DELIVERY OF IMPROVED SERVICES FOR HEALTH
THE CLIENT PERSPECTIVE:
What is quality health care service?
A Literature Review
By
Margaret Brawley
November 2000
USAID Cooperative Agreement 617-00-00-00001-00
In the simplest terms, total quality management advocates define quality as "Doing the
right thing right, right away.” An essential factor to consider when analyzing the quality of
care of health facilities is the perspective of the client. For clients and communities, quality
care is something that meets their perceived needs. Since a client's needs often differ, their
personal satisfaction ultimately depends on the perception, attitude and expectations of each
individual.
Despite its changing face, no one can argue that client satisfaction is unimportant. Patient
satisfaction is a strong influencing factor in determining whether a person seeks medical
advice, complies with treatments and maintains a relationship with the provider/health
facility. Ultimately, the dimensions of quality that relate to client satisfaction affect the
health and well being of the community.
The results of the literature review suggest that the most important dimensions of quality
for the client are technical competence, interpersonal relations, accessibility and amenities.
Technical competence refers to the skills and actual performance of the health providers in
regards to examinations, consultations and other technical procedures. It is important to note
that although clients are looking for proficient providers, often they can not assess this
dimension accurately. Furthermore, communities do not always fully understand their health
service needs. The interaction between the provider and the client comprises the category of
interpersonal relations. In this area, effective listening and communication skills have a
critical impact on customer satisfaction. Accessibility to the client means that the health care
services are unrestricted by barriers such as geography, economy or language. Finally,
amenities refer to a client's perception of the physical health care facility, as well as supplies
and equipment within the facility.
This literature review was conducted to support the Quality of Care Strategy, which is
designed "to support and strengthen the institutionalization of improved quality of health
services" with the implementation of basic health care standards. The goal of the literature
review was to identify areas of quality health care services that are particularly important to
the client and use this information as a basis for recommendations for client perspective
standards. The literature review involved an analysis of 17 articles and academic studies.
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I.
TECHNICAL COMPETENCE
A. Provider Competence/Training
The literature suggests that clients are particularly concerned about the qualifications and
training of service providers. The Quality of Reproductive Healthcare Study (DISH, 1999)
discovered that clients often expected facilities to have well qualified medical doctors and
laboratory technicians. Specifically, clients wanted providers to conduct a proper
examination, identify the problem and prescribe treatment. Many clients felt that the health
facilities lacked qualified staff and resented being treated by midwives or nurses who were
“training-on-the-job.” Although facilities often had one trained provider, this person, albeit
performing well, was often overburdened. Therefore, clients recommended that the facilities
maintain an adequate number of staff to satisfy demand and to eliminate the policy of
delegating responsibility to less qualified colleagues.
Gilson, et. al. (1994) also referred to the issue of unqualified health workers in Tanzania.
Many problems were thought to be caused by employment procedures, i.e. “some staff come
only as sweepers but after a while they are given posts as dispensers and nurses [nurse aides].
It is very dangerous.”
B. Service Provider Consultation
Clients consider the provider consultation when judging quality of care. Many studies cited
clients who felt disappointed that the provider did not spend more time with them to discuss
the problem and treatment. Clients thought providers should make the following
improvements:
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Spend more time listening to their problem
Explain the examination/procedure
Explain the treatment
Give clear instruction about medication
Give clients the opportunity to ask questions
Provide a referral if necessary
Although one study mentioned that clients valued referrals, more often than not referrals are
misunderstood. Sometimes clients view referrals as a failure of the staff or health unit to
correctly identify their problem (Nshakira et. al., 1996). Furthermore, it creates financial
problems for the user in terms of additional transport cost and unfamiliarity with a distant
health facility.
II.
INTERPERSONAL RELATIONSHIPS
The interpersonal relationship between a client and the provider is reported by many authors
to be one of the most important issues for clients’ perception of quality. Specifically, clients
prefer a service provider who:
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Gives a warm welcome
Acts friendly and polite
Shows respect and treats clients as a “human being”
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Is sympathetic
Acts fair and does not discriminate (Practices ‘first come – first serve’ principle)
Is humble
Communicates well in a language the client understands
Pays attention to the client
Expresses or demonstrates a commitment to their work
Assures clients of confidentiality
Client-centered care requires providers to respect a clients’ point of view, encourage clients
to discuss their needs, provide the appropriate medical information to the client and assist
them in making decisions rather than telling them what to do. (Kim et. al., 2000)
The relationship between health worker and client is a tenuous one. The health worker has an
opportunity to be extremely influential on a client simply by the way he or she interacts with
that person. Many people view health workers in the same light as a parent. Consequently,
clients expect health providers to behave and act in a manner deserving such respect.
Numerous studies cited low client satisfaction of quality of care because of poor attitudes
from health workers. For example, in Tanzania it was discovered that some dispensaries were
perceived as offering bad delivery care because of the bad attitude of staff (Opare, 1996).
III.
ACCESSIBILITY
A. Provider Availability/Waiting Time
Most of the literature suggests that clients would like to have increased access to health
workers. In particular, clients are looking for:
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A willingness to serve clients at any time of the day or night, even if the provider is not
on duty
A larger number of providers available
Punctuality
Shorter waiting periods at the facility
In many cases, clients reported the need for emergency services in the middle of the night and
described an acute sense of frustration and helplessness when providers did not arrive to
assist or arrived too late. The importance of staff living close to a health facility to provide
service whenever needed was cited as one main reason that clients prefer private clinics.
