Why service users do not complain or have 'voice': a mixed-methods study from Nepal's rural primary health care system

Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast

BACKGROUND

Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal.

METHODS

Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis.

RESULTS

We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents.

CONCLUSION

Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required.

Impact Analysis of COVID-19 Pandemic on Hospital Reviews on Dianping Website in Shanghai, China: Empirical Study

BACKGROUND

In the era of the internet, individuals have increasingly accustomed themselves to gathering necessary information and expressing their opinions on public web-based platforms. The health care sector is no exception, as these comments, to a certain extent, influence people's health care decisions. During the onset of the COVID-19 pandemic, how the medical experience of Chinese patients and their evaluations of hospitals have changed remains to be studied. Therefore, we plan to collect patient medical visit data from the internet to reflect the current status of medical relationships under specific circumstances.

OBJECTIVE

This study aims to explore the differences in patient comments across various stages (during, before, and after) of the COVID-19 pandemic, as well as among different types of hospitals (children's hospitals, maternity hospitals, and tumor hospitals). Additionally, by leveraging ChatGPT (OpenAI), the study categorizes the elements of negative hospital evaluations. An analysis is conducted on the acquired data, and potential solutions that could improve patient satisfaction are proposed. This study is intended to assist hospital managers in providing a better experience for patients who are seeking care amid an emergent public health crisis.

METHODS

Selecting the top 50 comprehensive hospitals nationwide and the top specialized hospitals (children's hospitals, tumor hospitals, and maternity hospitals), we collected patient reviews from these hospitals on the Dianping website. Using ChatGPT, we classified the content of negative reviews. Additionally, we conducted statistical analysis using SPSS (IBM Corp) to examine the scoring and composition of negative evaluations.

RESULTS

A total of 30,317 pieces of effective comment information were collected from January 1, 2018, to August 15, 2023, including 7696 pieces of negative comment information. Manual inspection results indicated that ChatGPT had an accuracy rate of 92.05%. The F1-score was 0.914. The analysis of this data revealed a significant correlation between the comments and ratings received by hospitals during the pandemic. Overall, there was a significant increase in average comment scores during the outbreak (P<.001). Furthermore, there were notable differences in the composition of negative comments among different types of hospitals (P<.001). Children's hospitals received sensitive feedback regarding waiting times and treatment effectiveness, while patients at maternity hospitals showed a greater concern for the attitude of health care providers. Patients at tumor hospitals expressed a desire for timely examinations and treatments, especially during the pandemic period.

CONCLUSIONS

The COVID-19 pandemic had some association with patient comment scores. There were variations in the scores and content of comments among different types of specialized hospitals. Using ChatGPT to analyze patient comment content represents an innovative approach for statistically assessing factors contributing to patient dissatisfaction. The findings of this study could provide valuable insights for hospital administrators to foster more harmonious physician-patient relationships and enhance hospital performance during public health emergencies.

The perceived benefits and effectiveness of patient feedback systems in strengthening patient-provider relationships in Rural Tanzania

INTRODUCTION

Patient feedback system (PFS) forms an important entry point for the medical personnel and healthcare administrators to identify healthcare service delivery gaps and develop responsive interventions. This may foster patient trust consequently increasing healthcare-seeking, engagement in decision, continuity, and satisfaction. However, research on the PFS in rural primary healthcare settings appears limited.

OBJECTIVE

The paper examines the perceived role and effectiveness of PFS in improving therapeutic relationships building on the recent research on patient-provider relationships in rural Tanzania.

METHODS

The paper examines the findings of qualitative descriptive research conducted in the Shinyanga Region which employed a human-centred design (HCD) approach to co-create an intervention package for improving nurse-client relationships between January and September 2022. The study used semi-structured interviews in Swahili to first explore drivers of poor provider-patient relationships with purposefully selected providers, patients, and administrators. The findings guided the co-designing of an intervention package in subsequent HCD steps. Interviews were concurrently translated and transcribed, then systematically coded to facilitate the development of themes using a deductive thematic analysis approach.

