Measuring client satisfaction and the quality of family planning services: A comparative analysis of public and private health facilities in Tanzania, Kenya and Ghana
verfasst von:
Paul L Hutchinson, Mai Do, Sohail Agha
Public and private family planning providers face different incentive structures, which may affect overall quality and ultimately the acceptability of family planning for their intended clients. This analysis seeks to quantify differences in the quality of family planning (FP) services at public and private providers in three representative sub-Saharan African countries (Tanzania, Kenya and Ghana), to assess how these quality differentials impact upon FP clients' satisfaction, and to suggest how quality improvements can improve contraceptive continuation rates.
Methods
Indices of technical, structural and process measures of quality are constructed from Service Provision Assessments (SPAs) conducted in Tanzania (2006), Kenya (2004) and Ghana (2002) using direct observation of facility attributes and client-provider interactions. Marginal effects from multivariate regressions controlling for client characteristics and the multi-stage cluster sample design assess the relative importance of different measures of structural and process quality at public and private facilities on client satisfaction.
Results
Private health facilities appear to be of higher (interpersonal) process quality than public facilities but not necessarily higher technical quality in the three countries, though these differentials are considerably larger at lower level facilities (clinics, health centers, dispensaries) than at hospitals. Family planning client satisfaction, however, appears considerably higher at private facilities - both hospitals and clinics - most likely attributable to both process and structural factors such as shorter waiting times and fewer stockouts of methods and supplies.
Conclusions
Because the public sector represents the major source of family planning services in developing countries, governments and Ministries of Health should continue to implement and to encourage incentives, perhaps performance-based, to improve quality at public sector health facilities, as well as to strengthen regulatory and monitoring structures to ensure quality at both public and private facilities. In the meantime, private providers appear to be fulfilling an important gap in the provision of FP services in these countries.
The online version of this article (doi:10.1186/1472-6963-11-203) contains supplementary material, which is available to authorized users.
Paul L Hutchinson, Mai Do and Sohail Agha contributed equally to this work.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors participated in research design and conceptualization, data analysis, writing, and revision of this manuscript. All authors have read and approved the final manuscript.
Background
Numerous studies have examined the effects of family planning quality on the uptake and continuation of family planning methods [1‐7]. One principal determinant of uptake and continued utilization of family planning services is overall client satisfaction with those services [8, 9]. Studies of contraceptive discontinuation rates, for example, have indicated that - with the exception of the desire to become pregnant - the principal reason for discontinuation is dissatisfaction with the quality of services [10].
Both the public and private sectors supply substantial portions of family planning methods in developing countries, but face different incentives to provide services of high quality and to ensure client satisfaction [11, 12]. Public sector health services, for example, are less likely to be motivated by economic incentives (since governments and their health facilities seldom go out of business) and have frequently been characterized by low staff morale, attendance and performance, often related to poor or infrequent pay, at least relative to the private sector [13, 14]; poor quality of care and treatment [15]; shortages of workers, medicine, supplies and functioning equipment; and waste and inefficiency [11, 15‐18].
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Motivated to maximize the demand for their services while minimizing their costs, private for-profit facilities generally face greater incentives to be efficient and client-friendly providers of health care. Even so, they have been shown to be of varying quality, often due to the inability of government regulatory bodies to adequately monitor and enforce standards [19‐22]. Private providers may also take advantage of informational asymmetries to sell unnecessary - or poor quality services - to unsuspecting consumers [21]. Non-governmental facilities, often not-for-profit and affiliated with religious, faith-based organizations, have been touted as being likelier to provide higher quality services because of their social mission, but evidence to support this has been mixed [13, 18].
As calls for privatization and performance-based incentive schemes have become an increasing part of the dialogue surrounding health systems strengthening in developing countries [11, 12, 23‐25], the need for evidence-based assessments of quality differentials between public and private providers has also increased. To date, only a handful of studies have examined differences in the quality of family planning services provided by the public and private sectors [13], and even fewer have sought to link those quality differentials to measures of client satisfaction [26]. As a result, little is known about how moves towards greater private sector provision of family planning will impact upon client satisfaction, contraceptive use, and ultimately fertility.
This study examines differences in technical, structural and process measures of quality between public and private health facilities, both in hospitals and primary care facilities, in three countries - Kenya, Tanzania and Ghana. These countries were chosen principally because of the availability of detailed information on random samples of family planning suppliers via Service Provision Assessments and because the private health sector varies in importance as a provider of family planning across the three countries. Data from Demographic and Health Surveys indicate that the percentage of women receiving contraceptive supplies from private family planning providers ranges from 12.7% in Tanzania (private medical 5.0%; religious/voluntary 7.7%) [27], to 30.5% in Kenya (24.2% private medical; 6.3% mission hospital/clinic) [28], and to 53.7% in Ghana [29]. Further, the family planning situation in these countries is fairly typical for Sub-Saharan Africa. For the region as a whole, the contraceptive prevalence rate is 20.9 percent of women aged 15 to 49 years [30], close to the rates observed in Tanzania (26.4%) [27] and Ghana (23.5%) [29]. Only Kenya has a contraceptive prevalence rate that significantly exceeds this average (45.5%) [28].
This study links measures of FP quality to measures of client satisfaction at each type of public and private family planning provider. Our hypothesis is that higher levels of quality - particularly indicators that measure clients' perceptions of client-provider interactions - will yield higher levels of client satisfaction. In turn, higher rates of client satisfaction have been shown to yield higher family planning adoption and continuation rates [10], though such outcomes are not the focus of this study. Importantly, this study will also assess which specific measures of family planning service quality achieve the largest incremental gains in client satisfaction.
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The next section describes the data, the quality measures, and analytical methods utilized in this study. Following that are discussions of the bivariate and multivariate analyses. The last section summarizes the results and discusses some policy recommendations.
Methods
Service Provision Assessments, developed by ORC Macro [31], are facility-based surveys intended to provide a comprehensive picture of the quality and availability of a basic health services, including those for maternal, child and reproductive health, in a given country. They are intended to be nationally representative of the supply environment, and provide a gauge of how capable existing services are to meet the needs of a country's population. The principal advantages of the SPAs are that they are standardized across countries, thereby allowing direct comparisons in assessments of family planning service availability and quality, and of sufficient sample size to generate sub-national level or facility-type estimates. Further, data collectors, recruited from among nurses and other health professionals trained in survey implementation and interviewing, possess the requisite technical skills to assess the quality and procedural correctness of provider-client interactions.
