Researchers Posing as Clients Find Inadequate Contraceptive Care by Some Kenyan Providers

H. Ball

First published online:

Poor quality of care—including long waits, inappropriate fees and misinformation about contraceptive methods—may impede women’s use of family planning services in Kenya, according to a recent study using simulated clients.1 Posing as contraceptive clients, six women visited 52 providers at public and private clinics in Kisumu East District. At most visits, the simulated clients received the method they requested, but in one-tenth of cases, providers refused to offer a method without a medically unnecessary pregnancy test or proof of menstruation. One-fifth of visits took five or more hours from arrival to departure, and all simulated clients reported being treated rudely or disrespectfully by at least one provider.

The researchers employed a simulated client approach to obtain accurate data about the quality of clinical services without the obtrusion of a third-party observer. They trained six female data collectors to observe and report on a number of aspects of family planning care during clinic visits in which they pretended to be contraceptive clients. The women were aged 23–30 and had 0–3 children; half were married, and half were slum residents. Each simulated client was assigned to request a particular contraceptive method: Three sought pills, and one each asked for an IUD, implant or injectable. After each clinic visit, the simulated clients filled out a short checklist on aspects of service quality and provided additional comments about the visit, most of which concerned interpersonal relations, provider competence, provider accessibility and inappropriate charges. The 19 clinics they visited—14 public and five private—represented all medium- and high-volume health care facilities providing contraceptive services in the Kisumu East District. The supervisors of all facilities consented to have their clinic included in the study.

The simulated clients made a total of 134 visits to 52 providers. Although the quantitative data collection tool did not solicit informal feedback, clients volunteered accounts of five visits in which they had had a positive interaction with their provider; for instance, the provider had been friendly or encouraging or had thoroughly discussed family planning options with the client. However, using the checklist, clients reported 24 visits in which providers failed to greet them in a respectful or friendly manner. All six simulated clients reported rude or disrespectful treatment by at least one provider; these incidents included a provider who shouted and another who accused a woman of trying to abort an undisclosed pregnancy through use of an injectable contraceptive.

At the vast majority of visits, the simulated clients were offered their preferred contraceptive method, but at 13 visits (10%) women were denied their method of choice until they could prove they were not pregnant (either by paying for a pregnancy test or by returning to the clinic once they were menstruating), even though contraceptives do not interrupt an established pregnancy. In most of these cases, the woman was not offered an alternative form of birth control. Some providers also appeared to be misinformed about certain methods. Further, three of the individuals who served clients at public facilities did not appear to have been trained in family planning provision; these included a volunteer and a lab worker.

At three facilities, at least one client was turned away after a long wait without having seen a provider or having obtained a contraceptive method. During visits in which clients did see a provider, the total time spent at the clinic between arrival and departure averaged three hours; 19% of visits lasted five hours or longer. On seven occasions, care was delayed because the provider arrived after the clinic’s scheduled opening time, did not return from a break or asked the client to return on a different day.

The clients were overcharged at three out of four visits at which they received oral contraceptives (prices were not discussed for the other methods, since women did not accept medically unnecessary contraceptive procedures). In some cases, women were charged fees even though the clinic’s policy was to provide pills at no charge. At 12 visits, simulated clients paid fees that differed from those paid by other simulated clients, and in two instances the simulated client was refused a receipt and observed the provider pocketing the money.

The researchers found no discernible pattern of quality of care issues across participating facilities and providers. However, the observed instances of misinformation, inappropriate requirements and fees, and poor client relations represent situations that could prevent women from obtaining contraceptive care and put them at risk for unintended pregnancy. The researchers point out that an important first step in improving service quality is "to better understand the perspective[s], needs, and motivations of the service providers," which in turn can help ensure "a manageable workload, timely and adequate pay, and respectful workplace practices." Further, they advocate offering providers training in counseling skills to improve interactions with clients, instructing them to use a checklist to determine pregnancy status (in lieu of requiring tests that may cause delays in service), and improving supervision and accounting systems to prevent absenteeism and corruption.,em>—H. Ball


1. Tumlinson K et al., Simulated clients reveal factors that may limit contraceptive use in Kisumu, Kenya, Global Health: Science and Practice, 2013, 1(3):407–416.