RESULTS

PFS emerged as one of the key themes in the deductive analysis when examining factors shaping provider-client relationships. The PFS theme was characterized by three major subthemes, which included perceived benefits, availability and accessibility, and perceived effectiveness. The perceived benefits of PFS cited by most participants included: reducing patients' confusion around the complaints process, promoting patients' positivity towards providers and hospitals, and reducing tensions between patients and providers. Suggestion boxes (SBs) were the most frequently cited PFS, but there were widespread concerns and disagreements among participants about their accessibility and effectiveness. Despite the providers (nurses) and administrators describing SBs as widely available, they stated that they had not received feedback or complaints from patients for a very long time. In contrast, most patients stated that SBs were either unavailable or ineffective in many facilities, with concerns about non-user friendliness and lack of responsiveness as the main issues when discussing effectiveness.

CONCLUSION

Despite the many benefits of PFS in improving healthcare service quality, their availability, user-friendliness, and responsiveness still pose challenges. A call is made to providers, health administrators and researchers to prioritize the PFS as both a useful entry point to reducing tensions in therapeutic relationships and, a tool for improving patient service uptake, continuity of care and satisfaction.

Making health insurance responsive to citizens: the management of members' complaints by mutual health organisations in Kinshasa, Democratic Republic of Congo

INTRODUCTION

In moving towards universal health coverage, a number of low-income and middle-income countries have adopted community-based health insurance (CBHI) as a means to reduce both the inequity in healthcare access and the burden of catastrophic health expenditures linked to user fees. However, organisations managing CBHIs face many challenges, including a poor relationship with their members. In the Democratic Republic of the Congo, CBHI schemes are managed by mutual health organisations (MHOs) and are in the process of enhancing their accountability and responsiveness to members' needs and expectations. This study assessed how MHOs have managed member complaints and their performance in grievance redressal.

METHODS

Using a sequential mixed-methods approach, we drew insights from four types of sources: review of approximately 50 relevant documents, 25 in-depth interviews (IDIs) with CBHI managers, 9 IDIs with health facility managers, 1063 surveys of MHO members and 15 focus group discussions (FGDs) comprising an additional 153 MHO members. MHO members in this study belonged to three different MHOs (Lisanga, La Borne and Mutuelle de santé des Enseignants de l'Enseignement Primaire, Secondaire et Professionnel) in the capital, Kinshasa.

RESULTS

The document review showed that there were no clear administrative processes for the implementation of the grievance redressal arrangement measures resulting in low member awareness of these measures. These results were confirmed by the IDIs. Of 1044 members surveyed, only 240 (23%) were aware of the complaint measures, and 201 (84%) of these declared they had used the measures at some point in time, 181/201 (90%) users who had used the measures declared being satisfied with the response provided. The FGDs confirmed that most members lack knowledge on the grievance redressal procedures, but those who were aware had made use of them and were often satisfied with the response provided.

CONCLUSION

MHOs should urgently improve communication with their members on the range of redressal measures put in place to address grievances. Attention should be given to properly monitor existing arrangements, and possibly adapt them with well-documented and communicated standard operating procedures.

Health practitioner regulation and national health goals

The role of health practitioner regulation in ensuring patient safety is well recognized. Less recognized is the role of regulation in addressing broader health system priorities. These goals include managing the costs, capacities and distribution of health professional education institutions; ensuring the competence and equitable distribution of health workers; informing workforce planning and mobilization; enabling the use of digital technologies; and addressing challenges related to the international mobility of health workers. Even where health practitioner regulation is designed to advance these goals, important gaps exist between the potential of regulatory systems and their performance. The response to the coronavirus disease 2019 (COVID-19) pandemic led many countries to introduce regulatory changes to allow more flexibility and innovations in the mobilization of health practitioners. Building on this experience, we need to critically re-examine health practitioner regulatory systems to ensure that these systems support rather than impede progress towards national health goals. We discuss the role of health practitioner regulation in contemporary health systems, highlighting recent regulatory reforms in selected countries, including during the COVID-19 pandemic. We identify the importance of dynamic, effective and flexible health practitioner regulatory systems in progress towards universal health coverage and health security.

"It's like asking for a necktie when you don't have underwear": Discourses on patient rights in southern Karnataka, India

BACKGROUND

Ensuring patient rights is an extension of applying human rights principles to health care. A critical examination of how the notion of patient rights is perceived and enacted by various actors through critical discourse analysis (CDA) can help understand the impediments to its realization in practice.

METHODS

We studied the discourses and discursive practices on patient rights in subnational policies and in ten health facilities in southern Karnataka, India. We conducted interviews (78), focus group discussions (3) with care-seeking individuals, care-providers, health care administrators and public health officials. We also conducted participant observation in selected health facilities and examined subnational policy documents of Karnataka pertaining to patient rights. We analyzed the qualitative data for major and minor themes.