This study makes use of Service Provision Assessments (SPAs) conducted in Ghana [29], Tanzania [31] and Kenya [32]. In Tanzania, the SPA was led by the National Bureau of Statistics in collaboration with the Ministry of Health and Social Welfare (MoHSW - Mainland and Zanzibar) and the Office of the Chief Government Statistician, Zanzibar. In Ghana, the SPA was carried out by the Ghana Statistical Service (GSS) with assistance and support from the Health Research Unit (HRU), the Ministry of Health (MOH), the Ghana Registered Midwives Association (GRMA), the Planned Parenthood Association of Ghana (PPAG), and the National Population Council (NPC). Finally, the Kenya SPA was undertaken by the National Coordinating Agency for Population and Development (NCAPD), the Ministry of Health (MOH), and the Central Bureau of Statistics. In each country, ORC Macro provided technical assistance.
Instruments
To provide a broad and detailed picture of the quality and availability of health services and perceptions of quality, the SPAs consist of four standardized data collection components. As noted above, all survey instruments and tools were previously fielded in a number of countries, though country-specific pre-testing was undertaken in each country to ensure that questions were appropriate to local circumstances:
(1)
The Facility Inventory Questionnaire was used to obtain information on staffing, training, infrastructure, medicines, supplies, and services offered. The focus was on ascertaining the functional ability of facilities to provide services of acceptable standards.
(2)
A provider interview collected information from samples of health care workers - in particular those who actually provide client services - in order to determine qualifications, experience and perceptions of the service delivery environment.
(3)
Observations of family planning services were conducted to assess providers' adherence to accepted standards of quality and service delivery.
(4)
Exit interviews were conducted with clients who received family planning services to determine the clients' experience of the client-provider interaction, recollection of instructions and FP related information, and perceptions of the service delivery environment.
Sampling
Facilities
In each of the countries, health facilities (Table 1) were chosen at random from among the population of public, private, and faith-based facilities that offered services for maternal, child, and reproductive health. Sample sizes were determined based on funding, logistical considerations and minimum sample sizes required when regional estimates were desired. Following similar analyses examining differences in coverage by public and private providers [11], facilities were stratified by operating authority (public vs. private) and by facility type (hospital and other) and a systematic sample was drawn after a random start. Private facilities were defined as those that were either for-profit providers or nongovernmental organizations using market-based approaches to service delivery. In some cases, over-sampling was done to permit analysis by region and facility type, and weights were created to adjust for unequal probabilities of selection.
Table 1
Sample of Health Facilities by Country
Ghana
Kenya
Tanzania
Number of facilities nationwide providing all services
1,444
4,742
5,663
Number selected for survey
428
440
611
Number offering FP services
386
323
482
The final sample of health facilities used in this study - restricted to those which offer family planning services - included 386 in Ghana, 323 in Kenya and 482 in Tanzania (Table 2). In each country, the majority of the health facilities were publicly operated. The weighted sample of hospitals made up 10% of facilities in Ghana, 7% of facilities in Kenya and 4% of facilities in Tanzania. Similarly, private sector providers made up 35% of facilities in Ghana and Kenya and 17% of facilities in Tanzania (Table 2).
Table 2
Sample Distribution of Facilities, Provider Interviews, and Client Exit Interviews
Ghana
Kenya
Tanzania
Pct. Distribution (weighted)
Weighted
Unweighted
Pct. Distribution (weighted)
Weighted
Unweighted
Pct. Distribution (weighted)
Weighted
Unweighted
Facilities
Public
Hospital
6.6
42
42
3.7
12
87
2.2
11
87
Health centers, clinics, dispensaries
58.0
216
185
61.2
198
72
80.4
388
315
Private
Hospital
3.3
12
12
3.6
12
60
2.0
9.5
24
Health centers, clinics, dispensaries
32.1
116
147
31.5
102
104
15.4
74
56
Total
100.0
386
386
100.0
323
323
100.0
482
482
Provider Interviews
Public
Hospital
31.1
262
140
26.0
223
310
9.1
113
393
Health centers, clinics, dispensaries
44.6
376
390
40.2
345
161
70.3
874
624
Private
Hospital
5.6
47
40
13.1
113
192
6.5
81
109
Health centers, clinics, dispensaries
18.7
157
275
20.7
178
197
14.1
175
118
Total
100.0
842
845
100.0
859
860
100.0
1244
1244
Exit Interviews
Public
Hospital
19.8
121
172
8.9
56
346
6.6
66
411
Health centers, clinics, dispensaries
53.7
328
242
66.7
419
130
83.2
836
493
Private
Hospital
3.1
19
32
2.9
18
67
2.7
27
58
Health centers, clinics, dispensaries
23.5
143
165
21.5
135
85
7.5
76
43
Total
100.0
611
611
100.0
628
628
100.0
1005
1005
Providers
In all three countries, a sample of health care workers/providers was selected from those who were present in the facility on the day of the survey and who provided services in the four areas (child health, family planning, maternal health, and sexually transmitted infections/HIV/AIDS) assessed by the SPA. If a facility had fewer than 8 health care workers, all who were present on that day were interviewed. In facilities with more than 8 providers, at least one provider from each service was interviewed to obtain a minimum of 8 providers. The samples of providers of family planning included 845 providers in Ghana, 859 providers in Kenya and 1,244 providers in Tanzania (Table 2).
Training and Data Collection
In each country, data collectors were recruited from nurses, clinical officers or social scientists with prior experience in survey implementation and interviewing. Data collectors spent approximately three weeks in training, which included classroom lectures, practical on-site experience in health facilities, and role-playing for observations and exit interviews.
Fieldwork lasted several months, and was undertaken by 13-17 teams of interviewers, generally consisting of one team leader and 2-4 interviewers. In small facilities, data collection took approximately one day, but larger facilities required several days. If a particular service for observation was not offered on the day of a visit, interview teams returned on a day when it was being offered. Interviews with providers of family planning were undertaken with those most knowledgeable of those services at a facility. Informed consent was also obtained from the providers and the facility in-charge.
Observations and Exit Interviews
Observations were conducted of clients who came for maternal, child, reproductive health or sexually transmitted infection (STI) services. This sample was opportunistic because it was not possible to know how many eligible clients would come to the facility on the day of the observation. Following the observation of client-provider interaction, exit interviews were conducted to determine client satisfaction with services provided. Information on refusal rates for the exit interviews was not available from the published sources or from the data. In total, 611 interviews with family planning clients were conducted in Ghana, 628 interviews in Kenya, and 1,005 interviews in Tanzania (Table 2).
Operational definitions of quality of care and client satisfaction
Over the years, researchers have developed numerous systems and indicators for measuring the quality of family planning services [6, 8, 9, 33, 34]. It is now well-understood that the quality of health services is more than just bricks and mortar availability of infrastructure, supplies or equipment. In this paper, we follow the structure outlined by Donabedian [35], focusing on several categories of quality measures which we describe in detail in Table 3. These include structural, interpersonal and technical attributes of service quality.
