight and a half minutes.

At Thika Clinic, the main reason for the long
waits was that staff were never ready to begin
providing services when the clinic opened. As one
nurse explains: "The average total time clients
used to spend in our clinic was about two hours
and 22 minutes. Of this, they waited for two hours
and 10 minutes and saw staff for 12 minutes. This
was because we always started the day with clean-
ing of equipment and preparation of the rooms.
Then we took long tea breaks and all had lunch
together while the clients waited. After the COPE
exercise, we decided to clean up and get things
ready in the afternoons when most of the clients
had gone. This way we could start services at 8
a.m. We also now have shorter tea breaks and stag-
ger lunch breaks. The result is that the client's
average time in the clinic is now 35 minutes: wait-
ing for 20 minutes and consultation for 15 min-
utes." Other benefits accrue from providing ser-
vices efficiently. "Now we have time to counsel
properly and help people to choose better. We
also finish with clients earlier in the day and have
time to do staff training sessions, COPE meet-
ings, or other important tasks."
In Nyeri, clients were being kept waiting at
the reception area because the receptionist was
doing too many jobs at once: retrieving files
(which were in disarray), collecting fees, issuing
receipts, and the like. In the meantime, the nurses
assumed that no more clients were awaiting ser-
vices. During COPE exercises, the receptionist
explained her problems to her colleagues. Now
the nurses have started helping with file retrieval
and the cleaner/messenger has also been trained
to help. At Eastleigh, clients were sometimes kept
waiting just because the files were so hard to find.
So the nurses decided to sort them out. Each one
took a calendar year of records to reorganize, and
now file retrieval is no longer a bottleneck.
In most clinics clients wait even longer if
for some reason they have to get out of line.
Therefore numbered cards are now issued in or-
der to insure implementation of the first-come,
first-serve rule. "Sometimes someone goes out of
turn for some reason, say for example when they
have been waiting for the doctor ... but we make
sure that we explain this to the other clients, so
that they can see we operate a fair system," says a
clinic nurse in Nyeri.
In fact, when FPAK staff looked at their
practices, they realized that some of their proto-
cols were actually denying women services. For

example, until 1993, FPAK clinics required spou-
sal consent to perform a tubal ligation, even
though this is not required by law. Clinic staff
decided that, although spousal consent was de-
sirable, it should not be mandatory. "Just as we as
providers are being trusted to make decisions, we
have to trust our clients, too, and believe that they
will do what's right for them." As a result of
thought-provoking discussions about women's
individual rights, rules regarding the provision of
family planning services to unmarried women
were also altered.
Recently, access has also been affected by
another factor: an increase in fees. For some clin-
ics this has meant a reduction in clientele. But
the issue of fair pricing of services, like everything
else at FPAK, is open for discussion. Some staff
think that the fees are just too high even if the
quality offered is good. Staff at Nyeri Clinic, how-
ever, disagree. They found that although the num-
ber of clients did decline when the fees first went
up, after comparing the good-quality of services
at FPAK's clinic to what was being offered for free,
clients began to come back. They had soon real-
ized that so-called "free" services were, in fact,
not free at all, because clients were often asked
to provide such essentials as gloves and needles.
While most staff accept the inevitability of charg-
ing realistic fees to clients, the fee structure re-
mains an issue for further discussion.
The client's right to method choice. The
introduction of Norplant in Kenya in 1992-al-
though coincidental to the quality-improvement
process under way within FPAK clinics-has pro-
vided an important addition to the method mix
available to the Association's clients. Norplant re-
movals, however, have been an issue of frequent
discussion at quality-improvement meetings. Staff
at Eastleigh Clinic, for example, were concerned
about the high number of removals requested.
After considerable discussion, they realized that
they needed to counsel clients more thoroughly
about side effects and the long-term nature of the
method. Once they started doing this, the num-
ber of requests for removals began to decline.
Staff at Phoenix House say training has
helped them counsel clients better about all meth-
ods. They admit that they used to direct clients
to a particular method, and only formally trained
counselors could talk to women about permanent
methods. At Ribeiro Clinic, staff became aware
that they were not sympathetic to clients who

