“I feel the difference, before and after. Now the providers explain everything. They talk to me more and I go home in peace.”

Thanks to feedback mechanisms implemented by the PRIME II Project, primary providers are improving services at 16 Paraguayan health facilities by acting on suggestions from clients like Maria, who visits Natalicio Talavera Health Post for prenatal care. The client feedback pilot project complements PRIME’s broader assistance to the Ministry of Health to improve the quality and accessibility of family planning and reproductive health care in Paraguay.

PRIME identifies timely performance feedback as one of five critical factors that support optimal provider performance. Clients are uniquely positioned to evaluate provider performance during their care, and client satisfaction is the most important determinant of their willingness to return for future services. Yet providers and their supervisors are often unaware of clients’ expectations and uninformed about clients’ perceptions. Dissatisfied clients simply fail to come back.

At the facilities in Paraguay, PRIME is comparing two strategies for client feedback: group meetings with clients and providers, and feedback cards that clients can leave in an “opinion box.” Both approaches feature public display of client communication posters to summarize the good things clients have said about services, their suggestions on ways to improve services, and the changes providers are making in response to the feedback. Providers attended workshops on feedback to prepare them for full participation in the project.

“We learned in the workshop that we’re doing this for a good purpose,” says Eva Segovia, an obstetric nurse from Paso Yobai Health Center. “That this is not to place blame but to ask ourselves how we can make things better.”

All the providers interviewed during monitoring visits in January 2004 report that the project is helping them strengthen services and communicate more openly and effectively with clients. Particular improvements have occurred in the areas of family planning information and counseling, advice on danger signs in pregnancy, and hand washing before and after clinical examinations.

“Now we talk more to the women about family planning, problems in pregnancy to watch out for, and proper nutrition,” notes Miguelina Paniaga, chief nurse at Villarrica Regional Hospital, where group feedback meetings are being held. “Even the doctor has changed a lot and talks more to his clients and explains more.”

At Ybycui District Hospital, where the opinion box is in place, nurses reference the feedback card to make sure they perform well in the six key areas clients will evaluate: “We put the card on the wall and it reminds us not to forget any of the things we should do and discuss with the pregnant woman. We now talk more about family planning with them. We wash hands. We talk to the women as we examine them, explaining what we are doing. These are all things we weren’t doing before.”

Clients participating in both the group meeting and feedback card approaches are reporting more positively on providers’ performance. At Paso Yobai Health Center, the first client meeting resulted in 35 positive and 13 negative responses to questions about provider performance. Only two negative answers were noted at the second meeting, which generated 22 positive comments.

While PRIME has conducted training for maternal health care providers in Paraguay to improve their knowledge and skills, the client feedback pilot and PRIME projects in other countries show that non-training interventions are also effective and may be necessary to resolve performance gaps that can’t be addressed through training.

“Feedback serves as an incentive for the provider to do their job better since they see in writing the clients’ voices,” sums up Dr. Maria Dofinda Rivas, director of Villarrica Regional Hospital. “In turn, the clients feel better attended. Before they felt a distance from us, which is why they would go to traditional birth attendants. Now we see an increase in births at the hospital.”

The PRIME II Project, funded by USAID and implemented by IntraHealth International and the PRIME partners, works around the world to strengthen the performance of primary providers as they strive to improve family planning and reproductive health services in their communities.