Table 3
Attributes and Indicators Used for the Assessment of Quality of Care in This Study
Definition of indicators
STRUCTURE
Infrastructure & equipment
Physical infrastructure
Number of amenities available at facility: electricity, water, working toilet, telephone, waiting area for clients (out of 5)
Examination room equipment
Number of following items present: table and stool for gynecological exam, source of light, speculum, soap, single-use towel, water for hand-washing, clean gloves, decontamination solution, sharps box, privacy in exam room (out of 10)
Management
Review of management
Whether there is a system for reviewing management/administrative issues
System to collect client opinion
Whether there is a system to obtain clients' opinions regarding services
Quality assurance program
Whether the facility has a routine program for quality monitoring
Supervision
Whether the last supervisory visit to the facility was in the last 6 months
Stock inventory, organization, and quality
Number of following items present at facility: inventory for contraceptive supplies, stock organized by expiry date, contraceptives protected from water, sun, and pests
Availability of services
Number of days services provided
Number of days per week that FP services are provided
Availability of provider
Whether a trained provider is always available at the facility
FP methods offered
Number of methods offered: combined oral pill, progesterone only pill, IUD, 2 or 3 month injectable, 1 month injectable, Norplant, male condom, female condom, spermicide, diaphragm, emergency contraception, counseling about natural methods, tubectomy, vasectory (out of 14)
Other reproductive health services offered
Number of RH services besides FP offered: STI services, immunization, antenatal care, postnatal care, postabortion care, and delivery (out of 6)
Counseling
Guidelines
Number of guidelines or protocols for counseling at the facility (out of 5)
Visual aids
Number of visual aids for demonstrating use of FP methods at facility (out of 9)
Privacy
Whether facility has private room for FP counseling
Individual client card
Whether there is an individual client card/record for FP
FP experience of providers
Number of years of experience of providers in providing FP services
Providers trained in FP
Number of providers who received any in-service training in FP in last 5 years
PROCESS
Interpersonal
Waiting time
Number of minutes client had to wait before being examined by a provider
Privacy ensured
Whether provider ensured visual and auditory privacy during examination
Client concerns noted
Whether provider asked client about concerns with methods or with currently used method
Confidentiality assured
Whether provider assured client of confidentiality
Method use explained
Whether provider explained to the client how to use the method
Injectable prescription
Whether provider prescribed an injectable to the client
Technical
Reproductive history
Provider asked the client about the following: age, number of living children, last delivery date, history of complications, pregnancy status, desire for more children, desired timing of birth of next child, breastfeeding status, regularity of menstrual cycle (out of 9)
Physical examination
Provider took/asked about the following during the physical exam: blood pressure, weight, asked about smoking, asked about STI symptoms, asked about chronic illness (out of 5)
Injectable procedure
Provider did the following when giving FP injection: checked client card, wash hands with soap before giving injection, use single-use towel for drying, use newly sterilized needle, stir bottle before drawing dose, clean and air-dry injection site before injection, draw back plunger before injection, allow dose to self-disperse instead of massaging, dispose of needle in puncture resistant container (out of 9)
Duration of consultation
Number of minutes provider spent on the consultation
OUTCOME
Client satisfaction
Clients reported that they had no problem with ALL of the following: waiting time, ability to discuss concerns with provider, amount of explanation given, quality of examination and treatment provided, visual privacy during examination, auditory privacy during examination, availability of medicines at facility, hours of service provision, cleanliness of facility, staff treatment of client
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Structural attributes provide an assessment of the overall capacity of health facilities to provide health services. At a bare minimum, the provision family planning services requires at least some minimal level of infrastructure. Specifically, structural attributes of quality were assessed by physical infrastructure, examination equipment, management systems, availability of services and the counseling environment. The Facility Inventory Questionnaire provided the source of data for this component.
Interpersonal and technical aspects of process attributes were considered separately. Interpersonal aspects of quality included maintenance of privacy, confidentiality and provider's handling of client concerns. Prescription of an injectable method by the provider was used as a measure of provider responsiveness to client needs, since the demand for injectables was extremely high among clients who visited these facilities. Technical aspects included elements such as taking a reproductive history, conducting a physical examination and a provider's observation of the correct procedure for administering the injectable contraceptive. The duration of consultation was used as a measure of the technical quality of care. Data for this component came from direct observation of client-provider interactions.
Client satisfaction was measured using clients' responses to questions about service quality, rated as both an index and a discrete measure of problems encountered during the FP visit (none versus any). Specifically, respondents to the exit interviews were asked to report on up to twelve facets of their perceptions of the quality of the visit (Table 4). Rather than examine each of these facets individually, we aggregated them into an index using the polychoricpca principal components command for discrete variables using the Stata 10.1 statistical software program [36]. While many methods exist for the construction of indexes, this method estimates the polychoric and polyserial correlations amongst the included variables and then performs principal component analysis on the resulting correlation matrix. The first principal component was used as the index for client satisfaction. Alternatively, a discrete measure of client satisfaction was constructed with a value of 1 given for respondents who reported "no problem" with all of the 12 aspects of quality and a value of 0 given for respondents who reported "large" or "small" problem with any of the twelve aspects.
Table 4
Measures of Client Satisfaction
Clients were told, "Now I am going to ask you some questions about some common problems clients have at health facilities. As I mention each one, please tell me whether any of these were problems for you today, and if so, whether they were large or small problems for you."
• Time you waited
• Ability to discuss problems or concerns about your health with the provider
• Amount of explanation you received about any problem or method of FP
• Quality of the examination and treatment provided
• Privacy from having others see the examination
• Privacy from having others hear your consultation discussion
• Availability of medicines or methods at this facility
• Hours of service at this facility
• Number of days services are available to you
• Cleanliness of the facility
• How the staff treated you
• Cost for services or treatment
• Any problem you had today that I did not mention
Data analysis
At the bivariate level, differences in quality of care between private and public sector facilities were assessed. The unit of analysis was the facility level. Because hospitals tend to be larger and offer a wider range of services than clinics, the analysis was stratified into hospitals and all other facilities (clinics, health centers, dispensaries, maternity units and stand-alone VCT centers). T-tests were conducted for continuous variables and chi-squared tests of independence were conducted for categorical variables. To examine the magnitude of the relationship between quality measures and client satisfaction, multiple regression analyses were employed. For the binary satisfaction outcome (i.e., reporting of no problems), a probit model was specified and estimated by maximum likelihood. For the continuous index of satisfaction (e.g. the score of the first principal component of the "problem" index), linear regression was used. In both cases, because clients and providers were nested within facilities, Huber-White standard errors were used to control for the non-independence of client observations clustered at the facility level.
