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
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
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Abstract |
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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
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Introduction |
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Improving client perceptions of service quality has become a central concern to health managers, policy makers and researchers in recent years [1, 2]. Consequences of low-perceived quality of care include poor compliance with treatment and advice, failure to pursue follow-up care and dissuading others from seeking care [3]. 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 services [4].
Afghanistan, relying on a strategy of partnering with contracted non-governmental organizations to implement a basic package of health services, has made substantial progress in the development of health services in recent years after many decades of conflict [5]. The Afghanistan Ministry of Public Health implements an innovative monitoring system to track client perceptions of quality on a routine basis as part of a Balanced Scorecard approach [6], but no study in recent years has examined the determinants of client perceived quality in Afghanistan.
The objectives of this study are to develop a scale to measure client perceptions of quality, assess its reliability and validity, and identify individual, household and health service characteristics that are associated with client perceived quality in Afghanistan.
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Methods |
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This study utilizes data derived from an assessment of health services conducted in Afghanistan in 2004. The assessment included a random sample of up to 25 health facilities implementing a basic package of health services in each province, stratified by health facility type: Basic Health Centers, Comprehensive Health Centers and District Hospitals. Each has different staffing levels and provides different sets of services [7].
In each sampled facility, a supervisor implemented a facility assessment instrument that measures infrastructure, staffing, service capacity, management processes and availability of equipment, drugs and supplies. Survey teams conducted five direct observations of patient–provider interactions involving patients under age five and five involving patients age five or older. An exit interview was conducted with each patient whose consultation was observed, or the caretaker if the patient was a child. During the exit interview, the patient or caretaker was asked a series of standardized questions regarding different aspects of their visit to the facility. The final sample included 617 health facilities in 33 provinces, 5719 direct observations of patient–provider interactions and 5597 exit interviews.
Outcome variable: client perceived quality
A scale of client perceptions of service quality was developed from eight items that measure desirable characteristics of health services. These items were derived from the indicator used to monitor client perceptions of quality on a routine basis through the Afghanistan Health Sector Balanced Scorecard [6]. The eight items, shown in Table 1, are based on statements read to each respondent during the exit interview. Each respondent was asked to rate his or her level of agreement with each statement, according to a four-point Likert-type scale. Each point on the scale was represented by a number of Afghan-style pieces of bread, naan. One naan represented ‘strongly disagree’, two naan ‘disagree’, three naan ‘agree’ and four naan ‘strongly agree’. Previous studies from low income and low literacy settings have used pictures of different denominations of money [2] or different numbers of pieces of locally made bread [8] to measure perceptions of health services. The naan scale was found through formative research and field testing to be relatively easily understood by participants in this setting. This approach had the additional advantage of providing a visual image of different number of naan in the form of a laminated photograph to which respondents could point to indicate their response to each item, in case they preferred to give non-verbal responses.
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Maximum likelihood factor analysis was conducted on the eight perceived quality items to identify the common factor or factors underlying the eight items [9]. It was theorized that a single factor, perceived quality, underlies the eight items.
Independent variables
Health service characteristics
Facility type is included to determine whether client perceived quality varies by level of the primary care system. The type of implementing agency refers to whether the Ministry of Public Health or a non-governmental organization is the direct provider of services. The physical condition of the facility measures both cleanliness and state of repair. Visible technical capacity measures technical capacity visible to patients, including presence of electricity, running water, refrigerator, laboratory, telephone and a vehicle. Maternal and child health service capacity measures capacity to provide antenatal care, delivery care, emergency caesarian sections, routine immunization services at the facility, outreach immunization services and oral rehydration therapy. The equipment index measures the extent to which a set of essential equipment items are present and in working condition, while the drug index measures the availability of five essential drugs. Management of patient flow measures patient waiting times before being seen by a provider. Four types of clinical processes are included: (i) taking patient histories, (ii) conducting physical examinations, (iii) communication with patients and (iv) time spent with patients.
Two health worker characteristics are included in the analysis: health worker type (doctor vs. other, a residual category that includes assistant doctors, nurses and a small number of other types of health workers) and health worker sex.
Patient and household characteristics
Six patient and household characteristics are included: (i) patient sex, (ii) patient age, (iii) household wealth status, (iv) time spent traveling to the facility, (v) amount of money spent for transportation to the facility and (vi) total amount paid in fees at the facility. An asset index was developed to measure household wealth status [10]. Principal component analysis was run on the reported ownership of household assets recorded during exit interviews and the first component was retained and used to classify all interviewed patients into one of five wealth quintiles using the pooled national sample.
All independent variables measured as indices were made into categorical variables by dividing cases into quintile groups, to facilitate interpretation of results.
Data analysis
Statistical analysis was conducted using Stata 9. To develop the perceived quality scale, principal component analysis and maximum likelihood factor analysis were conducted after examining the marginal frequency distributions of the items used to construct the scale, with the number of relevant factors underlying the items assessed through eigenvalues and scree plots [9].
