Health service responsiveness: A case study of integrated family planning and childhood immunisation services in Malawi

Effective birth spacing, commonly achieved through the use of modern contraceptives, is vital to the health and well-being of women and children worldwide. Yet approximately 218 million women have an unmet need for modern contraceptives in low- and middle-income countries, many of which are postpartum women. Evidence suggests that integrating family planning (FP) services with childhoodimmunisations could reduce the unmet need among postpartum women by providing repeat opportunities for timely contact with FP services. However, despite being a key determinant of contraceptive uptake and the repeat use of health services, little is known about whether women’s legitimate expectations for FP services are met when these services are integrated. This thesis addresses this knowledge gap through a multi-method case study of the responsiveness of integrated FP services delivered in routine outreach clinics in Malawi. Specifically, data from structured and semi-structured interviews with clients and their FP providers were analysed to assess and explain the ease of access, dignity, environment, confidentiality, choice of provider, communication, counselling, and service continuity experienced by clients. Additionally, a causal loop analysis of qualitative data was carried out to model and describe the system dynamics determining responsiveness in the studied context. Overall, this thesis demonstrates that in routine outreach clinics, FP services can be responsive to clients’ legitimate expectations when integrated with childhood immunisations in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Responsiveness is shown to be a product of the dynamic relationships between the organisational arrangement of resources, the processes involved in the provision of services, and the characteristics and behaviours of the actors interacting at the point of care. Crucially, by scrutinising these relationships using systems thinking, this thesis offers detailed recommendations for policy and practice.