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Results
Differences in quality of care: bivariate analysis
Table 5 Table 6 and Table 7 compare mean values of indicators representing structural and process attributes of quality by operating authority (private vs. public sector) stratified by facility type for each of the countries. Overall, quality varied more considerably at lower level facilities than at hospitals, and lower level public facilities appeared to be of a slightly lower quality on average than similar-sized private facilities. Fewer differences were detected between public and private hospitals.
Table 5
Differences in Attributes of Quality (bivariate analysis) - Tanzania
Hospitals
Health Centers, Clinics & Other Facilities
Mean
Value
P
Mean
Value
P
Public
(n = 87)
NGO
(n = 24)
Public
(n = 315)
NGO
(n = 56)
BASIC
Catchment area population
226,392
106,242
0.204
8,590
7,255
0.401
STRUCTURE
Infrastructure and equipment
Physical infrastructure(# of amenities)
3.72
3.85
0.308
2.51
3.65
0.000
Examination room (# of items present)
6.93
6.48
0.227
6.53
7.14
0.022
Management
System for review of management (%)
100.0
89.1
0.056
79.2
85.9
0.440
System for collecting client opinion (%)
95.9
89.6
0.928
82.1
39.7
0.000
Routine quality assurance program (%)
92.6
86.5
0.211
45.6
40.5
0.586
Last supervisory visit within 6 mths (%)
Facility has stock inventory and stock is organized and protected (out of 3)
79.8
60.1
0.004
64.0
44.6
0.001
Availability of services
Number of days FP services provided
5.0
5.2
0.000
4.9
4.6
0.000
Trained provider always present (%)
96.9
89.6
0.867
53.4
72.8
0.003
# of FP methods offered (out of 14)
6.8
6.1
0.029
4.5
4.0
0.004
# of other reproductive health services offered (out of 6)
4.8
4.8
0.270
4.7
4.0
0.000
Counseling
# of protocols on FP counseling(out of 5)
1.5
1.0
0.004
1.2
0.8
0.007
# of visual aids for demonstrating use of FP (out of 9)
4.3
2.1
0.000
2.9
2.3
0.011
Facility has private room for FP counseling (%)
81.0
64.6
0.650
80.9
71.8
0.089
Whether there is an individual client card for FP (%)
97.8
82.3
0.000
81.6
60.1
0.000
PROCESS
Waiting time1(minutes)
81.2
81.4
0.988
69.5
25.4
0.000
Interpersonal
Privacy ensured during examination (%)
91.9
100.0
0.025
79.4
74.4
0.644
Asked clients about concerns with methods or currently used method (%)
84.1
84.0
0.352
75.0
81.8
0.149
Confidentiality assured (%)
77.3
88.5
0.733
58.5
66.5
0.251
Provider explained method use (%)
87.4
98.2
0.104
86.2
76.9
0.173
Provider prescribed injectable (%)
60.3
52.7
0.492
58.5
49.9
0.398
Technical
Reproductive history (out of 11)
2.9
2.8
0.927
2.2
2.3
0.850
Physical examination (out of 5)
2.7
2.8
0.180
2.0
2.6
0.003
Injectable procedure2(out of 9)
3.5
3.6
0.699
3.0
3.1
0.701
Duration of consultation (minutes)
16.7
16.5
0.887
13.0
13.0
0.986
Table 6
Differences in Attributes of Quality (bivariate analysis) - Kenya
Hospitals
Health Centers, Clinics & Other Facilities
Mean
Value
P
Mean
Value
P
Public
(n = 87)
NGO
(n = 60)
Public
(n = 72)
NGO
(n = 104)
BASIC
Catchment area population
264,646
296,768
0.858
26,374
29,653
0.507
STRUCTURE
Infrastructure and equipment
Physical infrastructure(# of amenities)
4.56
4.87
0.103
3.37
3.78
0.076
Examination room (# of items present)
7.32
7.57
0.406
6.68
7.06
0.099
Management
System for review of management (%)
91.5
92.5
0.342
82.2
69.6
0.010
System for collecting client opinion (%)
74.3
78.2
0.555
58.4
65.9
0.203
Routine quality assurance program (%)
62.5
72.0
0.154
44.1
49.7
0.779
Last supervisory visit within 6 mths (%)
91.2
80.4
0.147
95.6
92.6
0.022
Facility has stock inventory and stock is organized and protected (%)
79.6
53.4
0.000
57.6
29.1
0.000
Stock inventory, quality (%)
60.5
40.9
0.007
49.41
24.0
0.008
Availability of services
Number of days FP services provided
5.1
5.2
0.342
5.1
5.5
0.043
Trained provider always present (%)
93.7
100.0
0.059
37.2
56.6
0.018
# of FP methods offered (out of 14)
6.8
5.8
0.026
4.9
3.9
0.001
# of other reproductive health services offered (out of 6)
4.4
4.2
0.296
3.6
3.5
0.301
Counseling
# of protocols on FP counseling(out of 5)
1.0
0.8
0.310
1.1
0.9
0.179
# of visual aids for demonstrating use of FP (out of 9)
3.0
2.1
0.001
2.4
1.8
0.000
Facility has private room for FP counseling (%)
75.8
81.0
0.753
75.8
81.0
0.725
Whether there is an individual client card for FP (%)
92.0
59.1
0.000
74.4
49.4
0.037
Number of years of FP experience of providers
6.3
5.6
0.026
8.1
7.5
0.306
PROCESS
Waiting time1(minutes)
69.2
67.8
0.954
65.2
21.9
0.000
Interpersonal (N = )
346
67
130
85
Privacy ensured during examination (%)
79.3
73.0
0.039
81.1
84.7
0.004
Asked clients about concerns with methods or currently used method (%)
74.9
70.5
0.937
61.0
90.2
0.003
Confidentiality assured (%)
53.4
51.9
0.893
35.7
52.7
0.004
Provider explained method use (%)
73.0
79.0
0.965
72.0
64.3
0.273
Provider prescribed injectable (%)
Technical
Reproductive history (out of 11)
3.0
2.1
0.008
2.3
2.7
0.322
Physical examination (out of 5)
3.2
3.2
0.827
2.9
3.0
0.618
Injectable procedure2(out of 9)
3.8
3.8
0.971
3.6
3.9
0.137
Duration of consultation (minutes)
16.2
15.7
0.796
13.8
18.5
0.106
Table 7
Differences in attributes of quality (bivariate analysis) - Ghana
Hospitals
Health Centers, Clinics & Other Facilities
Mean
Value
Signific. Level
p-value
Mean
Value
P
Public
(n = 42)
NGO
(n = 12)
Public
(n = 216)
NGO
(n = 116)
BASIC
Catchment area population
64,751
132,784
0.297
23,213
25,286
0.432
STRUCTURE
Infrastructure and equipment
Physical infrastructure(# of amenities)
4.8
4.7
0.471
3.4
4.2
0.000
Examination room (# of items present)
8.2
4.9
0.000
5.8
7.4
0.000
Management
System for review of management (%)
98.0
100.0
0.590
65.5
39.8
0.000
System for collecting client opinion (%)
83.1
85.8
0.470
49.9
58.7
0.027
Routine quality assurance program (%)
73.0
49.8
0.389
21.2
8.2
0.002
Last supervisory visit within 6 mths (%)
88.8
83.1
0.260
76.9
58.2
0.002
Availability of services
Number of days FP services provided
5.7
4.8
0.018
6.1
6.4
0.048
Trained provider always present (%)
98.0
100.0
0.590
37.4
53.6
0.006
# of FP methods offered (out of 14)
10.5
5.7
0.000
6.5
6.4
0.836
# of other reproductive health services offered (out of 6)
5.5
4.8
0.035
4.0
4.2
0.268
Counseling
# of protocols on FP counseling(out of 5)
2.4
1.1
0.002
1.2
2.4
0.000
