A shift to client-centred service positions human needs as the central focus of FP.  This has engendered development of strategies such as informed choice, quality service, new alternative systems and diversified services in RH and FP.

The reorientation is reflected in various activities.  Public education and legislation aim at protecting rights of women and children.  A project providing soft loans to more than 30,000 poor mothers supports further, women and children.  Men's participation in FP is now also encouraged, and adolescents are taught sex education through various in-school activities.  A few organisations issue awards to encourage intensive reporting on population issues and heighten public awareness.

Population NGOs have also expanded markedly, and China actively promoted international and bilateral exchanges and cooperation with population organisations.Following the adoption  of the Programme of Action (POA) at the International Conference on Population and Development (ICPD) held in Cairo in 1994, many national population and family planning (FP) programmes have been under reexamination and reorientation.  So is the case in the People's Republic of China.  This chapter discusses a pilot experiment initiated in 1995 by China's State Family Planning Commission (SFPC) to improve quality of care as a means to reorient the FP programme in China.  It will first review the context in which the experiment was initiated, followed by a description of the experiment's origins, goals and how it was implemented; then report on the progress and outcome of the experiment, and discuss the potential for expansion and future development.

The pilot experiment in improving quality of care as a means to reorient the FP programme in China is by no means an accidental event.  It is an outcome of a number of factors emerging in recent years, both within and outside of China.

China is a developing country with the largest population of the world.  It currently registers a population of over 1.2 billion, which accounts for more than one-fifth of the world's total population, or the total size of all the developed countries of the world altogether.  China's FP programme has been successful in achieving its demographic objectives.  For example, the total fertility rate (TFR), or the number of children per woman/couple has dropped to below replacement level, which is virtually at its lowest in history.  Meanwhile, the annual number of births at about 20 million and the growth of the population at 13 million remain at almost the highest in history.  Moreover, the population momentum is still very strong as suggested by the fact that an additional 400 million more people will be added to the already 1.2 billion plus population and it will take about another fifty years before China reaches the zero population growth.  It is no wonder that the population growth is still one of the priority concerns of China's government.

At the same time, China has undergone dramatic changes in recent decades.  In the wake of the cultural revolution at the end of the 1970s, China adopted an open-door policy and has been determined to move toward a market economy.  The economic reform and the development of a market economy have had a tremendous impact on various aspects of the society.  In the past two decades, the living standard of the Chinese has increased significantly; and the population at or below poverty level was reduced from 250 million in 1978 to 65 million in 1996.  As lawful individual freedom and responsibility have become increasingly real in various aspects of personal life, and individual initiative has become more respected, people are increasingly aware of personal interests and rights, and are more sensitive about the quality of life including personal reproductive health (RH) and reproductive rights, as well as gender equality.

The desire for child-bearing has been weakening particularly among the younger generation of the reform period.  While the FP programme has achieved the population goal set by the government for the "Eighth-Five" period (1991- 96), it has also received growing resistance and complaints from people of different age and sex groups.  Problems such as lack of attention to the concerns and needs of clients, families, and particularly women, and the poor quality of services provided, are identified as the demand for personal choice and reproductive health care increases.

At the same time, public debate at the international level has exerted a remarkable impact on China's programme.  The ICPD in Cairo in 1994 exposed China to the concept of reproductive health and reproductive rights, and the World Women's Conference in Beijing in 1995 exposed even more Chinese directly to the concepts of women's rights and interests, as well as women's empowerment.  International perspectives such as Bruce's framework on quality of care² have also been introduced to China.

Implementation of the Experiment

Goal of SFPC on Reorientation

At the beginning of the "Ninth-Five" period in late 1995, the SFPC issued an official call for reorientation of the FP programme from an emphasis on demographic targets towards client-centred approaches and from a narrow focus on contraceptive prevalence towards relevant integration with reproductive health and women's empowerment objectives.  In early 1998, the SFPC reiterated and elaborated its goal on programme reorientation.  If the innovative experiment in a number of pilot counties/districts by 2000 is successful, the client-centred and quality-focussed approach to family planning will be gradually expanded to the whole country, and the nation-wide reorientation of the programme will be realised by 2010.