wished to switch methods, so now they make a
determined effort to acknowledge clients' rights
in this area.
The client's right to safe services. The
client's non-negotiable right to safety has been re-
inforced by intensification of infection-protection
efforts in light of the HIV/AIDS epidemic. Staff
admit that, in the past, they frequently compro-
mised their own health and that of their clients,
in part because they were not in control of the
quality-assurance process. As one nurse explains,
"We were told we had to be more careful and
prevent infection, but we were not shown how or
given the right materials."
The COPE guides emphasize that infection
prevention is everyone's concern. AVSC has pro-
vided infection-prevention charts and has helped
FPAK organize updates and orientations for all
its staff. Once staff became committed to safety,
they were quick to request heavy-duty gloves,
decontamination buckets, and sterilizing fluids.
These changes have led to better protection for
clients. "I never used to even wipe the couch be-
tween clients," admits one nurse. "Now I make
sure I have everything ready and I do it reli-
giously." Another notes that, "In the old way of
doing things, the cleaner, the very person who
needs to know about safe waste disposal, would
have been left out of any training. Now that per-
son is included, and indeed is often chosen as the
one to teach others."
Today FPAK clients are more aware of in-
fection prevention and staff encourage this aware-
ness. Alice Ngugi of Phoenix House recalls that:
"Clients used to be so poorly treated, and so they

IF 'r" W.! E 'jrI SL;.''."aC-S TELL\

mistrusted our motives as service providers. I
think it's essential to be honest with clients; they
really want to be more informed. If we're provid-
ing safe services, then why not tell them so? It
makes them feel protected and know that we care
about them. It makes them come back again, with
their friends."
The client's right to privacy and confi-
dentiality. COPE exercises explore the many di-
mensions of the client privacy issue. After COPE,
the Eastleigh Clinic was renovated so that clients
could be counseled individually rather than in the
same room with others, and most sites now rec-
ognize the importance of not interrupting coun-
seling sessions. "We really did use to walk in and
out while a client was being counseled," says one
nurse, "but we rarely do it now." Staff at Phoenix
House Clinic also think back to the days when a
woman's file was not her own. "Husbands used to
come in here asking about their wives' consulta-
tion, and we used to tell them. Now we never
would do that...We respect a woman's right to
confidentiality and, at the same time, encourage
partner involvement and support."
The client's right to continuity. One of
the principal causes of the high rates of contra-
ceptive discontinuation in Africa is the unreliable
supply of commodities and frequent stock-outs.
Before COPE, headquarters did not trust the clin-
ics to keep proper records or to order supplies on
time. This led to a tendency to "push" supplies
into the clinics, causing overstocking of some
items and wastage. But when the COPE exercise
was carried out in the Central Stores department,
the situation started to improve.

Taking COPE Up the Organizational

When COPE was first introduced in the
clinics, poor supply of equipment and commodi-
ties appeared frequently as a major problem. As
a result, FPAK decided to undertake a modified
COPE exercise within the Central Stores unit in
Nairobi. The exercise revealed that the staff there
were just as frustrated with the logistics and sup-
plies system as were clinic staff. "We told ourselves
that we were fed up being the butt of everyone's
groaning," says Central Stores' Timothy Kioko.
"We were in the middle .... Clinics were com-
plaining, headquarters was complaining, and we
couldn't see anything positive about our work. But

when it was explained to us how important our
job was and that we needed to serve our custom-
ers (the clinics) or else women would suffer, we
set to work. How can we talk of a quality service
if the goods are not delivered on time? We do
that now and play a role as quality managers."
The process of empowerment in this depart-
ment was aided by the willingness of headquar-
ters staff to listen to the constraints the supply
unit faced and realize that procedures needed to
be changed. Millicent Kabugi of Central Stores re-
calls, "We designed new requisition forms and
ledgers, agreed on minimum stock levels with the
clinics, and then went to the clinics and trained
staff on the job as to how we needed them to com-
municate with us. ... Clinics had not been plan-
ning so well, but now it's better We helped
them, they helped us, and everyone is much
In fact, staff in the Central Stores unit be-
came so empowered that they took on IPPF head-
quarters in London! "Commodities coming from
London were often close to expiry," explains
Timothy Kioko. "Well of course in the past we
just accepted it, we felt grateful for what we were
receiving and our attitude was: 'Well these people
in London are the big people, who are we to ques-
tion what they do?' But then we started to use
the COPE approach to problem-solving and re-
alized that this was something we had to tackle.
What was the point in getting these things that
we couldn't use?" The staff wrote a letter to IPPF
explaining the problem. "The most recent ship-
ment had a shelf life of five years," beams Timo-
thy. "We sorted it out."
A new supply system has already solved 85
percent of the 41 problems the Central Stores
department listed in their first COPE exercise.
They have trained clinic staff how to order in a
timely fashion, how to assess buffer stocks, and
how to use the first in, first out (FIFO) system.
(FIFO is a method of organizing commodities so
that those received first are also those used first,
reducing the chance that they will expire before
they are used.) They also helped clinics coordi-
nate supplies to better support the FPAK's CBD
agents working in the field. Rebecca Isiche of
Ribeiro explains. "COPE has encouraged us to
get to know more about the CBD program in our
area, and we now see the volunteers as part of
our team. We appreciate the fact that they bring
us clients."