# of visual aids for demonstrating use of FP (out of 9)
5.0
3.8
0.081
3.7
3.9
0.397
Facility has private room for FP counseling (%)
77.4
78.7
0.600
76.8
84.4
0.119
Whether there is an individual client card for FP (%)
100.0
76.9
0.001
90.5
82.6
0.072
Number of years of FP experience of providers
PROCESS
Waiting time1(minutes)
30.8
38.0
0.612
24.5
33.2
0.149
Interpersonal
Privacy ensured during examination (%)
73.8
71.6
0.096
83.1
90.5
0.008
Asked clients about concerns with methods or currently used method (%)
78.3
84.9
0.270
73.5
83.4
0.089
Confidentiality assured (%)
37.0
40.8
0.355
46.5
36.1
0.311
Provider explained method use (%)
70.1
70.1
0.856
75.7
73.3
0.248
Provider prescribed injectable (%)
68.3
68.8
0.761
71.9
81.1
0.555
Technical
Reproductive history (out of 11)
3.0
2.6
0.438
2.2
2.2
0.822
Physical examination (out of 5)
2.4
2.4
0.883
2.2
2.2
0.529
Injectable procedure2(out of 9)
6.6
6.3
0.337
6.1
6.6
0.007
Duration of consultation (minutes)
28.3
24.1
0.466
25.9
22.8
0.251
Structural attributes of quality
In general, there did not appear to be systematic differences in infrastructure and equipment at the hospital level, with the exception of hospitals in Ghana. At the health center level and below, private facilities in all three countries scored higher on measures of physical infrastructure and necessary equipment in examination rooms.
On the other hand, public facilities - both hospitals and lower - tended to offer more FP methods than private facilities. Public Ghanian hospitals offered 10.5 FP methods on average, considerably more than private Ghanian hospitals which offered 5.7 methods on average. No statistically significant differences in FP availability were apparent at lower level facilities. Further, public facilities fairly consistently had higher levels of FP guidelines and protocols available, had more visual aids, and were more likely to have individual client cards than private facilities.
Only in Tanzania were measures of management systems significantly better at both public hospitals and health centers relative to private facilities. For example, nearly 80% of public hospitals in Tanzania had a stock inventory that was organized and protected as compared with only 60% of private/NGO hospitals. Similarly, 64% of public health centers had similar stock inventory systems as compared with less than half of private facilities.
Process attributes
While the picture surrounding structural quality at public and private facilities was mixed, process quality was clearly better at private facilities. In no country and at neither hospitals nor health centers were process measures of quality statistically significantly better at public relative to private facilities. For example, over 90% of clients at private health centers in Kenya reported that providers asked about client concerns regarding methods or method use as compared to only 61% of providers at public health centers. The probability that confidentiality would be assured also appeared higher at private relative to public facilities.
Further, waiting times were nearly always considerably longer at public facilities than private facilities, at least at lower level facilities. In both Tanzania and Kenya, FP clients waited over 40 minutes longer on average at public sector health centers than at private health centers and clinics. No statistically significant differences in waiting times were found at hospitals in any of the three countries; the duration of the FP consultation was roughly the same across public and providers in all countries as well.
There appeared to be few differences in technical aspects of quality between private and public facilities. In Kenya, providers in public hospitals were more likely to take reproductive histories but no such difference appeared in hospitals in the other two countries. At lower level facilities, private providers performed better in Tanzania, but not in the other two countries. Physical exams also appeared to be similar, as were injectable procedures.
Differences in satisfaction: bivariate analysis
At all levels and in all three countries, respondents reported higher satisfaction with the quality of the examination and treatment at private facilities (Table 8, Table 9, Table 10). In some cases, these differences were not large though they were statistically significant. For example, in Tanzania 96.8% of respondents reported "no problem" with the quality of treatment in public hospitals versus 99.4% of respondents at private hospitals. While this difference appears small, it was statistically significant at the 5% level. Differentials in perceptions of quality appeared largest with waiting times. For example, roughly 40% of clients reported problems with waiting times at public clinics in Kenya versus only 5% of clients at private clinics.
Table 8
Differences in Ratings of Satisfaction (Percent saying "No problem"), Tanzania
Hospitals
Health Centers, Clinics, & Other Facilities
Mean
Value
Signific. Level
p-value
Mean
Value
Signific.
Level
p-value
Public
(n = 87)
NGO
(n = 24)
Public
(n = 314)
NGO
(n = 55)
PROBLEMS
Time you waited
69.8
70.4
0.914
74.1
85.8
0.062
Ability to discuss problems or concerns about your health with the provider
94.8
98.8
0.022
96.7
100.0
0.002
Amount of explanation you received about any problem or method of FP
94.8
98.8
0.011
95.5
94.8
0.846
Quality of the examination and treatment provided
96.8
99.4
0.023
95.9
100.0
0.000
Privacy from having others see the examination
94.8
90.2
0.586
96.0
92.7
0.630
Privacy from having others hear your consultation discussion
95.2
100.0
0.001
95.9
90.1
0.391
Availability of medicines or methods at this facility
83.6
92.2
0.095
79.5
94.9
0.000
Hours of service at this facility
91.6
87.9
0.432
88.7
97.6
0.002
Number of days services are available to you
94.9
85.3
0.210
92.1
92.4
0.932
Cleanliness of the facility
87.0
94.0
0.131
87.0
97.4
0.003
How the staff treated you
93.8
99.4
0.000
92.4
100.0
0.000
Cost for services or treatment
93.8
95.1
0.762
96.0
92.4
0.395
Total "yes"
10.9
11.1
0.389
10.9
11.4
0.045
OUTCOME
Client satisfaction (%)
51.5
45.6
0.608
46.9
70.8
0.016
Table 9
Differences in Ratings of Satisfaction (Percent saying "No problem") -Ghana
Hospitals
Health Centers, Clinics, & Other Facilities
Mean
Value
Signific. Level
p-value
Mean
Value
Signific.