SFPC's Pilot Experiment on Quality of Care

The main mechanism adopted by the SFPC for reorienting the programme towards client-centred services, has been the selection of a number of rural counties and urban districts with relatively better-off conditions as pilots for quality service in family planning.  In early 1995, the SFPC selected five rural counties (Nongan County of Jilin Province, Liaoyang County of Liaoning Province, Jimo City of Shandong Province, Yandu County of Jiangsu Province, and Deqing County of Zhejiang Province) and one urban district (Luwan District of Shanghai) as first pilots for the experiment.  In 1997 an additional four urban districts (Xuanwu District of Beijing, Heping District of Tianjin, Xuanwu District of Nanjing and Zhuzhou City of Hunan Province) and one rural county (Liuyang County of Hunan Province) were added as SFPC pilots.

Objectives of the Pilot Experiment

By improving services and upgrading the quality of care, the overall intent of the experiment is to provide better reproductive health care and maintain the low fertility level.  While the SFPC has made an explicit call for the reorientation of the programme, the objective of the experiment is to demonstrate, through the pilot projects, how the programme can be reoriented and what a client-centred and quality-focussed programme looks like.  The experiment also seeks to convince the people in charge of the programme at all levels and all over the country of the feasibility of the reorientation process, a most crucial preparation for the full-fledged promotion of the reorientation of the programme after 2000.

The objectives of the experiment emerged over the course of the experiment as follows:

1.   Change Ideology.  The key to carrying out a sound experiment in quality of care is in creating wide acceptance of the philosophy of the client-centred approach among the numerous programme managers and service providers.  China's programme has been on a target-driven track for so long, many of the programme managers and service providers have become accustomed to it and find it difficult to conceptualize and implement the programme in an alternative manner.  Some were worried that negative demographic consequences may result from the less-stringent-approach to the programme, or that the experiment may meet resistance from the local management and providers because it may imply greater workload and responsibility, or that it may receive very little appreciation from the clients who may not be aware of and even skeptical about the necessity for reproductive health care.

 The experience of the pilots indicates that changing the ideology from a target-driven to a client-centred, quality-focussed and gender-sensitive approach is crucial as nothing can be done without the commitment to the reorientation of the local leaders and managers to the reorientation.  From the beginning of the experiment, seminars and workshops at all the levels were held to discuss the necessity and importance of reorienting the programme in terms of quality of care.  The leaders of the SFPC have paid great attention to the project and held several meetings with the leaders and managers of pilot counties/districts in Beijing in June 1995, December 1996, and October 1997.  They have consistently expressed strong support for the reorientation efforts during these meetings, and encouraged innovation in the pilot experiment.

2.   Upgrade Services.  Technical service has always been an important component of China's FP programme.  While the target-driven approach was in place, however, the quality of services and the care of clients tended to lose priority in the programme.  As the experiment progressed, many managers and service providers found they were not equipped with the capacity to provide services as the experiment's quality of care goals outlined.  For example, because there still exists a view that does not trust that the clients themselves can make an informed choice about what contraceptive is best for them in terms of their health and child-bearing status, the providers were only trained to do insertions and removals of intra-uterine device (IUD), but they were not trained to counsel clients on the advantages and disadvantages of the various IUDs, including the potential side effects of a given IUD.  The providers lacked a concept of and skills for pre-operation counselling and post-operation follow-up, as well as the professional training for inter-personal communication.  The experiment thus requires an overall re-training of the FP staff, including both managers and providers.

 The information, education, and communication (IEC) component of the programme also presents challenges.  Under the target-driven orientation, the IEC in the programme tended to focus on the adverse consequences of population growth to society and the country, publicising the population policy of the government and regulations on child-bearing.  Even though sometimes the contraceptive information was included, it tended to be too technical and thus unhelpful even for educated people, to say nothing of the majority of women in rural China who have an average education of six to nine years.

 During the project, the pilot counties were encouraged to experiment with informed choice and the introduction of counselling.  Moreover, these efforts were accompanied by the development and distribution of new IEC materials in which emphasis has moved away from the exclusive attention to demographic outcome, focussing instead on the knowledge and information that people need to protect their health and to safeguard their reproductive rights.  All the pilot counties have paid much attention to reorient the IEC component of the programme.  Many new varieties of IEC material that are less policy-focussed and more informative on contraception, child-bearing and rearing, and reproductive health care have been developed and disseminated.  The format has also changed with more graphics and fewer words so rural women with little education can grasp the information more easily.