The clustering of observations at the facility level was accounted for through Taylor linearized variance estimation [11]. Multiple linear regression models were used to compare differences in levels of perceived quality across groups. Model fit was evaluated using summary measures of fit and examining residual plots. Multicollinearity was assessed by estimating the Variance Inflation Factor. In order to assess whether the determinants of client perceived quality vary by patient sex, sex-stratified models were fit. Province was included in all multivariable models as a control variable.
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Results |
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Results for items measuring client perceived quality
The marginal frequency distribution of each item used to develop the scale is summarized in Table 1. Results from principal component analysis indicated that one factor explained 49% of the variance in the set of items.
Scale reliability and validity
Internal consistency reliability
The results indicate high internal consistency reliability, with an alpha coefficient of 0.84 and item-rest correlations that range from 0.63 to 0.77.
Construct validity
Based on the experience of study investigators using similar items in other settings [2], extensive consultative processes implemented as part of the development of the Afghanistan Health Sector Balanced Scorecard [6] and formative research conducted in health facilities and rural communities in Afghanistan prior to data collection, it was theorized that the items used reflect the latent variable perceptions of quality, with a single underlying dimension. The results from factor analysis indicate that this set of items does in fact measure a single underlying construct.
Concurrent validity
Concurrent validity was assessed by examining the association between the scale of perceived quality and a related variable: overall patient satisfaction. Compared with client perceived quality, overall patient satisfaction is a distinct but related construct [2, 12, 13]. Overall patient satisfaction reflects patients' personal preferences to a greater degree than perceived quality, while perceived quality reflects patient ratings of specific aspects of service quality [2]. In spite of these differences, overall patient satisfaction and perceived quality are related and a moderate level of correlation is expected [14]. In the current study, overall patient satisfaction was measured using the same four-point Likert-type scale as the perceived quality items. The correlation between the scale of perceived quality and overall patient satisfaction is 0.51, indicating reasonable concurrent validity.
Factors associated with client perceived quality
Bivariable results are summarized in Tables 2 and 3 and multiple linear regression results are summarized in Table 4. Holding other variables constant, client perceived quality is higher when health workers are more thorough in taking patient histories and conducting physical examinations (6.31 for highest quintile compared with lowest, P < 0.001) and communicating with patients (4.36 for highest quintile compared with lowest, P < 0.001).
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Client perceived quality is also higher when the health worker providing care is a doctor (4.02, P < 0.001) and when the patient's household is in the poorest quintile (2.05, P < 0.01). Neither the sex of the health worker nor the sex of the patient is associated with perceived quality, but when both the provider and the patient are female perceived quality is higher (4.29, P < 0.05).
Client perceived quality is lower when patients spend 100 or more Afs (1 US Dollar = 50 Afs) for transportation to the facility (–4.92, P < 0.01) and when the wait before being seen by a provider is longer (–4.44 for patients who wait >2 h compared with patients who wait 10 or fewer minutes, P < 0.001).
None of the other variables of interest were found to be significantly associated with perceived quality.
Female patients at district hospitals report lower perceived quality compared with female patients at basic health centers (–3.75, P < 0.05), holding other variables constant. Longer waiting times are also associated with lower perceived quality among women (–5.58 for those waiting >2 h compared with those waiting 10 or fewer minutes, P < 0.01). For female patients, being seen by a female provider is associated with higher perceived quality (3.49, P < 0.01).
Neither time nor money spent for travel is associated with perceived quality among female patients. In contrast, both time (–3.51 for those spending >60 min traveling compared with those spending 15 or fewer minutes traveling, P < 0.05) and money spent for travel (–5.68 for those spending 100–2000 Afs compared with those spending 0–99 Afs, P < 0.001) are associated with lower perceived quality among male clients.
The R2 value was 0.35 for the all clients model and male clients model and 0.39 for the female clients model.
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Discussion |
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Clients of primary care services in Afghanistan report relatively high levels of perceived quality. Most of the variation in client perceptions of quality that is explained by the models relates to the patient's interaction with the health worker and not to health facility characteristics, such as cleanliness, infrastructure, service capacity and the presence of equipment or drugs.
The finding that health worker thoroughness in taking histories, conducting examinations and communicating with patients was the strongest determinant of client perceived quality is largely, but not completely, consistent with the existing literature. Several studies have found that the behavior of health personnel is associated with client perceived quality, but this behavior is more commonly linked to interpersonal or relational aspects rather than technical aspects of care defined in clinical terms [2, 15–18]. Separating relational from technical aspects of care may be artificial, since histories and examinations are likely experienced by patients as intimately relational. This distinction, commonly drawn in the literature, may not be meaningful from the perspective of clients.