-iWa n

Looking Ahead

As the FPAK experience clearly demon-
strates, quality improvement is not a one-time
exercise but an ongoing and ever-changing pro-
cess. FPAK has been working at quality improve-
ment for more than 10 years, yet only recently
has the organization begun to witness real change.
Yet the job is still not finished. For example, FPAK
headquarters still has not used COPE to assess
its own performance. Doing so would be a strong
expression of goodwill and could help HQ to sup-
port their field staff more effectively. Godwin
Mzenge, FPAK's Chief Executive, notes that it
still takes 19 steps to get a check issued at head-
quarters, so they are planning to use the COPE
approach when discussing the processes in their
Finance Department. Decentralization of finan-
cial responsibility-a bedrock issue in system-
wide reform-is still in the planning stages. How-
ever, prospects are good, especially now that clin-
ics have increased their revenue base not only due
to the new fee structure but also because of in-
creasing numbers of clients.
Staff salaries, benefits, and replacement of
costly equipment are all issues frequently raised

during COPE exercises. To date they have been
the sole purview of the central administration,
but now these issues too are open to discussion.
Some progress has already been made in identi-
fying ways to reward staff in nonmonetary ways,
through such iniatives as "employee of the
month" and "clinic of the year" recognition.
FPAK is pleased with the results of the on-the-
job training approach thus far. However, most
existing family planning training materials and
curricula have been designed for centralized,
formal training programs so available materials
need to be carefully reviewed and a reassessment
made as to how competency is measured so that
staff can receive official recognition for what they
have achieved.
Thus far, the program in Kenya has deliber-
ately emphasized problem diagnosis and the use
of extremely simple tools that focus on the way
people do their jobs. The process has clearly dem-
onstrated that, in addition to identifying a prob-
lem, its cause must also be diagnosed and an ap-
propriate solution found. To do this on an ever-
widening scale, other diagnostic tools such as op-
erations research may need to be introduced. To
this end, FPAK staff could benefit from training

in interpretation and use of the data they are al-
ready collecting in their clinics.

Sharing What Has Been Learned

Observing FPAK's success with COPE, the
MOH has now introduced COPE as part of the
national improvement plan for family planning in
22 of its hospitals, and is planning eventually to
cover all district hospitals and health centers. "We
have a big adventure ahead of us," says Jane Asila,
"because the uses of this sort of technique and
strategy are limitless. It can be used (and has been
used) to raise awareness about other issues in our
health institutions, not just family planning." In
the past two years, FPAK and the Ministry of
Health have collaborated on a number of regional
quality improvement initiatives. At the national
level, inclusion of representatives of the Kenyan
Nursing Council in quality-improvement work-
shops is resulting in increased commitment to
quality of care initiatives. Other organizations such
as the Christian Health Association of Kenya,
Family Planning Private Sector, and Marie Stopes
International have also adopted similar quality-
improvement strategies. Outside of Kenya, Dr.
Achwal has worked with family planning associa-
tions in Eritrea, Nigeria, Tanzania, Uganda, and
Zimbabwe, helping them to adopt similar strate-
gies for change.

What Cost Quality?

When the quality-improvement process
began, some FPAK staff felt that it would be
costly in terms of staff time and client inconve-
nience. The COPE exercise takes almost two
days to complete, but most of the exercises are
conducted while staff continue to serve clients
and, as responsibility for carrying out COPE
exercises has gradually been transferred to local
staff, supervisors now spend less time managing
the process and more time providing technical
support. Also, as staff began to see the resolu-
tion of long-standing problems in their own clin-
ics, their perceptions of "cost" changed. They
now realize that there is a price to be paid for
not improving quality: dissatisfied customers,
underutilized centers, loss of business, declin-
ing staff morale. In other words, poor-quality
services actually cost more than good-quality