Level
p-value
Public
(n = 172)
NGO
(n = 32)
Public
(n = 242)
NGO
(n = 165)
PROBLEMS
Time you waited
90.6
96.0
0.220
90.1
93.1
0.300
Ability to discuss problems or concerns about your health with the provider
97.2
100.0
0.046
93.9
97.0
0.245
Amount of explanation you received about any problem or method of FP
96.3
100.0
0.008
92.0
96.1
0.172
Quality of the examination and treatment provided
96.2
96.5
0.952
93.2
97.1
0.122
Privacy from having others see the examination
97.1
100.0
0.047
95.5
95.7
0.926
Privacy from having others hear your consultation discussion
96.7
100.0
0.046
94.8
96.5
0.469
Availability of medicines or methods at this facility
94.9
98.2
0.208
96.4
97.6
0.537
Hours of service at this facility
94.8
96.0
0.762
93.0
97.7
0.032
Cleanliness of the facility
96.3
92.5
0.394
88.7
94.0
0.168
How the staff treated you
97.9
100.0
0.096
96.4
98.4
0.280
Other
88.8
89.6
0.928
84.3
96.1
0.009
Total "yes"
10.5
10.7
0.194
10.2
10.6
0.046
OUTCOME
Client satisfaction (%)
71.1
76.3
0.341
59.2
81.2
0.000
Table 10
Differences in Ratings of Satisfaction (Percent saying "No problem") - Kenya
Hospitals
Health Centers, Clinics, & Other Facilities
Mean
Value
Signific. Level
p-value
Mean
Value
Signific.
Level
p-value
Public
(n = 346)
NGO
(n = 67)
Public
(n = 130)
NGO
(n = 85)
PROBLEMS
Time you waited
59.4
69.0
0.262
60.3
95.2
0.000
Ability to discuss problems or concerns about your health with the provider
86.5
83.4
0.605
89.9
94.8
0.256
Amount of explanation you received about any problem or method of FP
8.83
88.4
0.991
85.9
93.2
0.119
Quality of the examination and treatment provided
88.3
93.9
0.196
89.0
99.0
0.001
Privacy from having others see the examination
90.5
82.8
0.238
87.6
87.2
0.961
Privacy from having others hear your consultation discussion
88.5
83.4
0.444
87.6
93.8
0.364
Availability of medicines or methods at this facility
73.8
82.8
0.108
67.6
90.6
0.014
Hours of service at this facility
83.1
88.0
0.294
86.8
99.0
0.001
Number of days services are available to you
88.0
90.4
0.532
89.2
98.1
0.009
Cleanliness of the facility
84.6
93.6
0.042
89.4
99.5
0.006
How the staff treated you
87.1
93.6
0.131
90.0
99.7
0.001
Cost for services or treatment
93.8
84.0
0.404
90.5
96.9
0.133
Total "yes"
10.1
10.3
0.669
10.1
11.5
0.000
OUTCOME
Client satisfaction (%)
34.1
51.7
0.000
29.1
63.6
0.000
A second area of clear differences between public and private facilities was with the availability of medicines or contraceptive methods. For example, only two-thirds of respondents reported "no problem" with availability at public clinics in Kenya, versus 91% at private clinics. A similar result was found in Tanzania though not in Ghana. Perceptions of quality were high at both public and private facilities in Ghana. The highest levels of dissatisfaction were with the cleanliness of public health centers, for which 12% of respondents reported a problem.
Using the discrete measure of quality - the absence of any problems during an FP consultation - the differences were starker, as shown by Figure 1. In four out of six cases, satisfaction was higher at private facilities relative to public facilities. In Kenya, nearly two-thirds of FP clients at private health centers reported no problem as compared with just under one-third of FP clients at public health centers. There tended to be greater parity in satisfaction at hospitals relative to health centers, and in fact satisfaction at public hospitals was higher in Tanzania - but not at a statistically significant level - than at private hospitals, though in both cases only about half of clients reported no problems.
Figure 1
Client satisfaction by Facility Management, Level and Country.
×
Anzeige
Correlates of client satisfaction - multivariate regression analysis
We examined the correlates of client satisfaction among clients of private and public sector facilities in each of the countries. Overall, even with controls for specific attributes of quality, private facilities seem to have higher levels of client satisfaction than public facilities (Table 11). This was true at the clinic level in all three countries and at the hospital level in Ghana. Further, the measures of quality that most impacted upon client perceptions of quality were those that were most directly observable by them, namely process attributes of quality, for which private facilities tended to score better.