RESULTS

Patient rights discourses were not based upon human rights notions. In the context of neoliberalism, they were predominantly embedded within the logic of quality of care, economic, and consumerist perspectives. Relatively powerful actors such as care-providers and health facility administrators used a panoply of discursive strategies such as emphasizing alternate discourses and controlling discursive resources to suppress the promotion of patient rights among care-seeking individuals in health facilities. As a result, the capacity of care-seeking individuals to know and claim patient rights was restricted. With neoliberal health policies promoting austerity measures on public health care system and weak implementation of health care regulations, patient rights discourses remained subdued in health facilities in Karnataka, India.

CONCLUSIONS

The empirical findings on the local expression of patient rights in the discourses allowed for theoretical insights on the translation of conceptual understandings of patient rights to practice in the everyday lives of health system actors and care-seeking individuals. The CDA approach was helpful to identify the problematic aspects of discourses and discursive practices on patient rights where health facility administrators and care-providers wielded power to oppress care-seeking individuals. From the practical point of view, the study demonstrated the limitations of care-seeking individuals in the discursive realms to assert their agency as practitioners of (patient) rights in health facilities.

How older adults’ health beliefs affect intention to perform COVID-19 self-examination: A reasoned action approach

BACKGROUND: COVID-19 self-examination is a significant part of the national recovery plan against the virus. Although it is easier to perform COVID-19 self-examination (CSE), only a small percentage of people prefer it. There are no precise statistics on CSE in Malaysia, but informal data from news agencies imply low CSE. Lack of awareness and conflicting information about the reliability of CSE results may have raised concerns about CSE’s efficacy and effectiveness. OBJECTIVE: This study investigates how Malaysian older adults’ health beliefs influence their intention to perform CSE. The study developed a framework combining illness threats (ITH), perceived barriers (PBA), medical motivations (MMO), and control over illness (COI) from the Health Belief Model (HBM) with the Reasoned-Action Approach’s attitude (ATT), perceived control (PCO), and intention (INT). METHODS: Structural Equation Modelling (SEM) analyses were conducted with AMOS 26 software to determine the influence of HBM on older adults’ attitude, perceived control, and intention. The study collected 200 data for the pilot study and 400 data for hypotheses testing. RESULTS: ITH, MMO, and COI have positive effects, whilst PBA affects ATT negatively. ITH and COI positively impact PCO, and PCO has a greater significant effect on INT than ATT. CONCLUSION: Given the HBM’s role in influencing older adults’ intention to perform COVID-19 self-examination, providing different levels of care and emphasising the perception of knowledge of illness are especially beneficial. Several recommendations are made to ensure that CSE remains relevant for older adults’ well-being, although COVID-19’s impact has become more stabilised.

Clients satisfaction at primary healthcare facilities and its association with implementation of client service charter in Tanzania

Background

Client service charter (CSC) provides information about what people can expect in a facility’s services; what is expected of clients and service providers. Tanzania implemented Star Rating Assessment (SRA) of primary health care (PHC) facilities in 2015/16 and 2017/18 using SRA tools with 12 service areas. This paper assesses the status of service area 7, namely client focus that checked if client was satisfied with services provided and implementation of CSC through three indicators–if: CSC was displayed; CSC was monitored; client feedback mechanism and complaints handling was in place.

Methods

We extracted and performed a cross-sectional secondary data analysis of data related to clients’ focus that are found in national SRA database of 2017/2018 using STATA version 15. Client satisfaction was regarded as dependent variable while facility characteristics plus three indicators of CSC as independent variables. Multivariate logistic regression with p-value of 5% and 95% confidence interval (CI) were applied.

Results

A total of 4,523 facilities met our inclusion criteria; 3,987 (88.2%) were dispensaries, 408 (9.0%) health centres and 128 (2.8%) hospitals. CSC was displayed in 69.1% facilities, monitored in 32.4% facilities, and 32.5% of the facilities had mechanisms for clients’ feedback and handling complaints. The overall prevalence of clients’ satisfaction was 72.8%. Clients’ satisfaction was strongly associated with all implementation indicators of CSC. Clients from urban-based facilities had 21% increased satisfaction compared rural-based facilities (AOR 1.21; 95%CI: 1.00–1.46); and clients from hospitals had 39% increased satisfaction compared to dispensaries (AOR 1.39; 95%CI: 1.10–1.77).