3.   Improve Facilities.  When quality of services rather than demographic target is stressed, the infrastructure and facilities, resource allocation, and staff recruitment of the programme have to be re-examined.  Since 1) a greater variety of graphic IEC is displayed in the front of the clinic, 2) more space is given for examination and counselling, 3) more attention is paid to ensure the privacy and confidentiality of the client and 4) there is closer observance of aseptic clinic conditions and service procedures protocols, many of the local service clinics in the pilot areas have been expanded or renovated.  The equipment necessary for improved quality of care and reproductive health care, such as those for the diagnosis and treatment of reproductive tract infections (RTIs), have been purchased and installed.  With the support of the local government, additional resources have been allocated to the programme during the experiment, and more qualified and capable staff have been recruited.

Strategy to Implement the Quality of Care Approach

Carrying out an experiment to reorient the FP programme for a 1.2 billion plus population to a quality of care approach is by no means an easy task.  The experience of the experiment in the pilot counties suggests that to ensure a sound and healthy transition, the following four strategic elements are key:

1.  To have a smooth transition, the pilot counties have adopted a strategy called "fade-in, fade-out."  This means that in the experiment, the focus should first be on introducing the new and innovative approaches into the programme, and making them workable and acceptable by the local people, including the clients, providers, managers, and even local leaders.  This process takes time.  Every effort should be made to avoid overzealous attempts to abandon the existing approach and systems prematurely.  When the new approach becomes entrenched and accepted by the local people, it is then opportune to fade out the old approach.

2.  To start the experiment with a few carefully selected pilots at settings with relatively favourable conditions.  How to introduce the quality of care approach in the context of China is a project with no precedent.  To promote the experiment in a step-by-step manner, first, a few pilot areas should be selected.  While the experiment has tended to be initiated in areas with better socio-economic conditions and sound performance of their FP programme, the pilots have to be selected on a voluntary base.  It is true that local determination, and in particular the local leaders' commitment to the experiment, tend to be crucial to the undertaking of the experiment.  Not only were all the SFPC pilots selected on a voluntary basis, but they were also promised no external resources, either from the national government or international organisations.  This reflects a concern for the replicability and sustainability of the experience of the pilots.  For the more external resources a pilot area receives for the experiment, the less convincing the pilot experience will be to those from the no-pilot areas, making  expansion of the effort difficult.

3.  To initiate the experiment with what is locally deemed feasible and acceptable.  Though SFPC has set the overall goal for the experiment as stated above, from the very beginning of the experiment, no fixed timetable and no specific procedures were instructed from the top.  The whole experiment emphasises respect for local initiatives, and encourages a great deal of diversity.  The experiment may start with any innovative efforts, such as adoption of informed choice of contraceptives; reorientation of new IEC material; issue of the newly designed Reproductive Health Care Handbook; restructuring of the service clinic by setting up the contraceptive display desk at the front of the clinic; inventing a contraceptive display package; setting up "quiet-talk" room for private counselling, or 24 hour hotline telephone service, etc.  As long as the pilots are moving toward the client-centred, quality-focussed approach to the FP programme, their efforts should be acknowledged and supported.  Sometimes the local initiative may appear controversial, but no negative conclusion should be made, rather it should be allowed to take its own course.

4.  To let people learn and understand the concepts of quality of care and reproductive health and rights through their own experiences.  During the experiment, particularly at the beginning, understanding the concepts of quality of care, programme reorientation, even informed choice varied considerably among the leaders, managers, and providers involved in the experiment.  Rather than talking about and attempting to clarify the concepts, the experiment takes the principle of "practice first", i.e., let people understand the concepts not just from books or lectures, but from their own practice or experience.  This has proven effective from the recent field assessment, presented in the following section of this chapter.

Outcome of the Experiment

Some of the Findings from Field Assessment of the Experiment of the First Six Pilots (1995-98)

An inter-disciplinary assessment team consisting of Chinese and international specialists with diverse backgrounds Ñ sociology, management, demography, women's studies, and public health, etc. Ñ was organised by the SFPC to carry out the field assessment of the experiment of the first six SFPC pilots in 1995-1998.  The assessment was conducted in August, and October to November 1998.  The purpose of the assessment was to undertake a thorough review the experiences of the first SFPC pilot county/district over the past three years, to assess the changes in the programme which have been set in motion by the experiment and the major effects of the reorientation and implementation of the programme, the reactions and feedback from the local leaders, FP managers, service providers and clients, as well as the key experience and lessons generated from the experiment among the pilot counties/district.  Moreover, the undertaking was to serve as an experiment to introduce into China a client-centred approach in the evaluation of the performance of the programme with an innovative qualitative methodology.  Some of the preliminary findings from the field assessment are briefly presented below:

¥ Stable low fertility.  Since the pilots were selected from areas with better programme performance, the local leaders were worried whether fertility would increase as a result of the change in programme approach.  In fact, after the new approach was introduced into the programme, the low fertility rate became even more stabilised, at the level much below replacement, among all the pilot counties.

