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International Journal for Quality in Health Care Advance Access originally published online on October 18, 2005
International Journal for Quality in Health Care 2006 18(1):30-34; doi:10.1093/intqhc/mzi079
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International Journal for Quality in Health Care vol. 18 no. 1 © The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

Quality of care of modern health services as perceived by users and non-users in Burkina Faso

Rob Baltussen1 and Yazoume Ye2

1 Institute for Medical Technology Assessment, Erasmus MC, Rotterdam, The Netherlands and 2 Department of Tropical Hygiene and Public Health, Heidelberg University, Heidelberg, Germany

Objective. Only one-fifth of the population in rural Burkina Faso uses modern health services. This article aims to identify barriers to increased use, which may help decision makers to develop policies to remove them.

Design. This article compares perceived quality of care of 853 pairs of users and non-users of modern health services. Non-users were matched to users on age, sex, occupation of the head of the household and distance to health post. Questions were structured according to four dimensions of quality of care.

Setting. Nouna health care district, Burkina Faso.

Results. Both users and non-users were relatively favourable about health personnel practices and conduct (77% versus 70% of the maximum attainable score), and about health care delivery (77% versus 74%). They were less favourable about adequacy of resources and services (51% versus 46%), and financial and physical accessibility of care (57% versus 51%). Both groups were very negative regarding the availability of drugs (33% versus 27%). Users were more favourable than non-users overall (66% versus 61%), and especially regarding payment arrangements (51% versus 43%) and costs (50% versus 40%). Observed differences were generally significant.

Conclusion. To remove barriers to increase utilization, policy makers may do good to target their attention to improve financial accessibility of modern health services and improve drugs availability. These factors seem most persistent in decisions of ill people to stay with home-based care and/or traditional medicine, or go to consult modern health services.

Keywords: qulity of care, burkina faso, utilization

Address reprint requests to Rob Baltussen, Institute for Medical Technology Assessment, Erasmus MC, PO Box 1738, 3000 DR, Rotterdam, The Netherlands. E-mail: r.baltussen{at}erasmusmc.nl

Accepted for publication September 10, 2005.

Research on people’s perceptions on quality of care has increased considerably in the past decade [1]. Research in developing countries is both qualitative and quantitative, referring to a wide range of services like family planning, primary health care, and urban health facilities. In the literature, various ways of evaluation have been used: exit interviews [2,3], mystery clients [4,5], household interviews [6,7], and focus groups [8,9]. Nearly all of these are user-perspective studies, that is, they predominantly aim to measure perceived quality of care of those people who actually visit the health facilities. The resulting information is then used as a basis to further improve quality of care with the ultimate goal to improve the effectiveness of care, and/or to increase utilization.

However, in assessing community preferences on modern health facilities, it is important not only to be informed about the preferences of those who actually use the facilities but also of those who do not use them. A documentation of the perceptions of these ‘non-users’ is necessary for policy makers and may shed light on the factors that influence peoples’ choice of health care services. In rural Burkina Faso, modern health care facilities are only consulted by 19% of the population; others choose home treatment (52%), traditional healers (17%), or local village health workers (5%) [10]. This translates in an utilization of government services as low as 0.17 consultations per capita in 1997 [11].

This article compares perceived quality of care of users and non-users of modern health services, and thereby aims to identify barriers to increased use, which may help decision makers to remove them [12,13]. This article applies a measurement scale of perceived quality of care that was developed and validated in Guinea [14] and adjusted for the specific context of Burkina Faso [15].


   Methods
Top
 Methods
Results
 Discussion
 Acknowledgements
 References
 
Study area
Burkina Faso is a land-locked country situated at the border of the Sahel region in West Africa with a population of about 10 million inhabitants and an estimated gallons per day (GPD) per capita of 150 $/year [16]. More than 95% of the population lives from subsistence farming. Infant mortality (105/1000) and under 5 years mortality (219/1000) [17] reflect large unmet needs. The study was performed in the Nouna health district in the northwest of Burkina Faso. In this district, malaria, diarrhoea, and respiratory diseases are estimated as the most important contributors to the total numbers of years of life lost [17].

Study population
‘Users’ of modern health care facilities were defined as those individuals who had visited the health care facilities at least once in the past 5 years and were at least 15 years old. The data collection procedure for this sample is described in detail elsewhere [15]. Upon inclusion of every user in the study, a ‘non-user’ was identified in the same community, and the questionnaire was administered at their home. Non-users were defined as those individuals who had not visited the health care facilities in the past 5 years and were at least 15 years old. Non-users were matched with users on age (with categories ≤25 years, between 25 and 45 years, ≥45 years), sex, profession of the head of household (farmer, other profession), and distance to the nearest health centre (0–5 km, 6–10 km, 11–15 km, 15+ km). These characteristics were selected on the basis of a literature review of factors influencing health care facility choice.

In total, data were collected on 853 pairs of users and non-users of modern health care. The response rate was 96% and 94% for users and non-users, respectively. In addition to the items dealing with quality, the questionnaire included questions on respondents’ sociodemographic characteristics. Most of the respondents were female (53%), farmers (89%), and uneducated (users 88.5%; non-users 81.8%). The average age was 34 years for both groups.

Questionnaire
The instrument for quality assessment was based on an instrument developed earlier for documenting quality of care in Guinea [14]. The process of adjusting the questionnaire to the context of rural Burkina Faso and the results of the factor analyses are described in detail elsewhere [15].

