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A Global Structural Examination of Quality and Rights


Despite significant variation in legal, economic and socio-political contexts, the following common themes emerged in all geographies:

  • Delivery of quality health services is dependent on a functional and coordinated government at the national and subnational levels.
  • The absence of an open, constructive relationship between government and civil society inhibits the ability of the health system to deliver quality services that meet community needs. It also impedes the government and health system from being accountable for ensuring reproductive health and rights.
  • The gap between written policies and implementation, as well as a lack of harmonization among legal and policy systems, hinders the provision of high-quality services. Existing policies and laws governing health services and rights are difficult to reverse or override with new frameworks.
  • Commodity stockouts, inadequately trained health care staff and unethical practices negatively impact quality of care and women’s rights.
  • The best efforts of legal, regulatory and policy frameworks to address quality and rights are easily overridden by values and social norms.
  • Youth and unmarried women are disproportionately affected by social and cultural taboos around sex and reproductive health.

The reproductive health of women and girls—particularly their ability to access modern contraception—is a critical factor for improving their lives and overall well-being. Preventing unintended pregnancies reduces maternal and infant deaths, decreases unsafe abortions and allows many adolescent girls to continue their education. Access to and use of contraception also gives women control over their sexuality and reproduction, which results in a healthy, productive life.

However, high-quality contraceptive services, information and supplies remain out of reach for 214 million women and girls around the world who want to prevent pregnancy. This reality not only paralyzes progress for women, but it also reflects a fundamental disregard of their rights. As duty-bearers, governments have a responsibility to respect, protect and fulfill the reproductive health and rights of their citizens—including provision of high-quality services and care. Yet despite rising national and international interest in expanding reproductive health access, policymakers often fail to emphasize the importance of the quality of care delivered and the rights of the women and girls receiving it.

The notion of quality is captured under the right to sexual and reproductive health services, information and education. Anchored in the needs of clients, quality of care is a multifaceted approach that adheres to high standards. These standards include, but are not limited to:

  • Access to a full choice of contraceptive methods.
  • Clear and medically accurate information, including the risks and benefits of a range of methods.
  • Availability of equipped provider(s) who are technically and culturally competent.
  • A client-provider interaction that respects informed choice, privacy and confidentiality, as well as client preferences and needs.

A woman receives high-quality care when she can choose from the full range of contraceptive options that fit her needs, and when the information she receives is accurate, appropriate and timely. This means that the clinical and other personnel she interacts with are technically competent and free of judgment. Any follow up services she needs must be available and of equal caliber.

Donors, governments and civil society have shown a renewed interest in assessing the quality of contraceptive services from the client-provider perspective. While these analyses have revealed important information about quality, they have not addressed the systemic drivers of and barriers to quality. Nor has there been an examination of the current legal, policy and regulatory spheres affecting the quality of care delivered and the rights of individuals receiving that care.

To better understand the factors influencing the quality of care and the fulfillment of women’s rights, PAI has embarked on a multiyear initiative called QUEST (Quality Upheld, Every Service, Every Time). The effort aims to strengthen the capacity of local advocates to assess and monitor the quality of family planning programs and make the case for quality and rights to be a national priority. PAI worked with partners to analyze the gaps, opportunities and challenges of providing high-quality, rights-based reproductive health care at the national and subnational levels in five countries: Democratic Republic of the Congo, with a focus on Kinshasa; Ethiopia, with a focus on Oromia; India, with focuses on Uttar Pradesh and Bihar; Myanmar, with a focus on Shan; and Pakistan, with a focus on Sindh. Unlike many of the other examinations of quality at the client and provider level, QUEST takes a unique approach by examining barriers and opportunities to improved quality and rights at the health systems, policy and governance level. While rarely integrated into considerations of quality at the client-provider level, macro-level systems’ issues can have a profound effect on a woman’s ability to exercise her rights and receive high-quality reproductive health care.

Our new report draws on the findings from landscape assessments of health systems’ legal, policy and governance frameworks conducted by partner organizations in each country between 2016 and 2017. The findings from the individual landscape assessments are supplemented with additional research conducted by PAI staff to provide context and thematic alignment among partner organizations’ findings.

Drawing on examples from the five QUEST countries, the report expands on 6 central themes and frames them through an examination of the Influencing Environment, Health System Strength and Management, as well as Values and Community Norms. Through this analysis, PAI aims to understand quality in reproductive health programs, as well as support changes in policies and health systems, correct imbalances and replicate conditions that drive quality.


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