Lessons Learned

1. You cannot legislate quality improve-
ment. When early attempts by management to
legislate quality failed, the experience taught both
FPAK and AVSC that quality improvement could
not simply be mandated. They learned that posi-
tive change is, in fact, a process that requires the
active participation of all staff, at all levels, within
the organization.
2. To achieve real change, management
also must be willing to change. The COPE
process has helped FPAK headquarters learn that
some authority is actually better exercised at the
local level and that junior-level staff can make im-
portant contributions to solving problems. FPAK
has, therefore, evolved from a highly centralized
organization to one where at least some financial
and management responsibility now rests with area
managers and clinic directors, and where clinic staff
have been empowered to use information and tools
themselves to improve performance.
3. Staff at all levels, not only service pro-
viders, are capable of assuming increased
levels of responsibility and contributing to
the process of change. For example, use of the
COPE process within the Central Stores depart-
ment had a significant impact on improving the
quality of services throughout the organization.
At the clinic level, active involvement of other
support staff (such as receptionists, cleaners, and
the like) has enabled these employees to contrib-
ute to the program in meaningful ways that had
never before been considered.
4. Viewing clients as "customers" and
understanding that your customers have
rights, serves to reframe the client-provider
relationship. This approach has enabled provid-
ers to see things from their clients' perspective
and to view them as "people like us." From that
perspective, keeping clients waiting while the
entire staff took a lunch break clearly was not the
right way to treat your customers. In the process,
clients are no longer seen as potential sources of
criticism but as allies in creating a more positive
work experience.
5. Improving the quality of services
does not have to mean increased costs. The
most common argument for not changing the way
services are provided is that change costs too
much. Yet a majority of the changes introduced
within FPAK through the use of COPE involve

increasing the efficiency of how existing resources
are used rather than increasing the actual invest-
ment in service delivery.
6. By involving other organizations in
the change process, the quality of services
can be affected more broadly, even to the
point of contributing to the development of
a comprehensive national strategy. FPAK's
mutually supportive relationship with the Minis-
try of Health has done more than legitimize its
work. Joint planning for quality workshops, de-
sign and testing of tools and strategies, and con-
stant communication and liaison, have meant
that a broad spectrum of reproductive health
services in Kenya are also benefiting from this
process. This changed perspective is already
apparent within the scope of national planning
to improve delivery of family planning services
in Kenya.


The author would like to thank the follow-
ing for their assistance in preparation of this is-
sue: At FPAK: Godwin Mzenge, Isaac Achwal,
Steven Mwangi, Margaret Thuo, and the staff of
the Central Stores unit, Eldoret, Phoenix House,
Thika, Nyeri, Ribeiro, and Eastleigh Clinics.
At AVSC International: Joseph Dwyer,
Grace Wambwa, Pamela Lynam, Karen Beattie,
Cynthia Steele, Beverly Ben Salem, and Ann-
Marie Walker.

For more information about COPE or other
quality improvement approaches and materi-
als developed by AVSC, contact Maj-Britt
Dohlie, at AVSC International, 79 Madison Av-
enue, NY, NY 10016 USA.


The Kenyan experience documented in this
edition of Quality/Calidad/Qualite may be
unique, but, increasingly, it is being emulated in
other parts of the region. Men and women in sub-
Saharan Africa are now taking part in a process of
transformation, and are taking control of their fer-
tility in a changing world. I am looking forward to
a future in which clients will not only participate
more actively in, but are willing to pay for what
they view as high-quality services. At a time when
donor funding is declining, the challenge of pro-
viding sustainable high-quality services is urgent
and real. As we approach the 21st century, ser-
vice providers will be called upon to provide infor-
mation and to facilitate informed decisionmaking
by women, men, and the young people they serve,
rather than simply to dispense contraceptives. As
we move toward this goal, much work remains to
be done and new challenges loom ahead.
Even though services for young people are
still viewed as challenging and controversial, we
cannot continue to turn a blind eye and a deaf
ear to their special needs in the area of sexual
and reproductive health. Young people represent
at least one of every five women and men of re-
productive age in sub-Saharan Africa today, yet
they are almost totally excluded by most service-
provision systems. The result of this neglect is
tragically expressed by the high incidence of teen-
age pregnancies, unsafe abortions, and sexually
transmitted infections, including HIV/AIDS,
among our youth.
Therefore, we must shift from the narrow
perspective of family life education to one of pro-
viding holistic and integrated sexual and repro-
ductive health programs and services for young
people. Although increasing awareness of these
needs has developed within governments and
NGOs in the region, their commitment in terms
of policies and funding is yet to be expressed. We
must address the sexual and reproductive needs
of young people honestly and effectively if they
are to achieve their full potential as individuals
and as tomorrow's citizens.
We must also address the medical and legal
barriers that limit access to services and bring
about an end to harmful traditional practices that
prevent women and young people-especially
girls-from achieving their right to enjoy volun-
tary and safe sexual relationships. Advocacy ini-