Table 11
Factors Associated with Client Satisfaction (multivariate analysis) (Coefficient and standard error)
Ghana
Kenya
Tanzania
Hospital
Clinic
Hospital
Clinic
Hospital
Clinic
Independent
Variables
No problems
Index of satisfaction
No problems
Index of satisfaction
No problems
Index of satisfaction
No problems
Index of satisfaction
No problems
Index of satisfaction
No problems
Index of satisfaction
FACILITY CHARACTERISTICS
NGO
0.4178
0.3034*
0.7329**
0.2128
0.4955
0.2300
0.4952
0.6930***
-0.4634
0.0566
2.4378*
1.1462*
0.231
0.014
0.002
0.149
0.178
0.099
0.119
0.000
0.108
0.760
0.029
0.014
Urban
0.027
0.0382
-0.8547
-0.8163*
0.967
0.91
0.19
0.013
Log (catchment pop)
0.4741
0.1487
0.1633
-0.1145
-0.0402
-0.0439
-0.0101
-0.0563
0.0933
-0.0037
-0.1155
-0.0689
0.051
0.194
0.534
0.369
0.675
0.48
0.952
0.561
0.268
0.95
0.265
0.278
STRUCTURE
Facility inventory
-0.0166
-0.0337
0.0993
0.0345
-0.0956
-0.0549
0.1234
0.1243**
0.1091*
0.0628*
-0.0587
-0.0129
0.865
0.429
0.053
0.199
0.117
0.117
0.125
0.005
0.022
0.048
0.11
0.577
Trained provider present 24 hours
-0.219
-0.0696
-0.0488
0.2186
-0.1617
0.7691*
0.0377
0.034
0.176
0.1819
0.1041
0.262
0.703
0.703
0.518
0.548
0.038
0.841
0.967
0.74
0.309
0.373
Supervisory visit in last 6 months
-1.1562*
-0.3568
-0.1475
-0.0381
-0.3477
-0.3453*
-1.4670*
-0.1202
0.028
0.057
0.580
0.789
0.260
0.033
0.042
0.736
Number of staff
0.0018
0.0011
0.0015
0.0018
-0.0004
0.0001
0.0171
0.0077
0.070
0.179
0.611
0.18
0.742
0.911
0.178
0.213
Number of days FP offered
0.4559*
-0.0724
0.0512
-0.0475
0.0479
-0.0531
0.0267
-0.1272
-0.4142
0.0081
0.0953
0.0085
0.049
0.629
0.380
0.126
0.841
0.606
0.885
0.219
0.124
0.957
0.295
0.886
System of quality assurance
-0.0946
0.0541
0.0457
-0.0835
-0.049
0.0566
0.0415
-0.1356
0.0086
0.3349
0.1257
0.0177
0.751
0.696
0.834
0.517
0.83
0.700
0.874
0.331
0.979
0.225
0.424
0.84
Total FP methods offered
0.016
0.0255
-0.0587
-0.0011
-0.0413
-0.0839*
-0.2152
0.0606
0.0781
0.0239
0.095
0.1195
0.861
0.486
0.289
0.977
0.478
0.023
0.079
0.294
0.248
0.582
0.222
0.085
Protocols on FP followed
-0.069
0.0495
-0.0117
-0.0297
0.0839
0.1239
-0.2139
-0.0046
0.0531
0.0086
0.1396
0.1376**
0.563
0.489
0.885
0.623
0.418
0.067
0.154
0.955
0.641
0.900
0.055
0.001
FP client record maintained
0.0612
0.2400
0.0341
-0.2400
-0.3421*
1.1700**
0.3688
0.1208
-0.0803
-0.1319
-0.1831
0.936
0.511
0.831
0.455
0.022
0.002
0.064
0.756
0.619
0.611
0.187
Quality stock inventory
0.4317*
-0.0026
-0.0481
0.121
-0.0622
-0.0477
0.2252
0.1147
0.0298
0.0753
0.0288
-0.0095
0.014
0.970
0.655
0.115
0.800
0.716
0.447
0.572
0.88
0.656
0.862
0.926
Number trained
-0.0589
-0.1385**
0.2183
-0.0317
0.352
0.004
0.099
0.648
PROCESS
Visual & auditory privacy ensured
0.0516
-0.1216
-0.176
0.0373
-0.1143
-0.0926
0.3986
0.0989
-0.0104
0.3347
0.0693
0.1567
0.891
0.603
0.437
0.824
0.61
0.626
0.286
0.656
0.984
0.433
0.727
0.255
No. of repro health and phys exam
0.0279
0.013
0.0203
0.0308*
0.0273
0.0431*
0.1418**
0.0268
-0.0251
-0.0227
0.0133
0.0222
elements performed
0.310
0.23
0.366
0.05
0.247
0.012
0.003
0.307
0.352
0.234
0.565
0.117
Client concerns noted
0.4387
0.0519
-0.0547
-0.1181
-0.0791
0.0142
0.2557
0.0177
-0.1051
-0.1891
-0.2422
-0.0059
0.082
0.604
0.764
0.369
0.716
0.917
0.511
0.932
0.647
0.166
0.175
0.961
Confidentiality assured
-0.0883
0.1231
0.0516
-0.1013
0.373
0.4389**
0.4255
-0.0138
0.4644
0.2149
-0.1702
-0.071
0.773
0.385
0.785
0.466
0.063
0.002
0.133
0.926
0.094
0.139
0.310
0.505
Client told about side effects
-0.0864
0.0104
0.442
0.5430**
-0.1149
-0.072
-0.2877
-0.0759
0.773
0.945
0.055
0.005
0.512
0.48
0.502
0.71
Injectable method prescribed
0.1259
0.149
0.2749
0.3884*
0.0921
-0.113
0.0998
-0.2611
0.5246**
0.3512*
0.0821
0.1483
0.618
0.264
0.135
0.032
0.668
0.271
0.785
0.174
0.002
0.036
0.560
0.142
Waiting time
-0.0048*
-0.0021*
-0.009***
-0.0037**
-0.008***
-0.004***
-0.011***
-0.003
-0.007***
-0.0030***
0.0406
0.0237**
0.019
0.042
0.000
0.001
0.000
0.000
0.000
0.090
0.000
0.000
0.096
0.008
CLIENT CHARACTERISTICS
Age
0.0003
0.0134
0.0029
0.0036
0.0027
-0.0058
-0.0188
-0.0219
-0.0358
-0.0002
-0.0048
-0.0019
0.988
0.294
0.788
0.446
0.839
0.468
0.402
0.159
0.074
0.987
0.604
0.732
Primary school educ
0.5967*
0.0369
-0.1207
0.3034*
-0.1155
-0.0878
-0.2297
-0.1586
-0.0238
-0.0342
-0.0602
0.0201
0.019
0.798
0.563
0.033
0.293
0.186
0.263
0.237
0.820
0.695
0.463
0.726
Secondary school educ.
0.8252**
0.0824
-0.1366
0.2054
0.002
0.587
0.380
0.086
Intercept
-4.5372*
-0.3599
-1.6069
-0.7146
1.8286
3.1225***
-0.675
0.5066
0.2395
-1.4728
-2.2200
-1.9172
0.042
0.597
0.204
0.260
0.288
0.001
0.755
0.710
0.913
0.314
0.272
0.059
N
197
204
407
407
390
390
208
208
322
322
450
450
r2
0.1158
0.1735
0.2579
0.2372
0.1653
0.0825
F
2.1151
.
2.879
1.2948
6.3419
14.0259
3.9912
2.7142
2.1756
4.4956
1.3143
1.1052
* p < 0.05, ** p < 0.01, *** p < 0.001
Structure
Few measures of structural quality appeared to affect client satisfaction. Service availability - as measured by the number of FP methods offered and the number of days per week that FP services were offered - had little impact on client satisfaction. Whereas public facilities appeared in bivariate analyses to have better management systems (e.g. having a system of Quality Assurance, having appropriate stock management procedures in place) - perhaps because competitive mechanisms and for-profit motives that encourage accountability at private facilities are less prevalent at public facilities - these did not show a statistically significant association with client satisfaction in the multivariate analyses. Having a supervisory visit in the last 6 months was actually negatively associated with client satisfaction in two cases, perhaps because more troubled facilities are likely to require closer supervision. Other structural factors that had no influence were the presence of FP protocols and guidelines, training of staff, and number of staff.