Conclusion

The implementation of CSC is low among Tanzanian PHC facilities. Clients are more satisfied if received healthcare services from facilities that display the charter, monitor its implementation, have mechanisms to obtain clients feedback and handle complaints. Clients’ satisfaction at PHC could be improved through adoption and implementation of CSC.

Patients' perception of safety climate in Irish general practice: a cross-sectional study

BACKGROUND

Although patients have the potential to provide important information on patient safety, considerably fewer patient-report measures of safety climate (SC) have been applied in the primary care setting as compared to secondary care. Our aim was to examine the application of a patient-report measure of safety climate in an Irish population to understand patient perceptions of safety in general practice and identify potential areas for improvement. Specifically, our research questions were: 1. What are patients' perceptions of SC in Irish general practice? 2. Do patient risk factors impact perceptions of SC? 3. Do patient responses to an open-ended question about safety enhance our understanding of patient safety beyond that obtained from a quantitative measure of SC?

METHODS

The Patient Perspective of Safety in General Practice (PPS-GP) survey was distributed to primary care patients in Ireland. The survey consisted of both Likert-response items, and free-text entry questions in relation to the safety of care. A series of five separate hierarchical regressions were used to examine the relationship between a range of patient-related variables and each of the survey subscales. A deductive content analysis approach was used to code the free-text responses.

RESULTS

A total of 584 completed online and paper surveys were received. Respondents generally had positive perceptions of safety across all five SC subscales of the PPS-GP. Regarding patient risk factors, younger age and being of non-Irish nationality were consistently associated with more negative SC perceptions. Analysis of the free-text responses revealed considerably poorer patient perceptions (n = 85, 65.4%) of the safety experience in primary care.

CONCLUSION

Our findings indicate that despite being under-utilised, patients' perceptions are a valuable source of information for measuring SC, with promising implications for safety improvement in general practice. Further consideration should be given to how best to utilise this data in order to improve safety in primary care.

Health workers' disrespectful and abusive behaviour towards women during labour and delivery: A qualitative study in Durban, South Africa

BACKGROUND

A high prevalence of disrespectful and abusive behaviour by health workers towards women during labour and delivery has been widely described in health facilities, particularly in Africa, and is a worldwide public health concern. Such behaviours are barriers to care-seeking, and are associated with adverse outcomes for mothers and newborns. This paper reports experiences of disrespectful care among informal working women in three public health facilities in Durban, South Africa.

METHODS

A qualitative longitudinal study was conducted among a cohort of informal working women recruited during pregnancy in two clinics in Durban. The study comprised a series of in-depth interviews conducted at different time points from pregnancy until mothers had returned to work, followed by focus group discussions (FGDs) with cohort participants. We present data from participatory FGDs, known as 'Journey with my Baby', conducted at the end of the study, during which women's experiences from pregnancy until returning to work were reviewed and explored. Thematic analysis was used with NVIVO v12.4.

RESULTS

Three 'Journey with my Baby' FGDs were conducted with a total of 15 participants between March and October 2019. Many participants narrated experiences of disrespectful behavior from nurses during labour and childbirth, with several women becoming very distressed as a result. Women described experiencing rudeness and verbal abuse from nurses, lack of privacy and confidentiality, nurses refusing to provide care, being denied companionship and being left unattended for long periods during labour. Women described feeling anxious and unsafe while in the labour ward because of the behaviour they experienced directly and observed other patients experiencing. Such experiences created bad reputations for health facilities, so that women in the local community were reluctant to attend some facilities.

CONCLUSION

Disrespect and abuse continues to be a serious concern in public health facilities in South Africa. We challenge the health system to effectively address the underlying causes of disrespectful behavior among health workers, initiate robust monitoring to identify abusive behavior when it occurs, and take appropriate actions to ensure accountability so that women receive the high-quality maternity care they deserve.

Health system responsiveness: a systematic evidence mapping review of the global literature

BACKGROUND

The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness.

METHODS

A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts.

RESULTS

Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system.

CONCLUSIONS

This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.

How do patient feedback systems work in low-income and middle-income countries? Insights from a realist evaluation in Bangladesh

BACKGROUND

Well-functioning patient feedback systems can contribute to improved quality of healthcare and systems accountability. We used realist evaluation to examine patient feedback systems at health facilities in Bangladesh, informed by theories of citizenship and principal-agent relationships.