tiatives for the elimination of female genital mu-
tilation by FPAK and other Kenyan NGOs such as
Maendeleo ya Wanawake must be strengthened
across the continent. Collaborative studies such as
Women of the World: Laws and Policies Affecting
Their Reproductive Lives carried out by the Cen-
ter for Reproductive Law and Policy (New York)
and the International Federation of Women Law-
yers (Kenya Chapter) F.I.D.A.-K in seven anglo-
phone countries (Ethiopia, Ghana, Kenya, Nige-
ria, South Africa, Tanzania, and Zimbabwe) have
been widely disseminated.5 National programs
must now use these data to remove the legal and
administrative barriers to women's access to safe
and noncoercive sexual and reproductive health.
Gender perceptions must be considered and
incorporated into our programs as well. Although
women-centered and youth-friendly services and
the affirmation of clients' rights must continue to
be central to all our strategies and innovations,
men's roles and responsibilities in sexual and re-
productive health also need to be addressed in or-
der for men to become true partners in women's
empowerment. In western Kenya, FPAK's male
project on sexual and reproductive health and the
treatment of sexually transmitted infections is one
positive step in this direction.
Finally, we need to rethink, re-examine, and
review the delivery of family planning and related
reproductive health services in the advent of the
HIV/AIDS pandemic. Certainly services for youth
offer the potential for early intervention before
risky sexual behavior has taken root. But what
about those already affected? Community-based
approaches to counseling and home-based care
will go a long way toward reducing the psycho-
logical trauma on the individuals concerned, as
well as the heavy burden the epidemic has placed
on an already strained health-care system.
The lessons learned through the COPE ex-
perience have improved tremendously the image
of the service provider within FPAK and its part-
ner organizations. Satisfied clients have spread the
word like wildfire in Kenya, and other institutions
are knocking on FPAK's door requesting training
in the use of COPE. Therefore, we need to cre-
ate a multiplier effect and extend the benefits not
only throughout Kenya, but in sub-Saharan coun-
tries as well. Today, for most clients in Africa,
quality services still remain a dream. The example
set by FPAK and its network, in partnership with
AVSC and IPPF, should be emulated in other

countries. The Kenyan example demonstrates that
achieving quality of care and building a culture
of self-evaluation and true staff involvement is
indeed affordable, attainable, and sustainable
within the African context.


2. For a summary of this approach, see Dwyer, J.
and T. Jerzowski. 1995. "Quality management
for family planning services: practical exper-
ience from Africa." AVSC Working Paper No.
7, February 1995, AVSC International, New

3. Huezo, Carlos and Soledad Diaz. 1993. "Qual-
ity of care in family planning: Clients' rights
and provider's needs, in Advances in Contra-
ception 9:129-139.
4. See IPPF, London. 1997. Medical and Service
Delivery Guidelines, 2nd edition. IPPF, Lon-
5. The Center for Reproductive Law and Policy,
Inc. and International Federation of Women
Lawyers (Kenya Chapter) F.I.D.A.-K. 1997.
Women of the World: Laws and Policies Af-
fecting Their Reproductive Lives, Anglophone
Africa. The Center for Reproductive Law and
Policy, New York.

