Which aspects of non-clinical quality of care are most important? Results from WHO's general population surveys of “health systems responsiveness” in 41 countries

Abstract

Quality of care research has reached some agreement on concepts like structure, process and outcome, and non-clinical versus clinical processes of care. These concepts are commonly explored through surveys measuring patient experiences, yet few surveys have focused on patient, or “user”, priorities across different quality dimensions. Population surveys on priorities can contribute to, although not replace participation in, policy decision making. Using 105,806 survey interview records from the World Health Organization's (WHO's) general population surveys in 41 countries, this paper describes the relative importance of eight domains in the non-clinical quality of care concept WHO calls “health systems responsiveness”. Responsiveness domains are divided into interpersonal domains (dignity, autonomy, communication and confidentiality) and structural domains (quality of basic amenities, choice, access to social support networks and prompt attention). This paper explores variations in domain importance by country-level variables (country of residence, human development, health system expenditure, and “geographic zones”) and by subpopulations defined by sex, age, education, health status, and utilization. Most respondents selected prompt attention as the most important domain. Dignity was selected second, followed by communication. Access to social support networks was identified as the least important domain. In general, convergence in rankings was stronger across subpopulations within countries than across countries. Yet even across diverse countries, there was more convergence than divergence in views. These results provide a ranking of quality of care criteria for consideration during health reform processes further to the usual emphasis on clinical quality and supply-side efficiency.

Introduction

The quality of care literature supports the view that non-clinical aspects of health care are important dimensions of service quality (Campbell et al., 2000, Donabedian, 1980, Sitzia and Wood, 1997, Wensing et al., 1998). In spite of interest in users' experiences of quality of care, Sitzia and Wood (1997) observed that “little, empirical data on the importance of the(se) components relative to each other has been published” (Sitzia & Wood, 1997, p. 1838). Apart from being of theoretical interest, the relative importance of different components of quality of care communicates meaningful information. The knowledge can contribute to social dialogue about what is important in health services (Wensing & Elwyn, 2003, Cleary, 1999), it can be used to construct composite indices measuring users' experiences with health services (Van Campen, Sixma, Kerssens, Peters, & Rasker, 1998); and it may help to anticipate the popularity of health system changes. Health policy changes inevitably favour one or more aspect of non-clinical quality of care over another. It follows, therefore, that differences between population groups within a country can lead to conflict, and across countries to misinterpretation of inter-country comparisons made with composite measures.

The World Health Organization's (WHO's) 2000 World Health Report, expressed a serious concern with exploring users' priorities with respect to different aspects of health services, including for a non-clinical quality of care concept called “health systems' responsiveness” (WHO, 2002). The responsiveness concept covered seven “domains”, to which an eighth was subsequently added (Gostin et al., 2002, Murray and Frenk, 2000, De Silva, 2000). The eight domains were categorized as “respect-for-persons” domains (covering dignity, autonomy, confidentiality, and (clear) communication) (Donabedian, 1980), and “client-orientation” domains (covering choice of care provider, prompt attention, quality of basic amenities, access to social support networks (during inpatient care) (Campbell et al., 2000)). WHO stated that these non-clinical domains were of “universal” importance, meaning important to all human beings, regardless of culture, sex, age and so on, a highly controversial claim at the time (Mooney & Wiseman, 2000).

Following this conceptual work, WHO launched the measurement of people's experiences with health services (labeled “performance”), and people's views on the relative importance of these characteristics within a health system (labeled “importance”), through the Multi-Country Survey Study on Health and Health Systems Responsiveness (the “MCS Study”). MCS questionnaires were administered to households in 70 general population surveys in 60 countries (Ustun et al., 2003). In 41 countries, questionnaires were administered by interviewers. In the remaining cases, surveys were self-administered (either delivered by hand, or postal services). This paper focuses on the interviewer-administered surveys (39 face-to-face and two telephone surveys (Canada, Luxembourg)), to reduce differences in bias associated with administration mode (Dillman and Tarnai, 1991, Sitzia and Wood, 1998).

Previous studies have proclaimed there to be divergences in priorities “between individual patients and between patients from different cultures and health cares systems”, but there has been little cross-country evidence to support these claims (Wensing et al., 1998). The individual characteristics shown to be most closely associated with patient priorities in the literature are respondent age, followed by education, health status, sex, and utilization rates (age came up in 36% of studies) (Jung, Baerveldt, Olesen, Grol, & Wensing, 2003). In a seminal study in 1991, the relative importance given to non-clinical quality dimensions was found to be similar for respondents utilizing both ambulatory and hospital inpatient services (Williams & Calnan, 1991). Later studies have reported weak associations between rankings and individual level characteristics (Fung et al., 2005, Jung et al., 2003, Sofaer et al., 2005).

Few studies have had sufficient empirical reach to test these hypotheses across countries (Sitzia & Wood, 1997). The largest empirical study to do so recently covered only 12 European countries (Kerssens, Groenewegen, Sixma, Boerma, & van der Eijk, 2004). WHO's MCS Study has produced the first large data set on the relative importance of several non-clinical dimensions of quality of care across a wide range of countries. Based on the literature, we expected to find that responsiveness respect-for-persons domains were very important to populations, and to see larger differences in domain importance across countries than within countries (Coulter and Jenkinson, 2005, Gandek et al., 1998, Groenewegen et al., 2005, Häkkinen et al., 2001, Mooney and Wiseman, 2000, Sofaer et al., 2005).