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

Abstract

Background: High 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 findings: We 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.

Conclusions: Majorities 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.

Fig 1. Vignettes describing poor-quality care.

All respondents received vignette A. A subset of respondents also received vignette B, C, or D. Please see S1 Appendix for full survey instrument and S2 Appendix for survey screenshot.

Fig 2. Ratings of good or better on vignettes describing poor-quality care.

Blood pressure visit, poor technical quality vignette: N = 17,996. Accident visit, poor technical quality vignette: N = 3,640. Blood pressure visit, poor interpersonal quality vignette: N = 3,541. Accident visit, poor interpersonal quality vignette: N = 3,667. AR, Argentina; CN, China; GH, Ghana; ID, Indonesia; IN, India; KE, Kenya; LB, Lebanon; MA, Morocco; MX, Mexico; NG, Nigeria; SN, Senegal; ZA, South Africa.

Fig 3. The cycle of low expectations and poor quality of care.

This analysis suggests that there may be a vicious cycle of low expectations and poor quality of care. The cycle may be broken by delivering high-quality care or by raising expectations of quality.