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Resum6 en franqais

Avis au lecteur : Cette publication porte sur
l'exercice COPE (client-oriented, provider efficient, ser-
vices efficaces ax6s sur le client) de 1'AVSC International.
Le COPE est un outil d'auto-6valuation qui a 6t6 utilis6
dans 35 pays, et cette publication examine son emploi
par I'association kenyane de planification familiale
(FPAK, Family Planning Association of Kenya). I1 s'agit
de la premiere d'une s6rie d'6ditions d6crivant les
diverse m6thodes qui permettent aux programmes de
planification familiale d'6valuer la quality de leurs ser-
La FPAK, organisation affili6e a la f6d6ration
international pour la planification familiale (IPPF), gire
14 centres de sant6 au Kenya, soit 250 employs
r6mun6r6s travaillant A plein temps et un r6seau de plus
de 1 000 agents b6n6voles. An depart, la FPAK inettait
i'accent sur le d6veloppement structure et les objectifs
d6mographiques. Toutefois, an milieu des ann6es 1980,
elle a commence a d6placer son centre d'int6rft,
l'importance de l'offre de soins de quality se faisant de
plus en plus sentir. Les premieres tentatives pour
r6soudre les problkmes n'6taient pas encourageantes, car
personnel ne voulait prendre la responsabilite des
problkmes identifies.
Dans le m&me temps, I'AVSC International essayait
un novel outil d'6valuation appel6 COPE (sigle de cli-
ent-oriented, provider-efficient). La FPAK a accept
d'essayer cette nouvelle m6thode pour r6soudre les
problkmes de quality des soins. Les exercises COPE
comprennent quatre outils fondamentaux : des guides
d'auto-6valuation, des entrevues avec les clients, une
analyse de l'acheminement des clients (en vue de
determiner les d6lais d'attente) et un plan d'action r6dig6
par le personnel, en se basant sur les r6sultats des trois
autres outils d'6valuation.
II s'est cependant av6er que la premiere version
de COPE 6tait trop ax6e sur les outils et des services
particuliers des cliniques, et non pas sur le personnel ou
les besoins des clients. Par ailleurs, 6tant donn6 que les
conclusions des exercises COPE 6taient directement
transmises aux sieges, on continuait d'accuser ou de
rejeter la responsabilit6 des problbmes sur des individus.
La FPAK s'est alors rendu compete que le problem
provenait non pas des personnel, mais plut6t du systdme
dans lequel ces derniers travaillaient, A savoir un system
trop centralis6, n'encourageant pas le personnel, et le
punissant parfois. II fallait adopter une nouvelle approche
qui accorderait au personnel le pouvoir d'agir et qui le
soutiendrait, plutot que de le blamer.
LAVSC, en collaboration avec la FPAK, a done
reformul6 le COPE. La nouvelle approche insistait sur
le fait que les outils d'am6lioration de la quality devaient
&tre utilis6s par le personnel des centres et non pas par
les superviseurs. A cet effet, on a appris au personnel a
faire les exercices COPE, et les rapports n'6taient plus

envoys aux sieges. Les conclusions sont ainsi revenues
la proprikt6 du personnel des centres. Ce dernier, ne
craignant plus d'&tre reprimand, a commence A analyser
les problmes en toute liberty et 4 envisager ses propres
solutions. La FPAK lui a 6galement donn6 plus de pouvoir
concernant de nombreuses activit6s. En consequence, les
prestataires de services, qui n'avaient plus peur d'assumer
des responsabilit6s, se sont sentis plus appreci6s par
Actuellement, le personnel a tous les niveaux
assisted et participe aux exercices COPE. Certains
membres du personnel 6taient initialement surprise que
des chauffeurs, des jardiniers et le personnel de nettoyage
soient convi6s aux reunions ; ils constatent A present que
ces personnel peuvent aussi contribuer A assurer le succs
de la methode. Le personnel de nettoyage joue d6sormais
un role primordial dans le maintien d'un environnement
sterile. Les jardiniers et les gardens, pour leur part, sont
en measure de donner une orientation de base en matiare
de planification familiale aux 6ventuels clients, surtout
les homes.
En outre, la nouvelle approche COPE soutient les
droits des clients. Elle fait en sorte que les prestataires
s'identifient naturellement avec leurs clients et cherchent
a connaitre leurs reactions. "Ici, nos clients se sentent
accepts. Ils estiment qu'ils sont traits avec respect et
ils sont contents de pouvoir s'exprimer librement,"
remarque un prestataire. "Les clients nous disent qu'ils
ont constat6 des am6liorations, (cela) me pousse a fair
beaucoup plus," ajoute une infirmiere.
Au d6but, certain membres du personnel de la
FPAK pensaient que l'am6lioration de la quality des soins
cofterait cher, mais deux jours suffisent pour faire les
exercises COPE et la plupart d'entre eux peuvent ktre
effectu6s pendant que le personnel sert les clients. Ces
membres du personnel s'apergoivent maintenant que le
fait de ne pas ameliorer la quality des services entraine
de nombreuses consequences: clients insatisfaits, centres
de santo insuffisamment utilis6s, manque de clients et
personnel d6moralise.
L'experience de la FPAK relative a I'emploi de la
m6thode COPE permet de tirer certain enseignements,
notamment que : 1) le changement positif est un proces-
sus continue qui necessite la participation active de tout
le personnel a tous les niveaux ; 2) certain types de
pouvoirs sont mieux exerces par le personnel local que
par l'administration central ; 3) tous les employs, et
pas seulement les prestataires de services, peuvent
assumer plus de responsabilit6s ; 4) le fait de consider
les patients comme des clients ayant des droits pent aider
a redefinir la relation entire le client et le prestataire et 5)
en impliquant d'autres organizations dans le processus
de changement, on peut am6liorer la quality des services
sur une plus grande 6chelle et m&me contribuer a
l'Olaboration d'une strat6gie national global.