METHODS

We collected and analysed data in two stages, using: document review; secondary analysis of data from publicly available web-portals; in-depth interviews with patients, health workers and managers; non-participant observations of feedback environments; and stakeholder workshops. Stage 1 focused on identifying and articulating the initial programme theory (PT) of patient feedback systems. In stage 2, we iteratively tested and refined this initial theory, through analysing data and grounding emerging findings within substantive theories and empirical literature, to arrive at a refined PT.

RESULTS

Multiple patient feedback systems operate in Bangladesh, essentially comprising stages of collection, analysis and actions on feedback. Key contextual enablers include political commitment to accountability, whereas key constraints include limited patient awareness of feedback channels, lack of guidelines and documented processes, local political dynamics and priorities, institutional hierarchies and accountability relationships. Findings highlight that relational trust may be important for many people to exercise citizenship and providing feedback, and that appropriate policy and regulatory frameworks with clear lines of accountability are critical for ensuring effective patient feedback management within frontline healthcare facilities.

CONCLUSION

Theories of citizenship and principal-agent relationships can help understand how feedback systems work through spotlighting the citizenship identity and agency, shared or competing interests, and information asymmetries. We extend the understanding of these theories by highlighting how patients, health workers and managers act as both principals and agents, and how information asymmetry and possible agency loss can be addressed. We highlight the importance of awareness raising and non-threatening environment to provide feedback, adequate support to staff to document and analyse feedback and timely actions on the information.

Improving maternal health services through social accountability interventions in Nepal: an analytical review of existing literature

BACKGROUND

The persistent quality gap in maternal health services in Nepal has resulted in poor maternal health outcomes. Accordingly, the Government of Nepal (GoN) has placed emphasis on responsive and accountable maternal health services and initiated social accountability interventions as a strategical approach simultaneously. This review critically explores the social accountability interventions in maternal health services in Nepal and its outcomes by analyzing existing evidence to contribute to the informed policy formulation process.

METHODS

A literature review and desk study undertaken between December 2018 and May 2019. An adapted framework of social accountability by Lodenstein et al. was used for critical analysis of the existing literature between January 2000 and May 2019 from Nepal and other low-and-middle-income countries (LMICs) that have similar operational context to Nepal. The literature was searched and extracted from database such as PubMed and ScienceDirect, and web search engines such as Google Scholar using defined keywords.

RESULTS

The study found various social accountability interventions that have been initiated by GoN and external development partners in maternal health services in Nepal. Evidence from Nepal and other LMICs showed that the social accountability interventions improved the quality of maternal health services by improving health system responsiveness, enhancing community ownership, addressing inequalities and enabling the community to influence the policy decision-making process. Strong gender norms, caste-hierarchy system, socio-political and economic context and weak enforceability mechanism in the health system are found to be the major contextual factors influencing community engagement in social accountability interventions in Nepal.

CONCLUSIONS

Social accountability interventions have potential to improve the quality of maternal health services in Nepal. The critical factor for successful outcomes in maternal health services is quality implementation of interventions. Similarly, continuous effort is needed from policymakers to strengthen monitoring and regulatory mechanism of the health system and decentralization process, to improve access to the information and to establish proper complaints and feedback system from the community to ensure the effectiveness and sustainability of the interventions. Furthermore, more study needs to be conducted to evaluate the impact of the existing social accountability interventions in improving maternal health services in Nepal.

A systematic review of patient complaints about general practice

BACKGROUND

Health care complaints are an underutilized resource for quality and safety improvement. Most research on health care complaints is focused on secondary care. However, there is also a need to consider patient safety in general practice, and complaints could inform quality and safety improvement.

OBJECTIVE

This review aimed to synthesize the extant research on complaints in general practice.

METHODS

Five electronic databases were searched: Medline, Web of Science, CINAHL, PsycINFO and Academic Search Complete. Peer-reviewed studies describing the content, impact of and motivation for complaints were included and data extracted. Framework synthesis was conducted using the Healthcare Complaints Analysis Tool (HCAT) as an organizing framework. Methodological quality was appraised using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

RESULTS

The search identified 2960 records, with 21 studies meeting inclusion criteria. Methodological quality was found to be variable. The contents of complaints were classified using the HCAT, with 126 complaints (54%) classified in the Clinical domain, 55 (23%) classified as Management and 54 (23%) classified as Relationships. Motivations identified for making complaints included quality improvement for other patients and monetary compensation. Complaints had both positive and negative impacts on individuals and systems involved.