Process
Consistently, longer waiting times were negatively associated with client satisfaction at all facilities and in all countries. Conversely, the performance of more physical and reproductive health exam elements increased satisfaction, as did prescribing an injectable method. Each of these aspects of quality are easily discernible, even to an untrained client, and therefore likely to perceptibly influence satisfaction, though they may have little impact on meeting the overall FP needs of clients. Other process factors had little influence, including the maintenance of confidentiality, informing clients of potential side effects, and noting client concerns.
Discussion
This study has focused on measuring the extent of quality differentials between public and private FP providers in three countries and then relating client satisfaction to both clients' perceptions and experts' assessments of the quality of FP services. As expected we found significant quality differences between public and private providers, mostly at lower level facilities, which accords with economic theory regarding supply side responsiveness to client demand. On the other hand, we found little evidence that private providers skimped on less (client) perceptible technical measures of quality.
We found little evidence that client satisfaction bears much relationship with technical aspects of quality, as perceptions of adherence to appropriate family planning procedures require greater technical knowledge and awareness than is likely to be possessed by the typical FP client. This is consistent with previous research [8, 21]. As noted by one set of researchers, "Consumers are usually unable to assess the technical quality of services, with the result that they place more weight on aspects of perceived quality, such as the interpersonal skills of providers and the comfort of the environment in which treatment occurs, both of which may be unrelated to technical competence. They may, therefore, be more exposed to inadequately qualified practitioners providing care of very poor quality" ([21] p. 326). Previous studies [37, 38] have found that the quality of client-provider interactions contributes significantly to client satisfaction and contraceptive continuation. In this study - and in confirmation with economic incentives - these aspects also tended to be better at private and NGO facilities relative to public facilities, at least at the clinic level.
These results, however, do not imply that client satisfaction should be the principal goal of providers. In fact, client satisfaction is inextricably linked to expectations, which may differ across clients of different types of facilities. Certainly the evidence exists to show that higher levels of client satisfaction with process measures of quality increases the likelihood of contraceptive use and continuation [10]. But structural measures of quality - such as frequent shortages of methods or inappropriate guidance - are also likely to inhibit long-term contraceptive continuation. Ensuring that clients are appropriately informed about methods, their uses, side effects and limitations; are correctly given physical exams; and are seen by trained providers are all important determinants of quality and contraceptive use [1, 2]. Other convenience measures, such as waiting times, seem to be important determinants of client satisfaction, but are less likely to have any impact upon the technical quality of services, though they may impact longer term use of methods if they inhibit clients from returning for follow-up visits. Regardless, FP providers would obviously be well-advised - regardless of their incentive structures - to monitor and ensure all aspects of FP quality.
One shortcoming of this analysis was the inability to distinguish between for-profit and not-for-profit private facilities, a lament shared by previous researchers [11]. This represents an important limitation because the incentive structures - such as the trade-off between cost savings and quality - may differ considerably between the two types. Nonetheless, in at least two of the countries, the size of the nongovernmental mission sector - and therefore as a proportion of our facility sample - is not large. In Kenya, for example, the private medical sector is the predominant private family planning provider, constituting 80% of all private provision of family planning. Similarly, in Ghana, the nonprofit nongovernmental sector provides only a very small percentage of overall family planning supply [29]. As a result, the results for these two countries are more likely a reflection of differences between government providers relative to private for-profit providers, rather than religious and mission providers.
An additional limitation relates to the use of exit interviews as a source of client satisfaction. Exit interviews by definition involve a sample of clients who have already made a choice to appear at a specific facility and are therefore likely to believe that the facility will be minimally satisfactory. Non-clients may have chosen to go elsewhere or to do nothing, simply because they do not believe that quality at a particular facility will be satisfactory. For example, potential clients who are particularly intolerant of long waiting times may eschew public facilities specifically because of perceptions that waiting times will be unacceptable. Therefore, the sample of actual clients - and those completing the exit interviews - may represent a group who cares less about waiting times, thereby understating the true effect of waiting times on client satisfaction. To fully address the effects of quality on client satisfaction would require a random sample of the larger population of reproductive age women, linking their reproductive health choices - and satisfaction - to the supply environment as measured with a SPA.
Conclusions
This study makes an important contribution by highlighting differences in quality between public and private facilities according to three aspects of quality and fills a gap in knowledge on this topic by linking structural and process quality to client satisfaction. The finding of significantly lower technical quality at lower level public facilities should raise some concern. Further study is clearly warranted to determine the principal causes of quality deficiencies - insufficient training of personnel, resource shortages, limited management oversight or some other reason. Our findings hint at a role for each of these causes.
Referring to one of the limitations of this analysis, future large-scale studies, such as the SPAs, should make a point to distinguish between different types of private facilities, and to make this data available to researchers. Additionally, the value of SPAs could be further enhanced if they were timed and coordinated to cover the same populations and catchment areas covered by large scale population surveys such as the DHS. Such a mechanism, as noted above, could provide a richer means by which to evaluate the effects of the health service supply environment on a wide range of health behaviors and choices in developing country populations.
Finally, as the private sector appears to be an important provider of reproductive health services in the three countries studied, care should be taken to prevent the implementation of policies or regulations that significantly burden or hamper the functioning of the private sector lest national-level reproductive health indicators suffer as a result.
Authors' information
Paul Hutchinson, PhD, and Mai Do, DrPH, MD, are Assistant Professors in the Department of International Health and Development in the Tulane University School of Public Health and Tropical Medicine. Sohail Agha, PhD, is a Senior Technical Advisor with Population Services International (PSI).
Acknowledgements
This study was conducted under the Private Sector Partnerships-One (PSP-One) project with support from the United States Agency for International Development (contract number GPO-I-00_04-00007- 00). The paper benefitted from technical review by Sara Sulzbach, PSP-One Research Director and Kathryn Banke, Senior Associate, PSP-One.
Institutional Review
The protocol, methods and all materials that constitute the study described in the manuscript were approved by the Biomedical Institutional Review Board of the Tulane University School of Public Health and Tropical Medicine.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors participated in research design and conceptualization, data analysis, writing, and revision of this manuscript. All authors have read and approved the final manuscript.
Measuring client satisfaction and the quality of family planning services: A comparative analysis of public and private health facilities in Tanzania, Kenya and Ghana