Resume en Espahol

Nota al lector: Esta edici6n de SEEDS/CALIDAD/
QUALITE esta dedicada a un m6todo de auto-evaluaci6n
denominado COPE (en base a la sigla en ingl6s de
"Orientado al Cliente, Eficaz para el Proveedor") y a la
experiencia de la Asociaci6n para la Planificaci6n Famil-
iar de Kenia (FPAK) con el mismo. COPE fue desar-
rollado por la AVSC y ha sido utilizado en 35 pauses. Esta
es la primera de varias ediciones que informarin sobre
metodologias que las asociaciones de planificaci6n famil-
iar pueden usar para evaluar la calidad de sus servicios.
FPAK, una afiliada de la IPPF, opera 14 clinicas
en Kenia con 250 empleados a tiempo complete y una
red de mis de 1.000 voluntarios. A mediados de la d6cada
de los 80, el 6nfasis que FPAK originalmente le habia
puesto al crecimiento institutional y las metas demogri-
ficas empez6 a cambiar como resultado de una creciente
conciencia sobre la importancia de la calidad en la
provision de servicios. Aunque se identificaron various
problems relatives a la calidad, los primeros intentos en
resolverlos no fueron fructiferos, dado que nadie querfa
tomar responsabilidad.
En esos moments la AVSC International estaba
realizando experiments con un m6todo de evaluaci6n
denominado COPE (orientado al client, eficaz para el
proveedor). Los dirigentes de FPAK decidieron que
estaban dispuestos a probar COPE como una manera mis
de tender a los problems de calidad. Los ejercicios COPE
tienen cuatro components: gufas para la auto-evaluaci6n,
entrevistas con clients, analisis del movimiento de clients
(para determinar los tiempos de espera), y un plan de
acci6n redactado por el personal en base a los resultados
de las tres herramientas de evaluaci6n reci6n descritas.
Las primeras versions de COPE resultaron estar
demasiado enfocadas en las herramientas y en los servicios
clinics en si-en vez de prestarle atenci6n a las
necesidades del personal y de los clients. Y dado que los
resultados del COPE eran pasados directamente a los
gerentes en la sede de FPAK, la evaluaci6n no hacia nada
por eliminar las acusaciones mutuas y la asignaci6n de
culpas entire miembros del personal. Fue entonces que
los dirigentes de FPAK se dieron cuenta que el problema
no estaba con los miembros del personal; al contrario, el
problema surgia de la falta de apoyo, la excesiva
centralizaci6n, y la tendencia punitive del sistema en que
el personal debia trabajar. Era evidence que se necesitaba
una nueva manera de practicar la auto-evaluaci6n, una
manera que reconociera y celebrara las contribuciones
de los empleados en vez de echarles la culpa.
Junto con FPAK, la AVSC empez6 a reformular el
COPE. La nueva version empez6 por enfatizar que las
herramientas para mejorar la calidad le pertenecian al
personal, no a los supervisors. El personal aprendi6 a
llevar a cabo los ejercicios COPE por su cuenta y los
resultados ya no se mandaron a la sede. Una vez que

vieron que los resultados quedaban s6lo entire ellos, los
miembros del personal dejaron de preocuparse por la
posibilidad de recibir amonestaciones y empezaron a
analizar los problems y desarrollar sus propias soluciones.
FPAK tambi6n decidi6 darle mis autoridad al personal
local en cuanto al manejo operational, lo cual hizo que
los empleados se sintieran mis capaces de asumir
responsabilidades y, como resultado, que se sintieran mis
valorados por la organizaci6n.
En la actualidad todos los niveles del personal de
FPAK participan en los ejercicios COPE. Aunque algunos
empleados al principio se sorprendieron cuando los
choferes, jardineros y trabajadores de limpieza fueron
invitados a participar, hoy se reconoce que ellos tambi6n
pueden contribuir. Los trabajadores de limpieza ahora
son los primeros en asegurar el mantenimiento de
condiciones antis6pticas, mientras que los jardineros y
choferes ahora son capaces de dar una orientaci6n bAsica
en planificaci6n familiar a clients potenciales (y
especialmente a hombres).
La nueva version del COPE tambi6n apoya los
derechos del client, al permitir que los proveedores
sientan una identificaci6n natural con sus clients y que
les pidan sus comentarios. "Nuestros clients perciben
que los aceptamos y que los tratamos con respeto, y les
gusta poder decirnos lo que piensan libremente", sefiala
un proveedor. "Los clients nos dicen que han notado
mejoras", dice una enfermera, i"eso me inspira a lograr
mis todavia"!
Al principio algunos de los empleados de FPAK
pensaron que mejorar la calidad de atenci6n serfa muy
caro, pero luego vieron que los ejercicios del COPE
requieren s61o dos dias para completar y que muchos se
pueden llevar a cabo mientras los proveedores siguen
atendiendo clients. Es mis, ahora todos entienden que
si no se mejora la calidad tambi6n se paga un precio en
clients insatisfechos, clinics que operan por debajo de
su capacidad, p6rdida de mercado, y deterioro en el inimo
del personal.
Entre las lecciones que se aprendieron en base a
la experiencia de FPAK con el COPE esthn: 1) El cambio
positive es un process de largo plazo que require la
participaci6n active de todos los niveles del personal; 2)
Hay ciertos tipos de responsabilidades que las unidades
locales pueden manejar mejor que la gerencia central; 3)
Todos los empleados, y no s6lo los profesionales, pueden
asumir mayores niveles de responsabilidad; 4) Concebir
del client en el sentido commercial, que otorga derechos
al buen servicio, puede ayudar a mejorar la relaci6n en-
tre client y proveedor; y 5) Al involucrar a otras
organizaciones en el process de cambio se puede influir
en la calidad de los servicios en una escala mayor, y hasta
se puede llegar a contribuir al desarrollo de una estrategia
national de la calidad.