CONCLUSION

This review highlighted the high proportion of clinical complaints in general practice compared to secondary care, patients' motivations for making complaints and the positive and negative impacts that complaints can have on health care systems. Future research focused on the reliable coding of complaints and their use to improve quality and safety in general practice is required.

The influence of corruption and governance in the delivery of frontline health care services in the public sector: a scoping review of current and future prospects in low and middle-income countries of south and south-east Asia

BACKGROUND

The dynamic intersection of a pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for 'corruption' in the LMICs of south and south-east Asia region. 'Corruption' works to undermine the UHC goals of achieving equity, quality, and responsiveness including financial protection, especially while delivering frontline health care services. This scoping review examines current situation regarding health sector corruption at frontlines of service delivery in this region, related policy perspectives, and alternative strategies currently being tested to address this pervasive phenomenon.

METHODS

A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted, using three search engines i.e., PubMed, SCOPUS and Google Scholar. A total of 15 articles and documents on corruption and 18 on governance were selected for analysis. A PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was filled-in to complete this report. Data were extracted using a pre-designed template and analysed by 'mixed studies review' method.

RESULTS

Common types of corruption like informal payments, bribery and absenteeism identified in the review have largely financial factors as the underlying cause. Poor salary and benefits, poor incentives and motivation, and poor governance have a damaging impact on health outcomes and the quality of health care services. These result in high out-of-pocket expenditure, erosion of trust in the system, and reduced service utilization. Implementing regulations remain constrained not only due to lack of institutional capacity but also political commitment. Lack of good governance encourage frontline health care providers to bend the rules of law and make centrally designed anti-corruption measures largely in-effective. Alternatively, a few bottom-up community-engaged interventions have been tested showing promising results. The challenge is to scale up the successful ones for measurable impact.

CONCLUSIONS

Corruption and lack of good governance in these countries undermine the delivery of quality essential health care services in an equitable manner, make it costly for the poor and disadvantaged, and results in poor health outcomes. Traditional measures to combat corruption have largely been ineffective, necessitating the need for innovative thinking if UHC is to be achieved by 2030.

Nepal's Health Facility Operation and Management Committees: exploring community participation and influence in the Dang district's primary care clinics

AimTo describe community representation in Nepal's Health Facility Operation and Management Committees (HFMCs) and the degree of influence of community representatives in the HFMC decision-making processes.

BACKGROUND

Community participation has been recognised as one of the key components for the successful implementation of primary health care (PHC) strategies, following the 1978 Declaration of Alma-Ata. In low- and middle-income countries (LMICs), HFMCs are now widely considered as a mechanism to increase community participation in health through community representation. There is some research examining the implementation process, impact and factors affecting the effectiveness of HFMCs. Despite the documented evidence of the importance of factors such as adequate representation, links with wider community, and decision-making power, there is limited evidence about the nature of community representation and degree of decision making within HFMCs in the PHC setting, particularly in LMICs.

METHODS

Qualitative interviews with 39 key informants were held to explore different aspects of community representation in HFMCs, and the influence of the HFMC on health facility decision-making processes. In addition, a facility audit at 22 facilities and review of HFMC meeting minutes at six health facilities were conducted.FindingsThere were Dalit (a marginalised caste) and Janajati (an ethnic group) representations in 77% and 100% of the committees, respectively. Likewise, there were at least two female members in each committee. However, the HFMC member selection process and decision making within the committees were influenced by powerful elites. The degree of participation through HFMCs appeared to be at the 'Manipulation' and 'Informing' stage of Arnstein's ladder of participation. In conclusion, despite representation of the community on HFMCs, the depth of participation seems low. There is a need to ensure a democratic selection process of committee members; and to expand the depth of participation.

Unhappy Patients Are Not Alike: Content Analysis of the Negative Comments from China's Good Doctor Website

BACKGROUND

With the rise in popularity of Web 2.0 technologies, the sharing of patient experiences about physicians on online forums and medical websites has become a common practice. However, negative comments posted by patients are considered to be more influential by other patients and physicians than those that are satisfactory.

OBJECTIVE

The aim of this study was to analyze negative comments posted online about physicians and to identify possible solutions to improve patient satisfaction, as well as their relationship with physicians.

