Perceived quality of care among households ever enrolled in a community-based health insurance scheme in two districts of northeast Ethiopia: a multilevel analysis

Abstract

ObjectivesThe purpose of this study was to examine how clients perceived the quality of health care, and to identify related individual and facility-level factors.DesignCommunity-based, cross-sectionalSettingHealth centers affiliated with community-based health insurance schemeParticipants1081 rural households that had ever been enrolled in community-based health insurance and had visited a health center at least once in the previous 12 months, as well as 194 health care providers working in 12 health centers.Outcome measuresThe outcome variable of interest was the overall perceived quality of score, which was measured using a 17-item scale. Respondents were asked to rate the degree to which they agreed on 5-point response items relating to their experiences with health care in the outpatient departments of nearby health centers. A multilevel linear regression analysis was used to identify predictors of quality of care.ResultsThe mean perceived quality of care score was 62.85 (SD=10.49). Five quality of care dimensions were extracted from the factor analysis, with patient-provider communication dimension having the highest mean score (M=72.29, SD=12.66) and information provision having the lowest (M=55.83, SD=17.34). Wealth status, current insurance status, perceived health status, presence of chronic illness, time since the most recent visit to a health center, patient volume and health care providers’ work experience were significantly associated with the perceived quality of care. An interaction term between patient volume and staff job satisfaction also showed significant association.ConclusionsMuch work remains to be done to improve the quality of care, in particular, on information provision and access to care quality dimensions. People’s perceptions of the quality of care differed depending on a variety of individual and health center-level factors. For better quality of care, it is vital to determine an appropriate patient volume per care provider, and improve staff job satisfaction.Strengths and limitations of this study▸The study tried to assess the quality of care from the clients’ point of view using a validated multidimensional scale.▸This is the first cross-sectional study in Ethiopia which considered health center (cluster) level variables that have association with the perceived quality of care.▸We tested for endogeneity between current insurance status and quality of care, but there is still the possibility of endogeneity due to omitted variables, as a result of which active members may report higher care quality due to their desire to remain in the scheme.▸Because of the cross-sectional nature of the study, it is impossible to establish a cause- and-effect relationship.