¥ Few contraceptive failures.  Counselling, informed choice, knowledge-focussed IEC, all these measures adopted in the experiment made clients, particularly women, more knowledgeable about contraceptive use, thus avoiding a great deal of unnecessary contraceptive failures.

¥ Fewer abortions resulted from unintended pregnancy.  Many women said that they did not want anymore pregnancies or children, and they wanted to use contraceptives.  They were concerned about contraceptive failure and consequent unintended pregnancy and abortion.  Fewer abortions are the direct results of fewer contraceptive failures.

¥ Normal sex ratio at birth.  Abnormal sex ratio at birth has been a salient and disturbing demographic phenomenon since the mid-1980s in China and some other populations in Asia with rapid fertility decline.  Even today, the sex ratio at birth in China has not dropped to normal level.  But among the pilot counties the sex ratio at birth has all returned to normal over the course of the experiment.

¥ Sound relationship between clients and providers.  When providers' attention shifts from narrowly demographic quotas to quality services, clients are happy to see the change.  Many service providers also said their work became easier even though their workload increased due to more pre- and post-operation services such and door-to-door visits  for they are pleased to see their services meet the needs of their clients, and even to become friends with the clients.

¥ Sound relationship between people and managers.  In the past, the programme managers were constantly worried about the possible occurrence of out-of-quota pregnancy and subsequent birth, and people hated to be manipulated and watched.  But with the quality of care experiment, the relationship has totally changed.  When managers became more concerned about how to better serve the needs of the people, the people became less suspicious and more receptive.  As a result, the experiment has made family planning more accepted and effective.

¥ Expansion of services to reproductive health care.  Prior to the experiment, the technical service in the programme mostly focussed on  contraceptive use, measured in terms of contraceptive prevalence rate.  In the experiment, the service has greatly expanded to include a wide range of RH care, such as diagnosis and treatment of RTIs, training seminars on knowledge related to reproductive health care, child-bearing and rearing, pre-natal and post-natal service and maternal care for both mother and newborn baby.  Many of the pilots have launched the life-cycle service in reproductive health care for people in different age and sex groups, for instance, sex education and contraception for adolescents, and healthcare for women during menopause.

¥ More awareness of women on reproductive rights.  The new IEC programme focussed not only on the knowledge of reproductive health care but also emphasised reproductive rights.  Both programme managers and clients are clear that the FP programme has to be carried out in a lawful manner.  In some of the pilots, a system has been set up whereby the client is compensated if the programme fails to provide the service promised or in a timely manner.

¥ People, particularly women feel respected and cared for.  When the counselling, informed choice, and follow-up visit, etc. are introduced into the programme, people, particularly women feel that their position in the programme has been greatly changed.  In the experiment, the providers are concerned with learning about and satisfying better the contraceptive and reproductive health needs of people, and the managers are concerned about the reaction of the people in terms of quality of care and their satisfaction with the services.  All these send clear messages to clients they are no longer patients to be watched, but rather, they are to be respected and cared for.

¥ Programme changes from being compliant to being innovative.  Since there was no timetable nor procedures specified for the experiment, and the pilots were encouraged to be flexible and diverse, the local programme managers and providers have had to be creative from the beginning of the experiment.  For a long time the managers were used to carrying out the programme by complying with the superior's instructions, but in the case of the experiment they had to be innovative.  Initially, the local managers were thrown into "uncharted territory" in terms of work challenges, but after three years, they have a sense of deep satislfaction as they developed the innovative programme by themselves.

¥ Local leaders are pleased to see tension with people is much relieved.  In the past, when the programme encountered resistance from clients, the local leaders were occasionally called upon as backup to implement the programme, particularly when the situation became tense.  With the experiment, the relationship between the clients and providers has become much sounder, and programme implementation became a smoother process.  Many local leaders are pleased that they can concentrate more on the overall development of the local economy.

