Improving Quality in Low- and Middle-Income Health Systems by Raising Expectations of Care

Abstract

A growing body of literature shows that the quality of healthcare experienced by people in low-and middle-income countries (LMICs) is remarkably poor. Effective systemic improvement approaches that can have large-scale impact are urgently needed. Though quality improvement usually focuses on the supply of healthcare, this doctoral work explores the potential of demand-side approaches that engage populations and raise expectations of care. A thorough review of the theoretical and empirical literature on expectations of healthcare led to a new conceptual framework. This conceptual framework then drove an empirical examination of expectations of care in LMICs using the results of a 12-country internet survey. Internet users who made errors in entering webpages in 12 LMICs were sampled in August and September of 2017 using random domain intercept technology (RDITtm). A 24-question survey about experiences and perceptions of healthcare quality was administered. The survey included vignettes of hypothetical healthcare scenarios designed to describe poor quality care which were used to measure expectations of care. Descriptive statistics were calculated and a multivariable logistic regression based on the conceptual framework of expectations of care was fit to understand predictors of low expectations. A theory of change was then developed to better explore implications of translating the evidence into health system improvement strategies that raise expectations of care in LMICs. The analysis of 17,996 surveys showed that over half of respondents have low expectations of healthcare and that male gender, low education, good self-reported health status and a history of discrimination in the healthcare system are associated with these low expectations. Though the gap in expectations is large, an examination of the literature suggests that several promising intervention types do exist that may raise expectations of health care and generate demand for quality care. Raising expectations is theorized to put demand-side pressure on health systems to improve when people preferentially use higher quality options and when they directly advocate for better services. Approaches that raise expectations and generate demand for quality care warrant more attention from the global quality improvement community and should be considered when planning national health system improvement strategies.