Previous studies have found that presence of qualified personnel at the facility is associated with client perceptions of quality [19, 20], but existing literature contains little evidence on the relationship between the type of health worker providing care and the client's perceptions of service quality. The association between having a doctor providing care and higher perceived quality is consistent with findings from the companion study of observed measures of quality that showed that doctors are associated with higher quality clinical processes, compared with other health workers [21]. This association holds even when controlling for the thoroughness of the provider in patient histories, physical examinations and communicating with patients, indicating that these factors alone are not sufficient in explaining why doctors are associated with higher client perceived quality. Given the preference for doctors, patients may bypass facilities without doctors when they have a choice to go to facilities with doctors—this may hinder efforts to extend health services to remote areas.
The present study of perceived quality and the companion study using observed measures of quality are consistent in finding that the sex of the client in itself is not associated with variations in quality, but that quality is higher when both the patient and provider are female [21]. Previous studies of the effect of patient sex on perceived quality and patient satisfaction show mixed results that vary by setting [14, 22–24]. Existing literature contains little evidence on the effect of provider sex on perceived quality, but several studies have found an association between provider sex and patient satisfaction, with patients of female providers generally reporting higher levels of satisfaction than patients of male providers [25]. Among studies that have examined patient and provider sex concordance, three have found that female patients of female providers are the most satisfied [26–28], while one found female patients of female providers the least satisfied and male patients of female providers the most satisfied [29] and another found male patients seen by younger female physicians the least satisfied [30].
The effect observed when female providers serve female patients is likely to be highly specific to local cultural context. Increasing the number of female providers has long been seen as a way to increase access to health services for women in Afghanistan [31]. Increasing the number of female providers may also reinforce the level of service quality received by women in Afghanistan. However, female providers are a small proportion of providers in this study, and existing providers may be different from a pool of potential providers, who might not have the same skills. This indicates a need for further investigation into the level of service quality provided by newly recruited female providers in Afghanistan.
Consistent with results from previous studies, this study shows that client perceptions of quality are sensitive to the amount of time clients are kept waiting before being seen by the provider [15, 16], but not sensitive to the amount of time the provider spends with them. A few minutes spent with the provider appears not to have a negative effect on perceived quality, while time spent waiting for the often brief consultation to begin is associated with lower perceived quality.
The sex stratified models show that the negative association between waiting times and perceived quality is much stronger among female than male clients. One possible explanation for this is that the lack of separate waiting areas for female clients may create difficulties for female clients who wait a long time before being seen by a provider.
Little research has been conducted on the association between the amount of money spent by a client for services received or for travel to the facility and client perceptions of quality. One study in Tanzania found that both men and women perceive more distant facilities to be of lower quality than closer facilities [20]. In the present study, the negative association between time and money spent for travel and perceived quality is much stronger among male than female patients. One possible explanation for this is that women tend to travel with a male escort, who is likely to disburse the money. Furthermore, the opportunity cost of traveling to the facility may be lower for women, since they are less likely to work for an income than men, and women who tend to be confined to the home may view a trip to a health facility outside the community as less onerous than men.
Results from this study showing that client perceived quality is higher among the poor than the non-poor, along with results from the companion study of observed measures of quality showing that the poor receive equal or higher levels of service quality at non-governmental organization facilities [21], indicate that Afghanistan's approach to rapidly expanding health services has led to an increase in access to quality services among the poor.
It is important to note what was found not to be associated with variations in perceived quality. No characteristics related to the physical condition of the facility, service capacity or the presence of equipment or drugs were associated with variations in client perceived quality. This is contrary to results from studies conducted in other settings that have found lack of drugs [16, 18], availability of a larger constellation of services [20], presence of microscopes [19] and type of facility [20] to be associated with client perceived quality. This finding suggests that in Afghanistan interventions that focus on health worker performance in clinical processes is likely to have a greater impact on client perceived quality than interventions that focus on facility structures or inputs.
The size of the female health workforce in Afghanistan should be increased, with further research on the quality of care provided by female providers newly recruited into the health workforce. The management of patient flow should be improved to reduce patient waiting times, especially for women, and facilities should be designed to meet the needs of female clients, with separate waiting and consultation rooms for women. Interventions that focus on subsidizing the cost of transportation to reduce the expense and time required to travel to the facility should be developed and evaluated.
Minimizing negative perceptions of health services, reinforcing favorable perceptions and engaging non-users of services may lead to increased utilization of health services in Afghanistan, contribute to the stability of the government and advance its efforts to rebuild the health system.
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Funding |
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This study was funded by a contract between the Afghanistan Ministry of Public Health and the Johns Hopkins Bloomberg School of Public Health, in collaboration with the Indian Institute of Health Management Research.
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Acknowledgements |
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The contributions of the Johns Hopkins University and Indian Institute of Health Management Research Third Party Evaluation team and the Ministry of Public Health's Monitoring and Evaluation Department are gratefully acknowledged, along with the helpful comments from the editors and the anonymous reviewers.
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