METHODS

A Java-based program was developed to collect patient comments on the Good Doctor website, one of the most popular online health communities in China. A total of 3012 negative comments concerning 1029 physicians (mean 2.93 [SD 4.14]) from 5 highly ranked hospitals in Beijing were extracted for content analysis. An initial coding framework was constructed with 2 research assistants involved in the codification.

RESULTS

Analysis, based on the collected 3012 negative comments, revealed that unhappy patients are not alike and that their complaints cover a wide range of issues experienced throughout the whole process of medical consultation. Among them, physicians in Obstetrics and Gynecology (606/3012, 20.12%; P=.001) and Internal Medicine (487/3012, 16.17%; P=.80) received the most negative comments. For negative comments per physician, Dermatology and Sexually Transmitted Diseases (mean 5.72, P<.001) and Andrology (mean 5, P=.02) ranked the highest. Complaints relating to insufficient medical consultation duration (577/3012, 19.16%), physician impatience (527/3012, 17.50%), and perceived poor therapeutic effect (370/3012, 12.28%) received the highest number of negative comments. Specific groups of people, such as those accompanying older patients or children, traveling patients, or very important person registrants, were shown to demonstrate little tolerance for poor medical service.

CONCLUSIONS

Analysis of online patient complaints provides an innovative approach to understand factors associated with patient dissatisfaction. The outcomes of this study could be of benefit to hospitals or physicians seeking to improve their delivery of patient-centered services. Patients are expected to be more understanding of overloaded physicians' workloads, which are impacted by China's stretched medical resources, as efforts are made to build more harmonious physician-patient relationships.

Mothers' experience of disrespect and abuse during maternity care in northern Ethiopia

BACKGROUND

The provision of respectful and satisfactory maternity care is essential for promoting timely care-seeking behaviour, and ultimately ensuring the health and well-being of mothers and their babies. Disrespectful and abusive care has been recognized as one of the barriers to seeking timely maternity health services. However, the issue has not been adequately researched in community settings in low- and middle-income countries using validated measurement tools.

OBJECTIVE

This study was conducted to assess the extent of, and factors associated with, disrespectful and abusive maternity care reported by women who utilized facility-based delivery services in northern Ethiopia.

METHODS

We conducted a community-based cross-sectional study in Tigray, northern Ethiopia. Women who gave birth in the preceding year and visited health institutions for these deliveries were selected using a multistage cluster sampling procedure. Data were collected using a pretested questionnaire. Six domains of disrespect and abuse (D and A) were included in the questionnaire. Socio-demographic and obstetric related factors associated with D and A were tested using a negative binomial regression model.

RESULTS

Of the 1125 women in the sample, 248 (22%; 95% CI: 19.8%, 24.4%) reported at least one incident of D and A during delivery at a public health facility in northern Ethiopia. Higher incidents of D and A were reported by women who were older than 19 years at the time of delivery (aIRR = 2.649 (95% CI: 1.455, 4.825) compared to younger women. Incidents of D and A were reported more by women residing in urban areas, by women educated to the ninth grade and above, by women who experienced longer labour duration, and also by women who were not permitted to have support persons attend labour and delivery.

CONCLUSIONS

A fifth of the women reported D and A while receiving care during labour and delivery. Policies and practices aimed at ensuring universal coverage for institutional deliveries need to promote respectful maternity care for women in all facilities.

Do experiences and perceptions about quality of care differ among social groups in Nepal? : A study of maternal healthcare experiences of women with and without disabilities, and Dalit and non-Dalit women

BACKGROUND

Suboptimal quality of care and disparities in services by healthcare providers are often reported in Nepal. Experience and perceptions about quality of care may differ according to women's socio-cultural background, individual characteristics, their exposure and expectations. This study aimed to compare perceptions of the quality of maternal healthcare services between two groups that are consistently considered vulnerable, women with disabilities from both the non-Dalit population and Dalit population and their peers without disabilities from both non-Dalit and Dalit communities.

METHODS

A cross-sectional survey was conducted among 343 total women that included women with disabilities, Dalits and non-Dalits. Women were recruited for interview, who were aged 15-49 years, had been pregnant within the last five years and who had used maternal care services in one of the public health facilities of Rupandehi district. A 20-item, Likert-type scale with four sub-scales or dimensions: 'Health Facility', 'Healthcare Delivery', 'Inter-personal' and 'Access to Care' was used to measure women's perceptions of quality of care. Chi-square test and t test were used to compare groups and to assess differences in perceptions; and linear regression was applied to assess confounding effects of socio-demographic factors. The mean score was compared for each item and separately for each dimension.

RESULTS

All groups, women with disabilities and women without disabilities, Dalit and non-Dalit rated their perceptions and experiences of quality of care lowly in a number of items. While perceived quality of care between women with disabilities and without disabilities in the 'Health Facility' dimension and associated items, was found to differ (p<0.05), this difference was linked to disability status, but was not linked to caste differences. For example, differences in mean scores relating to 'Cleanliness and Facilities', 'Open and Friendliness' and 'Compassion and Kindness' were highly significant (p<0.001), with women with disabilities rating these as better than women without disabilities. On the other hand, women without disabilities rated the 'Availability of cash Incentives' more highly (p<0.01). No significant differences were found between Dalit and non-Dalit women in perceived quality of care, except in relation to 'Cleanliness and facilities', which Dalit women rated lower than non-Dalits (p<0.05).

CONCLUSIONS

Perceptions about the quality of care differed significantly by disability status but not by caste. All groups rated the quality of healthcare delivery, interpersonal and personal factors as well as access to services 'low.' Poor service user experiences and perceptions of quality of care undermine opportunities to translate increased healthcare coverage into improved access and outcomes. Greater attention is required by policy makers, health planners and providers to the improvement of quality of care in health facilities.

A meta-ethnography of the facilitators and barriers to successful implementation of patient complaints processes in health-care settings

Objective

To synthesize experiences of the patient complaints process for patients and health‐care professionals to identify facilitators and barriers in the successful implementation of patient complaints processes. This will assist the development of cultural change programmes, enabling complaints managers to incorporate stakeholder perspectives into future care.

Design

Systematic literature search and meta‐ethnography, comprising reciprocal syntheses of “patient” and “professional” qualitative studies, combined to form a “line‐of‐argument” embodying both perspectives.

Data sources

MEDLINE, CINAHL and PsycINFO (database inception to April 2015) were searched to identify international literature in primary and secondary health‐care settings, involving qualitative data collection and analysis. Further studies were identified from hand‐searching relevant journals, contacting authors, article reference lists and Google Scholar.

Results

A total of 13 papers, reporting 9 studies from the United Kingdom, Sweden, Australia and New Zealand, were included in the synthesis. Facilitators and barriers to the successful implementation of patient complaints processes were identified across the perspectives of both patients and health‐care professionals. Patients sought to individualize the complaints process by targeting specific professionals who engaged in practices that undermined the identity of patients. In contrast, professionals obscured their own individualism through maintaining a collective identity and withholding personal judgement in relation to patient complaints.

Conclusions

Complainants recognized health‐care professionals as bearers of individual accountability for unsatisfactory care, in opposition to the stance of collective responsibility endorsed by professionals. Implementation of patient complaints processes must reconcile the need for individualized resolution, whilst striving to improve the future provision of health care through a collaborative approach between patients and professionals.

Citizen's Charter in a primary health-care setting of Nepal: An accountability tool or a "mere wall poster"?

BACKGROUND

Despite some empirical findings on the usefulness of citizen's charters on awareness of rights and services, there is a dearth of literature about charter implementation and impact on health service delivery in low-income settings.

OBJECTIVE

To gauge the level of awareness of the Charter within Nepal's primary health-care (PHC) system, perceived impact and factors affecting Charter implementation.

METHOD

Using a case study design, a quantitative survey was administered to 400 participants from 22 of 39 PHC facilities in the Dang District to gauge awareness of the Charter. Additionally, qualitative interviews with 39 key informants were conducted to explore the perceived impact of the Charter and factors affecting its implementation.

RESULTS

Few service users (15%) were aware of the existence of the Charter. Among these, a greater proportion were literate, and there were also differences according to ethnicity and occupational group. The Charter was usually not properly displayed and had been implemented with no prior public consultation. It contained information that provided awareness of health facility services, particularly the more educated public, but had limited potential for increasing transparency and holding service providers accountable to citizens. Proper display, consultation with stakeholders, orientation or training and educational factors, follow-up and monitoring, and provision of sanctions were all lacking, negatively influencing the implementation of the Charter.

CONCLUSION

Poor implementation and low public awareness of the Charter limit its usefulness. Provision of sanctions and consultation with citizens in Charter development are needed to expand the scope of Charters from information brochures to tools for accountability.