Research Article: Expectations of healthcare quality: A cross-sectional study of internet users in 12 low- and middle-income countries

Date Published: August 7, 2019

Publisher: Public Library of Science

Author(s): Sanam Roder-DeWan, Anna D. Gage, Lisa R. Hirschhorn, Nana A. Y. Twum-Danso, Jerker Liljestrand, Kwanele Asante-Shongwe, Viviana Rodríguez, Talhiya Yahya, Margaret E. Kruk, Kathryn Chu

Abstract: BackgroundHigh satisfaction with healthcare is common in low- and middle-income countries (LMICs), despite widespread quality deficits. This may be due to low expectations because people lack knowledge about what constitutes good quality or are resigned about the quality of available services.Methods and findingsWe fielded an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal, and South Africa in 2017 (N = 17,996). It included vignettes describing poor-quality services—inadequate technical or interpersonal care—for 2 conditions. After applying population weights, most of our respondents lived in urban areas (59%), had finished primary school (55%), and were under the age of 50 (75%). Just over half were men (51%), and the vast majority reported that they were in good health (73%). Over half (53%) of our study population rated the quality of vignettes describing poor-quality services as good or better. We used multilevel logistic regression and found that good ratings were associated with less education (no formal schooling versus university education; adjusted odds ratio [AOR] 2.22, 95% CI 1.90–2.59, P < 0.001), better self-reported health (excellent versus poor health; AOR 5.19, 95% CI 4.33–6.21, P < 0.001), history of discrimination in healthcare (AOR 1.47, 95% CI 1.36–1.57, P < 0.001), and male gender (AOR 1.32, 95% CI 1.23–1.41, P < 0.001). The survey did not reach nonusers of the internet thus only representing the internet-using population.ConclusionsMajorities of the internet-using public in 12 LMICs have low expectations of healthcare quality as evidenced by high ratings given to poor-quality care. Low expectations of health services likely dampen demand for quality, reduce pressure on systems to deliver quality care, and inflate satisfaction ratings. Policies and interventions to raise people’s expectations of the quality of healthcare they receive should be considered in health system quality reforms.

Partial Text: A growing body of literature describes systematically poor quality of healthcare in low- and middle-income countries (LMICs) today [1–4]. For example, only 21% of providers correctly managed tuberculosis in a study using standardized patients in India [5]. Health workers in 18 LMICs performed on average less than half of recommended reproductive, maternal, newborn, and child health actions during a visit, and a patient in Africa is twice as likely to die after surgery than the global average [2,6]. An analysis of global data estimated that 8.6 million lives lost in LMICs in 2016 could have been prevented by high-quality healthcare; whereas 40% did not have access to care, 60% made it to a facility but did not receive the high-quality care needed to avert death [7]. Nonhealth outcomes such as confidence in the health system and cost of care also suffer in settings of low quality [8].

Of the 57,786 respondents who opted to take the survey, 17,996 respondents (31%) completed the survey questions for this analysis; this formed our analytic sample (Table 1). The completion rate is similar to rates reported for similar studies [35–38]. After weighting the data with population census weights, approximately half of respondents (51%) were male, 35% were between the ages of 18 and 29, 39% were between the ages of 30 and 49, and 25% were over the age of 50. Rural residents made up 41% of the sample. Nearly half of respondents (45%) had a primary education or less. The vast majority (73%) reported good general health with a mean number of outpatient healthcare visits over the last year of 2.5 (SD 3.0). One-third of all respondents (34%) reported that they experienced discrimination in the healthcare system in the past.

Responses from nearly 18,000 internet users in 12 LMICs show that good ratings for poor quality are common: over 50% of respondents indicated that objectively poor quality of care described in vignettes was good, very good, or excellent. Vignettes highlighting poor technical quality and poor interpersonal quality yielded similar results, supporting the hypothesis that low expectations, not lack of technical knowledge, drives these ratings. The prevalence of good ratings is especially notable given that internet users are likely to be more affluent and educated than the general population and thus more likely to access better quality care and have higher expectations of quality [40,41]. Our finding that a majority of people in the study countries have low expectations of healthcare quality points to a lost opportunity to keep health systems accountable for the quality of care that they deliver. This work may help explain current high satisfaction ratings and inform efforts to better measure people’s assessment of health system performance.



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