title: Comparison of Perceived and Technical Healthcare Quality in Primary Health Facilities: Implications for a Sustainable National Health Insurance Scheme in Ghana.
abstract: BACKGROUND
  Quality care in health facilities is critical for a sustainable health insurance system because of its influence on clients' decisions to participate in health insurance and utilize health services. Exploration of the different dimensions of healthcare quality and their associations will help determine more effective quality improvement interventions and health insurance sustainability strategies, especially in resource constrained countries in Africa where universal access to good quality care remains a challenge.
  
  
  OBJECTIVE
  To examine the differences in perceptions of clients and health staff on quality healthcare and determine if these perceptions are associated with technical quality proxies in health facilities. Implications of the findings for a sustainable National Health Insurance Scheme (NHIS) in Ghana are also discussed.
  
  
  METHODS
  This is a cross-sectional study in two southern regions in Ghana involving 64 primary health facilities: 1,903 households and 324 health staff. Data collection lasted from March to June, 2012. A Wilcoxon-Mann-Whitney test was performed to determine differences in client and health staff perceptions of quality healthcare. Spearman's rank correlation test was used to ascertain associations between perceived and technical quality care proxies in health facilities, and ordered logistic regression employed to predict the determinants of client and staff-perceived quality healthcare.
  
  
  RESULTS
  Negative association was found between technical quality and client-perceived quality care (coef. = -0.0991, p<0.0001). Significant staff-client perception differences were found in all healthcare quality proxies, suggesting some level of unbalanced commitment to quality improvement and potential information asymmetry between clients and service providers. Overall, the findings suggest that increased efforts towards technical quality care alone will not necessarily translate into better client-perceived quality care and willingness to utilize health services in NHIS-accredited health facilities.
  
  
  CONCLUSIONS
  There is the need to intensify client education and balanced commitment to technical and perceived quality improvement efforts. This will help enhance client confidence in Ghana's healthcare system, stimulate active participation in the national health insurance, increase healthcare utilization and ultimately improve public health outcomes.
authors.affiliation: Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, Netherlands; Department of Epidemiology, Noguchi Memorial Institute for Medical Research (NMIMR), University of Ghana, Legon, Accra, Ghana; University of Amsterdam (UvA), Amsterdam, Netherlands.
authors.forename: Robert Kaba
authors.initials: RK
authors.lastname: Alhassan
authors.affiliation: Department of Epidemiology, Noguchi Memorial Institute for Medical Research (NMIMR), University of Ghana, Legon, Accra, Ghana; Department of Development Economics, Vrije University (VU), Amsterdam, Netherlands.
authors.forename: Stephen Opoku
authors.initials: SO
authors.lastname: Duku
authors.affiliation: Department of Development Economics, Vrije University (VU), Amsterdam, Netherlands.
authors.forename: Wendy
authors.initials: W
authors.lastname: Janssens
authors.affiliation: Department of Economics, University of Ghana, Legon, Accra, Ghana.
authors.forename: Edward
authors.initials: E
authors.lastname: Nketiah-Amponsah
authors.affiliation: PharmAccess Foundation, Amsterdam, Netherlands.
authors.forename: Nicole
authors.initials: N
authors.lastname: Spieker
authors.affiliation: Joint Commission International (JCI), Chicago, United States of America.
authors.forename: Paul
authors.initials: P
authors.lastname: van Ostenberg
authors.affiliation: Department of Epidemiology, Noguchi Memorial Institute for Medical Research (NMIMR), University of Ghana, Legon, Accra, Ghana.
authors.forename: Daniel Kojo
authors.initials: DK
authors.lastname: Arhinful
authors.affiliation: Department of Development Economics, Vrije University (VU), Amsterdam, Netherlands.
authors.forename: Menno
authors.initials: M
authors.lastname: Pradhan
authors.affiliation: Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, Netherlands; PharmAccess Foundation, Amsterdam, Netherlands.
authors.forename: Tobias F
authors.initials: TF
authors.lastname: Rinke de Wit
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005191:Family Characteristics; D005260:Female; D005869:Ghana; D006268:Health Facilities; D006282:Health Personnel; D006801:Humans; D008297:Male; D008875:Middle Aged; D009313:National Health Programs; D010465:Perception; D011320:Primary Health Care / Q000191:economics / Q000592:standards*; D011787:Quality of Health Care; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires