Operationalizing Client-Centered Care: A Strategic Framework and Measurement Approach to Guide Sexual and Reproductive Health Programming

BACKGROUND

The promotion of client-centered care (CCC) has long been recognized as a key objective in the delivery of quality reproductive health services.^1,2 Client-centered approaches, a form of patient-centered care, enable the delivery of human rights-based care, ensuring that all potential clients are treated with dignity and respect, that they make fully informed choices about their reproductive health, and that they are equal partners in decisions on their health care alongside health professionals. CCC in sexual and reproductive health (SRH) is both intrinsically important (all clients have the right to be treated with dignity and respect) and instrumentally important (through association with reproductive health care utilization and outcomes).³ Notably, positive SRH service experiences can lead to the successful use of contraceptives, in particular by decreasing the risk of premature method discontinuation, which leaves women at risk of unintended pregnancy.^4–10 Provision of CCC is also associated with improved staff satisfaction, motivation and well-being, which are all contributing factors to sustaining a committed health workforce.^11,12 Poor quality provision, including mistreatment by staff and concerns about privacy, can push clients to discontinue contraception or use unsafe care, which is a particular problem in the provision of abortion.¹³

In 2019, the international nongovernmental organization (NGO), MSI Reproductive Choices (MSI), set out to develop a CCC strategic framework and measurement approach with the goal of institutionalizing a culture of care within its SRH programs in low- and middle-income countries. The aim was to move beyond counseling and quality improvement interventions aimed solely at frontline providers, which generally have had mixed effects on sustained provider behavior change, and instead seek to address broader challenges including poor awareness among clients of what good client care should look like; insufficient client feedback or failure to act on it; didactic provider and supervisor training that was not sufficiently interactive; and evaluation metrics that did not support adequate accountability for all aspects of care quality, including CCC.

In this article we describe the process of developing the CCC strategic framework and a linked CCC measurement approach; a suite of tools that can support CCC strengthening; and the lessons learned on CCC operationalization. Case studies of pilot CCC training packages from Nepal and Zambia are also presented as part of the framework development, as their experiences and insights fed into the global approach (Figure 1).

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FIGURE 1

Timeline for Development and Implementation of MSI’s Client-Centered Care Framework and Metrics

Abbreviation: CCC, client-centered care.

The insights and learnings presented in this article come from different data sources. Client exit interview data used in the CCC metric received ethical approval from MSI’s independent Ethics Review Committee (MSI/ERC, 022-19A and 022-20AA). Nepal and Zambia case study data come from annual client exit interviews (ethical approval Zambia ERES, 2018-Oct-25; Nepal NHRC, 2052020P). Staff interview data from Nepal are from an unpublished process evaluation of CCC (NHRC, 2052020P; MSI/ERC 037-19).

DEVELOPMENT OF THE STRATEGIC FRAMEWORK

To develop the strategic framework and measurement approach, a rapid scoping review was undertaken using PubMed (MEDLINE and PubMed Central) and hand-searching of selected SRH organizational websites. The aim was to identify effective CCC approaches and interventions, as well as existing strategy or measurement frameworks used by other organizations. Interventions identified predominantly focused on provider communication and behavior, and these had inconsistent results in their impact on client outcomes.^14,15 Interventions with supervisors and managers were limited.¹⁶ Recent efforts to improve CCC measurement were helpful, but a focus on care processes at the client-provider interface meant they lacked an adequate framework to guide organizational or programmatic strategy.^17–22

The literature scoping and MSI’s own practical experience as an SRH care provider indicated that systemic factors were key to sustained provision of CCC. This requires attention not only to common structural challenges in the health sector (such as client load and staff turnover) but also to the organizational culture underpinning the system.^23–27 Tackling the ‘software’ of the health system and its management—factors like motivations, values, agency, commitment, and trust—is also instrumental in addressing complex behavioral and organizational change.^28,29 Poor provider motivation is often driven by poor leadership and management.^30,31 Studies also highlighted the need to minimize the burden on staff time during quality assessments; regularly evaluate quality (including clinical competence and interpersonal relations); use standardized tools; and ensure actions can be integrated into daily activities.^16,32

Using these insights, a global CCC strategy team (involving 8 specialists on client care, provider support and motivation, human resource management, clinical assessment, program management, evaluation, and digital feedback systems) worked together to conceptualize a strategic framework to guide CCC. The structure and content of the framework needed to be simple in order to make the strategy understandable and the implementation operationalizable. We also sought to ensure that the approach built on and used preexisting quality improvement tools. Concurrent country pilots of a CCC training package in Nepal and Zambia also fed into the global strategic framework and measurement approach (Box 1). The framework and measurement approach underwent several rounds of review by operational and medical programming teams throughout the organization.

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FIGURE 2

Select Client-Centered Care Indicators Before and After Training, Nepal and Zambia MSI Clinics and Outreach Services, 2018–2021

Source of data: Annual client exit interviews.

Abbreviation: CCC, client-centered care.

Following the experiences and insights gained from the Nepal and Zambia pilots, the global team opted to develop a 3-layered model that emphasized the role of the whole organization in delivering CCC. The new CCC framework is shown in Figure 3. Its structure is derived from socioecological models that recognize how outcomes and behaviors are driven by broader sociocultural, political, or economic influences. It values attributes of care that are essential to the SRH sector, including positive and empowering client experiences to support women in their rights to reproductive autonomy, as well as an organizational culture that respects total confidentiality and strives for equitable access to care, ‘leaving no one behind.’ To support cultural change within a results-driven organization, it also measures success not only by numbers of clients served but also by the client experience. Perhaps most importantly, it draws attention to the critical role of health providers, guiding programs to ensure that they are supported and cared for, as well as training in CCC competencies. Provider support is particularly critical in environments where SRH is highly stigmatized or where health workers face backlash from family and community members.³³

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FIGURE 3

MSI Strategic Framework to Guide Client-Centered Care

Abbreviation: SRH, sexual and reproductive health.

Measurement Approach

A strong measurement approach is critical to track progress in CCC efforts, to manage performance and reward success. To avoid a large reporting burden, we opted to select indicators of CCC performance rather than aiming for a comprehensive assessment of each level of the framework. Figure 4 details all the indicators and resultant CCC scoring bands. The CCC metric complements other core quality metrics used in assessment of country program performance.^34,35

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FIGURE 4

MSI Client-Centered Care Indicators and Scoring Mechanism

Abbreviations: CCC, client-centered care; CEI; client exit interview; GES, global staff engagement survey; QTA, quality technical audit.

^a The 4 CCC staff statements are: (1) I believe my team delivers a high-quality service to its clients; (2) I feel confident clients receive the support they need to choose services they feel is right for their health and well-being; (3) My team regularly discusses ways to improve the service for our clients; and (4) My colleagues show concern for the well-being of the clients we support in a caring and meaningful way.

^b Net Promoter Score is calculated from the proportion of respondents rating their likelihood to recommend at 9 or 10 out of 10, subtracting the proportion rating their likelihood at 6 or less out of 10. Measured as an integer from −100 to +100.

^c The 2 staff well-being statements are: (1) My employer cares about its staff; and (2) My employer gives me the help I need to manage my well-being effectively.

^d The 3 CCC client experience statements are: (1) I was treated with respect during my visit; (2) I understood what the provider was telling me; and (3) I found it easy to ask the provider questions.

^e Safeguarding score (1 item); privacy score (2-3 items); counseling score (about 15 items). Numbers of items for each score varies by service channel.

Note: For all scaled items, agreement scores include both ‘agree’ and ‘strongly agree’ categories.

Existing monitoring and evaluation mechanisms were reviewed and updated to ensure the collection of the necessary CCC data. Indicators were drawn from 3 preexisting quality monitoring tools: a client exit interview survey, conducted annually among a representative sample of clients and service delivery points; a quality technical audit, conducted annually in a representative sample of service delivery points; and a digital staff global engagement survey, sent to all staff. The staff engagement survey was newly introduced in 2021 and was instrumental in comprehensive measurement of CCC. While a research company was hired to run the staff survey, similar tools are publicly available.³⁶

The metric therefore relies on self-reported data from clients and providers as well as observed data from external clinical auditors. Each of these data collection processes has their own quality assurance processes to ensure the validity and reliability of the data collected.

A new global ‘Client Experience’ team helped program managers to operationalize the concepts, set goals, and track progress. The strategy was communicated to senior leadership teams across 28 countries through multiple channels including webinars, in-person presentations, and regular technical support meetings.

Each country program receives their CCC scores annually, disaggregated by service delivery channel; total country scores are weighted by client volume in each channel. Teams review their CCC score via a global dashboard (Figure 5).

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FIGURE 5

Example of MSI’s Client-Centered Care Dashboard (anonymous country)

Abbreviations: CCC, client-centered care; CEI, client exit interview; CX, client experience; QTA, quality technical audit.

Low and medium value scores trigger suggested actions (‘tips for improving your scores’) as well as links to relevant tools that can be used to improve performance over the following year (Box 2).

BOX 2

Tools and Guidance to Support Strengthening of Client-Centered Care

The following guidance and tools can be used and adapted to support CCC strengthening. Most are publicly accessible. Items with an asterisk (*) are available upon request from the corresponding authors.

Organization-wide policies and strategies:

• Code of conduct (signed by all staff, supported by online and in-person training*)

• Safeguarding guidance, including adult safeguarding policy

• Data privacy guidance* (MSI’s guidance aligns with UK General Data Protection Regulation [GDPR] standards) to ensure that client and staff data are kept fully confidential

Clinical and nonclinical training:

• Comprehensive clinical guidance, competency assessments, and audit process*

• Values Clarification and Attitude Transformation (VCAT) workshops to support positive attitudes to clients accessing SRH care and to reduce stigma

• CCC training modules* for frontline teams exploring key CCC themes and how these can be practically addressed during the delivery of health care services

• ‘Providers Share’ workshops for abortion providers to address their own stigmatizations

Client-facing materials and support:

• Client Charter – MSI’s full resource pack* includes editable posters and video, describes values of client-centered health care, and encourages client to hold the organization accountable and provide feedback

• ‘Choice Counsellor’ (digital contraception decision aid), which provides clients with information on their method options and where to seek further advice and support

• ‘Choice Kit’ (contraceptive method demonstration kit) and counseling flipcharts, which support providers to deliver client-centered contraceptive counseling

Resources for monitoring the client experience:

Feedback review and action-planning form part of the organizational culture score in the CCC framework and are emphasized in CCC training. Tools include:

• Client exit interviews provide a detailed annual overview of the profile of clients and their health care experiences

• Global client feedback toolkit supports service teams to implement simple mechanisms for collecting routine feedback from clients and helps them use and respond to this data

• Client experience checklists* empower staff and managers to put themselves in the shoes of clients and understand their full health care journey, including potential pain points, to identify areas for improvement

• Mystery client survey protocol* provides objective assessment of client experiences and client-provider interactions

In 2021, the year in which the CCC framework and metric were first introduced to countries, scores ranged from 5 to 17 out of a possible 18 points. In 2022, the second year of the strategy rollout, almost half (13/28) of countries had been able to achieve improvements in their overall program score (there was no change in 5 countries and a decrease in scores in 10 countries, with the latter driven by low staff engagement data). Improvements continued into 2023, with 19 of 28 country programs increasing their scores year-on-year (6 countries saw no change and only 3 had decreases). Common areas of improvement included the strengthening of the collection and use of client feedback and some small but positive shifts in staff engagement and well-being.

LESSONS LEARNED

FUTURE EVOLUTION OF THE APPROACH

Future work may involve iterations of the CCC metric to ensure all core attributes of care are covered. Given an increasing body of evidence on the potential for coercive practices and provider bias in contraceptive provision,^40,41 greater attention to the measurement of coercion and/or reproductive autonomy may be needed. This can be informed by recent work on measures of fully informed choice and reproductive autonomy.^42,43 Work is also needed to integrate equity measures (on poverty and disability) into the metric, while adaptation of the measure for different models of service delivery could be helpful (e.g., for community health workers). Improved measures of client confidentiality and privacy may also be helpful given their importance as a key aspect of CCC to both clients and providers. Many programs are also striving to increase client voice and participation in health service planning and improvements. This means using participatory approaches to involve clients in the co-creation of improvements to direct service delivery and exploring how health delivery organizations can support and encourage social accountability. Both approaches could be incorporated into a CCC framework.

While the Zambia and Nepal case studies in Box 1 show encouraging signs of CCC’s impacts on client outcomes, further evaluation work would also be helpful to demonstrate that the CCC strategic framework, measurement approach, and suite of tools make a meaningful difference to client experience and provider and institutional outcomes, both in the short and long term. A larger controlled study to evaluate the impact of strengthened CCC in a program with previously low performance on client experience and/or staff engagement indicators would be helpful for budgetary advocacy. Further research on the impacts on specific client groups, in particular adolescents, may also be helpful.

CONCLUSIONS

The CCC framework, measurement approach, and tools presented in this program case study are successfully supporting NGO-run SRH programs in low- and middle-income countries in their efforts to improve the quality of care provided to their clients. The simplicity of the framework and metric, linked to a range of available tools and resources, has allowed managers to identify and act on opportunities to strengthen the delivery of CCC in their contexts according to their specific needs. The widespread acceptance of the framework and positive feedback from managers and providers from a diverse range of country settings has been encouraging. This initiative complements the work of other organizations attempting to promote person-centered approaches to health care, including in the SRH health sector.^44,45 These efforts continue to be important as recent evidence documents encroachments on or violations of human rights within reproductive health programs across a range of country contexts, including low-, middle-, and high-income settings.^40,46–51

A frequently asked question is whether CCC is feasible within busy health programs, where providers are rushed off their feet and face overwhelming demands from clients. Experience from MSI services, on the whole, shows that it is possible to be client-centered within a busy service environment. Being respectful and kind to clients does not necessarily require more time—rather, it necessitates a culture in which the provider feels equally cared for and respected by their employer. Engendering this culture of care does not necessarily mean having to pay providers more (though this may be helpful!), but it does involve good management practice in which providers feel rewarded and recognized for their work. This, in turn, needs to be supported by an institutional culture that places the client experience (and in the SRH sector, the fulfillment of human rights) at the core of their organization. Further effort is now needed to support all health programs (public, private, nonprofit, faith-based) to foster such supportive management practices in order to grow a culture of care in their organizations.