(Nshakira et. al., 1996)
The DISH project also found that lack of providers at a health facility had a negative impact
on clients’ perception of quality. Since available providers were overwhelmed this often led
to untrained providers delivering reproductive health services which in most cases were
poorly handled. (DISH, 1999)
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B. Cost of Services
It is no surprise that many clients believe that health services should be provided free or that
fees charged should be reasonable. Patients desire:
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Affordable fees
Not to be denied services because they can’t pay
Charges for drugs, but not examination or consultation services
No unfair charges for beds, “drip water,” or medical forms
One study found that people were uncertain about exact costs of health services because the
charges varied depending on the service a client received. In addition, clients complained of
numerous informal charges that they had to pay - over and above the formally established
fees. Other users mentioned the need to negotiate and bargain for reduced charges or service
that is commensurate with the money they have – “even if it means getting only one capsule
and two aspirins” (Nshakira et. al., 1996). Other clients complained that family and friends
were flatly denied treatment because of their inability to pay.
In the Tororo District, Opare (1996) discovered that communities were in fact willing to pay
for improved quality of services. The problem of course, was affordability. Despite an
appreciation for improved services, some people could still not afford the services.
IV. AMENITIES
A. Infrastructure
Clients typically noted the following concerns for quality of the facility:
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building in good repair
running water & electricity available
cleanliness/sanitation (examination rooms, toilets/latrines)
privacy/comfort
- plenty of seats/mats in waiting room to accommodate clients
- adequate space to maintain client confidentiality (curtains or private rooms/areas)
- beds vs. floor
B. Equipment/Supplies
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Availability of drugs
Many studies show that patients equate availability of drugs with high quality services. In
Kenya, one study reported that drug availability in the health facility had a positive impact on
demand for services. Another study in the Tororo District also concluded that the availability
of drugs in the rural health facilities brought satisfaction not only to the users, but also to the
providers (Opare, 1996).
The DISH Project found that a reliable supply of drugs and medicine was a critical but
lacking factor in provision of service. “…This factor needs to be addressed if the demand
and utilization of services is to increase.” (DISH, 1999)
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“To be frank, drugs are a big problem. It has reached the stage where we have to buy drugs
and put them in our pockets, then we go to the dispensary to get them administered,” said one
participant of a focus group discussion among village council members in Tanzania. (Gilson
et. al, 1994). This study found that drugs are a main reason why people seek care in alternate
locations.
At the same time, some clients believe drugs are necessary for treatment. Users often think
that receiving drugs means receiving treatment. Therefore, a consultation without drugs is a
waste of time. As a result, many users will choose a health facility where they expect to find
drugs all the time, such as private clinics. (Nshakira et. al., 1996)
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Proper equipment available
The DISH Project reported that clients believe a health facility with good quality service must
be equipped with diagnostic equipment, blood testing equipment and laboratory equipment.
Other suggestions included operational equipment, ambulance, furniture, beds, mattresses
and gloves. (DISH, 1999) The lack of equipment was also a major criticism of outreach
services in Tanzania – “examinations are done on the floor” or “women have to lie on the
desks, which is very painful” (Gilson et. al., 1994). Villagers in Zaire were asked what they
would do if the microscope was to disappear from the health center, and many expressed their
readiness to go to another facility (Opare, 1996).
V. PROVIDER CONCERNS
Although the main focus of this literature review was to evaluate the client perspective of
quality health care, it is also interesting to note some concerns that service providers have
regarding this topic. Typically, providers mentioned the following items about quality care:
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Cost is reasonable, but they recognize the need for a credit scheme for patients.
There is not enough trained staff available.
There is a need for continuous training to improve technical practice.
Proper examination of patients is a must for quality care.
The equipment needed for specific examinations is often lacking.
At times, patient demands inhibit proper medical practice (i.e. the desire for injections).
Providers recognize the need for adequate communication about procedures and a
positive interaction with the client (i.e. receiving patient politely, showing kindness, using
language a client understands)
Availability of drugs: Providers more often stressed supply problems rather than
management or prescription habits as the reason for lack of a drug supply at the facility.
In addition, providers mentioned a high demand for injections from their patients.
Poor pay, delayed salaries and lack of allowances are not conducive to the provision of
quality of care. These things cause low morale and motivation for providers.
Providers would also like to see proper appointment and confirmation of their positions,
as well as occasional promotions.
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VI.
RECOMMENDATIONS
The client perspective on quality health care service is too important to neglect. Client
satisfaction with overall service can have a tremendous impact on the future health of
communities in Uganda. For this reason it is recommended that the Quality of Care Strategy
incorporate a section geared directly to client satisfaction. This segment should address the
following client concerns to the best of its ability:
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Provider Training
Provider Competence
Interpersonal Relations
Availability of Providers
Waiting Time
Cost of Services
Infrastructure
Equipment & Supplies
In the Draft Basic Standards of Quality of Care, under the section of Customer Service, there
is a suggested list of 10 specific standards to address client concerns about quality:
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3
3
2
---10
Provider Training/Competence
Interpersonal Relations
Availability of providers/waiting time/cost of services
Amenities
Total
In addition, interspersed throughout the other categories, you will find reference to additional
client issues such as infrastructure and supplies.
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