Improvements in the constellation of services in the African context are largely addressed through attaining better measures of service integration, which can be achieved through improved referral across categories of health programs. The use of an unobtrusive referral message that linked family planning and the Expanded Program of Immunizations (EPI) services was tested in an operations research study in Togo. The introduction of the referral message was accompanied by an 18-percent increase in awareness of available family planning services and an increase in the average monthly number of new family planning clients of 54 percent. These positive results indicate that the use of referral can have a significant and dramatic impact on family planning services in a relatively short time. In Togo, no evidence existed of a negative impact on EPI services, and a majority of the EPI providers reported satisfaction with the effect of the referral message at the close of the study.

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A case-control, quasi-experimental study was designed (post-test only) to investigate the effect of a performance-based incentive payment scheme on behaviours of public-sector service providers in delivering a basic package of maternal and child-health services in Egyptian primary healthcare units. The results showed significant improvements in the quality of family-planning, antenatal care, and child-care services as reported by women seen in clinics where the incentive payment scheme was in operation as measured by various indicators, including both technical and inter-personal communication content. An analysis of characteristics of the service providers and clients found no significant or meaningful differences between the study groups, and the facilities of both the study groups were essentially the same. Some findings are suggestive of other influences on behaviours of the service providers not captured by the data-collection instruments of the study. Subsequent to this study, the payment scheme has been rolled out to other districts in Egypt.

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The "simulated client" method was first detailed in the family planning literature in 1985, but it has not been extensively covered since. As used by the authors to study client-provider interactions in family planning programs, this method essentially consists of sending women to a family planning service provider to request information, and interviewing them after the encounter. The women do not reveal to service providers they are participating in the study. This report describes the method; reviews some of the theoretical, ethical, and methodological issues related to it; and underlines its usefulness as a tool for examining quality-of-care issues in family planning programs.