The scale included 20 items and was structured according to four dimensions of quality of care. The first dimension consisted of six items related to the practices and conduct of health personnel: patient follow-up, clinical examination, reception of the patient, compassion, respect, time spent, and honesty of staff. The second dimension included four items related to the adequacy of resources and services in the facility: that is, adequacy of the number of doctors, adequacy of doctors for women’s treatment, adequacy of equipment, and adequacy of rooms. The third dimension included four items regarding measures of health care delivery: that is, prescription, quality of drugs, diagnosis, and care outcomes. The fourth dimension included five items, related to the financial and physical accessibility of health care, that is, the adequacy of fees, the possibility of making special payment arrangements, distance, the ease of obtaining drugs, and the time devoted by the doctor.

For each question, respondents could express their opinion on a five-point Likert scale: very unfavourable (–2), unfavourable (–1), neutral (0), favourable (+1), and very favourable (+2). An unweighted aggregation procedure was used. This article reports the perceptions as percentages of the maximum attainable scores, and these can be interpreted as means scores. A paired Student’s t-test was performed to test for differences between scores of users and non-users of modern health services.


   Results
Top
 Methods
 Results
Discussion
 Acknowledgements
 References
 
Item analyses
Both users and non-users were relatively favourable about health personnel practices and conduct, and about health care delivery (Table 1). They were less favourable about adequacy of resources and services, and financial and physical accessibility of care. Both groups were very negative regarding the availability of drugs.


View this table:
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  		Table 1 Perceived quality of modern health services by users and non-users

 

Overall, users were more favourable than non-users. They rated interpersonal communication higher than non-users, such as compassion and support for patients, respect for patients, and reception of patients. Users also rated financial accessibility higher than non-users, including adequacy of payment arrangements and costs.


   Discussion
Top
 Methods
 Results
 Discussion
Acknowledgements
 References
 
There is considerable variation in perceived quality of care between various dimensions of modern health services, and between users and non-users. Barriers to increased utilization are likely related to those dimensions that are rated poorly by all respondents (as they may deter overall use) and/or that show large differences in perceived quality between users and non-users (as they may explain why the latter group refrains from using modern health services).

Non-users rate the financial accessibility poorly and more so than by users, and inadequate payment arrangements (e.g. lack of credit) and costs appear an important barrier to increased utilization. Users of modern health care are somewhat more positive about the financial accessibility, possibly because they have a higher ability to pay [18,19] and can afford the services. Health care financing schemes like prepayment or health care insurance as, for example, being established on an increasing scale in Ghana [20] could be viable policy options to increase utilization of modern health services among those who do not use them now. This confirms findings of other research in Burkina Faso, which states that financially accessibility is a key determinant of patient initiation of use of modern health services [21]. However, supplementary findings show that patient retention merely depends on people perceptions of other dimensions of quality [21].

Both users and non-users were negative about resources and services, and especially the availability of drugs. Many studies have shown that drug supply is an important determinant of the utilization of health services [5,6,22], and policy makers may therefore pay particular attention to drug purchasing and distribution policies, and the use of low cost generic medicines.

Differences in perceived quality were large regarding health personnel practices and conduct, although both users and non-users were relative favourable on this. The latter would indicate that inadequate behaviour of health personnel is not an important barrier to increased utilization, unlike suggested in other studies [23]. All respondents were also relative favourable on items related to health care delivery. The area of technical aspects of quality seems therefore not an important reason to deter people from using modern health services, possibly because lay people are in a position to adequately judge technical quality of care [15]. The large attention decision makers usually pay to this issue [24,25] may therefore not so much increase utilization but has its rationale in improving effectiveness of services per se.

The results are in line with observations from Tanzania, where it was found that prices tend to deter use, and improved quality of services tends to increase the likelihood of a facility being chosen [26]. However, in this study as well as in a study in China [27], severity of disease was also found to have a large impact in the decision to consult modern health services or not. In our study, we did not control for severity of disease, and it may be that non-users of modern health care have been less ill or have not been ill at all in the past 5 years, and have not felt the need to seek modern health care. Their decision not to use the modern health facilities might in these cases merely be a result of their health status rather than perceived quality of care. However, regarding the frequent occurrence of disease in Burkina Faso [17], this argument seems not persistent and merely theoretical.

Another methodological concern is the tendency for respondents to respond favourable to questions, as is systematically noted in research on perceived quality of care [2,14]. This may be related to survey instruments that are prone to giving socially desirable responses. We tried to control for this by interviewing the users (and obviously non-users) at home, and not near the health centre, and a few days after the visit to the health centre. Also, interviewers made clear that they were not related to the health centre. Furthermore, one can question whether there is a valid framework for studying perceptions of non-users of care, as their quality perceptions will not be based on actual experiences, but rather on expectations? We argue that it is possible, because it is individuals’ expectations that determine whether they consult modern health services or not. If health professionals manage to change these expectations—by changing the actual performance of modern health care or by changing the image of modern health care—our finding suggest that utilization will increase.

This study has shown the relative importance of different dimensions of quality of care, and how it may affect utilization patterns. To remove barriers to increase utilization, policy makers may do good to target their attention to improve financial accessibility of modern health services and improve drugs availability. These factors seem most persistent in decisions of ill people to stay with home-based care and/or traditional medicine, or go to consult modern health services.


   Acknowledgements
Top
 Methods
 Results
 Discussion
 Acknowledgements
References
 
This study was funded by University of Heidelberg. We thank all the staff of the CRSN, interviewers, health workers, and the persons who accepted to participate in the study. We also thank Catherine Kyobutungi for proofreading the article.


   References
Top
 Methods
 Results
 Discussion
 Acknowledgements
 References
 

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