International Journal for Quality in Health Care Advance Access originally published online on September 16, 2008
International Journal for Quality in Health Care 2008 20(6):384-391; doi:10.1093/intqhc/mzn040
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Client perceptions of the quality of primary care services in Afghanistan
1 Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
2 Health Economics and Financing, Public Health Foundation of India, New Delhi, India
3 Department of Health Information Systems, Ministry of Public Health, Kabul, Afghanistan
Objective. To identify factors associated with client perceptions of the quality of primary care services in Afghanistan.
Design. Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers.
Setting. Primary health care facilities in every province of Afghanistan.
Main outcome measure. Numerical scale of client perceptions of service quality.
Results. Clients report relatively high levels of perceived quality in Afghanistan. Most of the variation that is explained relates specifically to the patient's interaction with the health worker and not to other health facility characteristics, such as cleanliness, infrastructure, service capacity and the presence of equipment or drugs. The strongest determinants of client-perceived quality identified are health worker thoroughness in taking patient histories, conducting physical examinations and communicating with patients. Being seen by a doctor and being from a household in the poorest quintile are also associated with higher perceived quality. For female patients, being seen by a female provider is associated with higher perceived quality, while for male patients time and money spent for travel to the health facility are negatively associated with perceived quality.
Conclusions. Clinical quality and client perceived quality appear to be mutually reinforcing, and efforts to improve health worker performance in taking histories, conducting exams and communicating with patients are likely to increase client perceived quality in this setting. Client perceptions of service quality assume additional importance in Afghanistan, where the perceived legitimacy of the government may depend partially on its ability to convince the population that it can deliver essential health services.
Keywords: client perceptions, quality of care, Afghanistan, primary care
Address reprint requests to: Peter Meredith Hansen, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Room E8132, 615 N. Wolfe Street, Baltimore, MD 22105, USA. Tel: 410-955-3928; Fax: 410-614-1419; E-mail: phansen{at}jhsph.edu, pmhansen{at}gmail.com
Accepted for publication August 14, 2008.