About the Authors
Jan Bradley is currently a Canadian-based population health scientist, with training in health
services management, planning, and policy. From 1983 to 1996, she was based in Nairobi,
Kenya and worked as a consultant to various local and international agencies. Since the begin-
ning of 1998, she has been a Research Associate at AVSC International.
Judith Bruce is a Senior Associate in the International Programs Division of the Population
Council in New York. Soledad Diaz is Senior Scientist at the Social Service Research Unit of
the Instituto Chileno de Medicina Reproductiva in Santiago, Chile. Carlos Huezo is Medical
Director of the International Planned Parenthood Federation (IPPF), based in London.
Kalimi Mworia is the Associate Regional Director for Advocacy and Resource Mobilization
at the IPPF's Africa Regional Office in Nairobi, and the former Executive Director of the
Family Planning Association of Kenya.

Quality/Calidad/Qualite Advisory Group
lan Askew Geeta Rao Gupta Kirsten Moore Karen Stein
Karen Beattie Nicole Haberland Nancy Newton Nahid Toubia
Martha Brady Joan Haffey John Paxman Gilberte Vanintejan
George Brown Judith Helzner Julie Reich Beverly Winikoff
Judith Bruce Ann Leonard Deborah Rogow
Charlotte Gardiner Magaly Marques Jill Sheffield
Adrienne Germain Elizabeth McGrory Cynthia Steele

Cover Photo: Ann Leonard
Typography: Heidi Neurauter
Printing: Graphic Impressions
Editorial and Production
Coordination: diane rubino

Quality/Calidad/Qualite Booklets Currently Available
Celebrating Mother and Child on the Fortieth Day: The Sfax Tunisia Postpartum
Program by Francine Coeytaux, Introduction and Afterword by Beverly Winikoff, 1989.
(Available in English; text in Spanish and French available in typewritten format)
Man/Hombre/Homme: Meeting Male Reproductive Health Care Needs in Latin America
by Debbie Rogow, Introduction and Afterword by Judith Bruce and Ann Leonard, 1990.
(Available in English and Spanish)
Gente Joven/Young People: A Dialogue on Sexuality with Adolescents in Mexico by
Magaly Marques, Introduction by John M. Paxman and Afterword by Judith Bruce, 1993.
(Available in English and Spanish)
The Coletivo: A Feminist Sexuality and Health Collective in Brazil by Margarita Diaz and
Debbie Rogow, Introduction by Jos6 Barzelatto, 1995. (Available in English and Portuguese)
Doing More with Less: The Marie Stopes Clinics of Sierra Leone by Nahid Toubia, Intro-
duction by Grace Eban Delano, 1995. (Available in English)
Introducing Sexuality within Family Planning: The Experience of Three HIV/STD Preven-
tion Projects from Latin America and the Caribbean by Julie Becker and Elizabeth
Leitman, Introduction by Mahmoud F Fathalla, 1997. (Available in English and Spanish)
(Each English edition contains a one-page summary in both French and Spanish.)

We invite your comments and ideas for projects that might be included in future editions
of Quality/Calidad/Qualitd. If you would like to be included on our mailing list, please
write to Quality/Calidad/Qualiti, Population Council, One Dag Hammarskjold Plaza,
New York, NY 10017 USA, or e-mail us at pubinfo@popcouncil.org

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