Understanding Family Planning Counseling in the Private Sector through a Behavioral Economics Lens

"There is a specific need for improved interventions that ensure effective interactions between private providers and their patients."

The Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project conducted a qualitative study using a behavioural economics lens to explore how cognitive and behavioural biases influence the provision of family planning counseling by private sector providers in India and Malawi. This brief presents the results of the study and provides recommendations to address bias to facilitate family planning counseling that is tailored to client needs and supports informed choice.

According to SHOPS Plus, informed choice in the context of high-quality family planning counseling means provision of information about side effects and alternative methods. One reason clients may not receive this information is provider biases that arise from socio-cultural norms, observations, and perceptions of a client's personal characteristics (e.g., age, parity, education, economic status). Behavioural economics offers an approach to understanding the ways in which biases influence decisions. A key construct on this approach is choice architecture, which is the layout, sequencing, and range of choices that are available to an individual. Constructing a choice architecture for a family planning client is a complex process in which the provider must take into account client-side factors and motivations, while simultaneously describing aspects of each available method.

Notably, although both India and Malawi have a wide range of method choices at varying price points, with most short- and long-acting methods available in the private and public health sector, one method dominates the mix in each country: In India, female sterilisation continues to dominate (36%), and in Malawi, injectables comprise 30% of all modern methods adopted. Given the variety of methods available, the dominance of one method at the exclusion of others could suggest provider bias, consumer preference, or both.

The qualitative study used semi-structured, in-depth interviews with a purposive sample of healthcare providers practicing in India and Malawi. The summary of findings found in Table 2 and the categorisations shared in the brief demonstrate - using behavioural economics concepts and terminology - how private providers' and clients' family planning choice architectures can contribute to skewed method mixes. For example, one approach found among providers in India is the use of representative heuristics (or rules of thumb) to simplify the decision-making process by excluding choices based on a few client attributes. And in Malawi, the majority of providers stated that client demand for a specific method makes it challenging, frustrating, and time consuming to counsel clients on other types of contraception. According to providers, the influence of friends and family (herd behaviour) is a key driver for injectable demand. (However, there is no evidence that providers are relenting blindly in the face of client demand.)

The recommendations gleaned from the study results were derived from in-country consultative meetings between practitioners and the research team. In addition to the fact that providers should become aware of their own biases and how those biases can have a negative impact on the health outcomes of their clients, two behavioural-economics-inspired approaches to making family planning counseling and service provision easier are to:

1. Reduce complexity via checklists and job aids, which can shorten time and improve quality of counseling sessions, better align services with Ministry of Health standards, and give providers a feeling of greater contribution to national family planning goals.
2. Make complexity easier to overcome by reframing to identify and correct for bias, which influences decision making at a subconscious level. Two approaches include:
   • Reframe for perspective: Train providers to consider how clients' negative experiences with family planning or other aspects of health service delivery have negatively impacted their lives. By humanising the client, a provider can see the negative consequences their biases can have.
   • Reframe for gain: Equip providers with the knowledge and communication skills to present methods from the perspective of what exactly a client may gain (gain frame) rather what the client may lose (loss frame) (e.g., side effects). For example, providers in Malawi stated that one reason the injectible Depo-Provera (Depo) is preferred to other methods is that it is less expensive in the immediate term than are intrauterine devices (IUDs) and implants, the cost of which is less over the longer term; providers need a better approach for reframing the cost decision for their clients.

In conclusion: "Helping providers to deliver family planning counseling and services more easily, while also being respectful of their clients' needs and desires, is key to ensuring clients are satisfied with their family planning method."