Background Perspectives of patients as clients on healthcare offer unique insights into the process and outcomes of care and can facilitate improvements in the quality of services. Differences in the tools used to measure these perspectives often reflect differences in the conceptualization of quality of care and personal experiences. This systematic review assesses the validity and reliability of instruments measuring client experiences and satisfaction with healthcare in low- and middle-income countries (LMICs). Methods We performed a systematic search of studies published in PubMed, SCOPUS, and CINAHL. This review was reported according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Studies describing the development and psychometric properties of client experience and satisfaction with general health care were included in the review. Critical appraisal of study design was undertaken using the Appraisal tool for Cross-Sectional Studies (AXIS). The Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and Terwee’s criteria were used to appraise the psychometric properties of the included studies. A narrative synthesis approach was used in the interpretation of the findings. Results Of the 7470 records identified, 12 studies with 14 corresponding instruments met the inclusion criteria and were included in the final review. No study assessed all the psychometric properties highlighted by the COSMIN criteria. In most instruments, we found evidence that initial development work incorporated client participation. The most evaluated measurement properties were content validity, internal consistency, and structural validity. Measurement error and responsiveness were not reported in any study. Conclusion Reliability and validity should be considered important elements when choosing or developing an instrument for professionals seeking an effective instrument for use within the population. Our review identified limitations in the psychometric properties of patient experience and satisfaction instruments, and none met all methodological quality standards. Future studies should focus on further developing and testing available measures for their effectiveness in clinical practice. Furthermore, the development of new instruments should incorporate clients' views and be rigorously tested or validated in studies with high methodological quality. Trial registration CRD42020150438.

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Objective The objective of this study was to assess the feasibility and acceptability of institutionalizing Health Technology Assessment (HTA) in Malawi. Methods This study employed a document review and qualitative research methods, to understand the status of HTA in Malawi. This was complemented by a review of the status and nature of HTA institutionalization in selected countries.Qualitative research employed a Focus Group Discussion (FGD ) with 7 participants, and Key Informant Interviews (KIIs) with12 informants selected based on their knowledge and expertise in policy processes related to HTA in Malawi.Data extracted from the literature was organized in Microsoft Excel, categorized according to thematic areas and analyzed using a literature review framework. Qualitative data from KIIs and the FGD was analyzed using a thematic content analysis approach. Results Some HTA processes exist and are executed through three structures namely: Ministry of Health Senior Management Team, Technical Working Groups, and Pharmacy and Medicines Regulatory Authority (PMRA) with varyingdegrees of effectiveness.The main limitations of current HTA mechanisms include limited evidence use, lack of a standardized framework for technology adoption, donor pressure, lack of resources for the HTA process and technology acquisition, laws and practices that undermine cost-effectiveness considerations. KII and FGD results showed overwhelming demand for strengthening HTA in Malawi, with a stronger preference for strengthening coordination and capacity of existing entities and structures. Conclusion The study has shown that HTA institutionalization is acceptable and feasible in Malawi. However, the current committee based processes are suboptimal to improve efficiency due to lack of a structured framework. A structured HTA framework has the potential to improve processes in pharmaceuticals and medical technologies decision-making.In the short to medium term, HTA capacity building should focus on generating demand and increasing capacity in cost-effectiveness assessments. Country-specific assessments should precede HTA institutionalization as well as recommendations for new technology adoptions.

BackgroundThe objective of this study was to assess the feasibility and acceptability of institutionalizing Health Technology Assessment (HTA) in Malawi focusing on the form, scope, capacity and financing requirements for a limited resource setting such as Malawi.MethodsThis study employed a desk review and qualitative research methods. An extensive literature review was conducted on relevant key policy documents, reports and publications to understand the status of HTA in Malawi. The study included one focus group discussion with 7 participants and 12 key informant interviews with key stakeholders selected purposely based on their knowledge and expertise in HTA. ResultsThe study found that partial or informal HTA processes exist and that HTA is practiced without a standardized framework. The partial HTA processes are executed through three structures; Ministry of Health Senior Management Team, Technical Working Groups and Pharmacy and Medicines Regulatory Authority (PMRA) with varying levels of effectiveness. The results revealed that lack of an institutional HTA creates severe shortfalls. This includes partial HTA mechanisms, limited evidence use, especially concerning cost-effectiveness, lack of a standardized framework for technology adoption, donor pressure, lack of resources for the HTA process and technology acquisition, laws and practices that undermine cost-effectiveness considerations. ConclusionInstitutionalizing HTA in Malawi is acceptable and feasible. The results suggest that any HTA institutionalization in the short to medium term could involve strengthening the capacity of PMRA to appraise Cost-effectiveness Analysis (CEAs) within academia and MOH health financing division. Furthermore, rather than creating new HTA institutions, country-specific assessments should precede any specific recommendations for new technology adoptions. A technical capacity in Academic institutions such as Health Economics and Policy Unit (HEPU) at Kamuzu University of Health Sciences (KuHes) can be developed either as “offshore” HTA capacity fully aligned to MOH and executing HTA evidence and knowledge management function in a sub-contractor capacity.Running HeadHealth technology assessment in Malawi