¥ The positive image of the family planning programme in the society is getting re-established.  Under the target-driven approach, the programme was seen as a tool to fulfil targets, or to achieve a certain rate of demographic outcome rather than care of people.  The experiment reoriented the focus of the programme to people's well-being and reproductive health care, thus greatly improving the image of the programme among the clients in particular and in society in general.

¥ Based on the experiment, most local leaders and managers are fully convinced that the quality of care approach is not only feasible in the local context but the best way to implement the programme in a sound, healthy, and sustainable manner.  This is regarded the most important achievement among all the findings from the field assessment.  However, a period of three years is a short.  Although the pilots have progressed impressively in their efforts to reorient the local programme, they still have a long way to go before completion of the reorientation.  But in the field assessment not only has the new approach received wide applause among local people and women, many local leaders and managers also show great appreciation of the experiment.  In different words, they expressed how much they are convinced that the quality of care approach is the best way to carry out the programme, and showed great determination and commitment to the approach.

Development of International Contacts and Collaboration

While the SFPC experiment was initiated on its own with virtually no external assistance, it was clear that there was a necessity and advantage of exposing the experiment to international experiences as well as of requesting support from international experts.  This would allow the Chinese experiment to move forward quickly, and to build on the success of the quality of care transition.  It would also allow learning from other countries' experiences and avoiding unnecessary mistakes.

At the first meeting of the SFPC pilots in Beijing in June 1995, Ian Howie and Susan Holcombe were invited to give talks on ICPD.  At the same time, some of the international literature on quality of care were translated into Chinese and published as a book entitled International New Approach to Reproductive Health and Family Planning.  In 1996, a delegation of pilot leaders visited Thailand to observe the quality of care innovations.  Ruth Simmons of the Population Council was invited to talk at a pilot workshop about international experience on programme reorientation in Changchun in late 1996.  With the support of the Beijing office of the Ford Foundation, an international expert team from the Population Council, University of Michigan, Australian National University and the Ford Foundation gave talks at the pilot workshop in Yandu in April 1997, where more Chinese programme managers learned about a variety of international experiences in programme reorientation.

As a demographic giant, China always has a natural interest in the programme of neighbouring India, particularly after India's announcement to adopt a target-free approach in its programme.  A Sino-India meeting was held in Beijing, in October, 1997, followed by a visit of a SFPC delegation to India in March 1998 to have a frank exchange of experiences and mutual concerns in programme reorientation.

In mid-1998 a joint project between the SFPC, the Population Council, and University of Michigan on improving quality of care and women's empowerment in RH/FP services in China was developed, and an international contact group was set up for the project, which has received support from the Ford Foundation.  As part of the workplan of the project, the Population Council, University of Michigan and International Council on Management of Population Programmes participated in a workshop on quality of care, held in Qingdao in August in 1998, with about 100 programme managers and specialists from all over the country attending.  Representatives from the University of Michigan and the Population Council participated in the whole process of the field assessment in late 1998.

Expansion and Development of the Experiment

Reactions to these quality of care initiatives have been most encouraging.  The experiments have received an extraordinarily positive response from child-bearing women as well as FP managers and service providers.  These innovations are tangible, convincing, and sustainable.  They eloquently demonstrate the feasibility of a service-oriented approach in the programme in the context of China.  While the experiment was not publicised at the beginning so as not to avoid interference, the experiment and the progress made are gradually becoming known throughout the country.  Hundreds of FP managers and providers from all over the country have come into the pilot counties/district to learn about the experience of the pilot experiment.  The training course on programme reorientation and pilot experience has had to be expanded from one to four turns with double participants.  In particular, at the briefing meeting of the SFPC pilots to the leadership of the SFPC in December 1996, the SFPC leaders urged provincial leaders to consider initiating their own regional pilots with reference to the SFPC pilots, triggering the swift expansion of the experiment on programme reorientation to many provinces of the country since then.

With the preliminary success in the SFPC pilot counties and the encouragement of the SFPC leadership, there are more than a hundred counties and districts which have been selected in 1997 as provincial pilots to initiate the quality service experiment.  It has expanded to 200 counties/districts at the beginning of 1998, and to 300 counties/districts (which accounts for more than 10 percent of the country total) by the end of 1998, as the various provincial family planning commissions initiated local pilots to adopt a quality of care approach in the FP programme.