This study has offered insight into the non-clinical quality of care attributes, simultaneously by measuring patients ‘experience and expectations of quality among public and private PHC providers respectively, in two regions of Albania. The findings of this study are discussed based on the relevance of the main non-clinical quality attributes (domains) and their perceived responsiveness by healthcare provider type.
Quality of care by type of health care provider
The study indicates that urban public PHC services and private outpatient clinics do perform similarly in respect to attributes of non-clinical quality of care. This is in contrast to, Bleich and colleagues who identified lower quality rates amongst private healthcare users compared to public counterparts, in a study conducted in 21 European Union countries .25 These results deviate from findings of other studies indicating that private health facilities appear to be of higher (interpersonal) process quality, including responsiveness and effort, and conceivably being more patient- orientated than public facilities. 21, 22, 23
Our results do suggest that while the overall quality ratings were similar, private providers are rated better, on quality of basic amenities, confidentiality and autonomy. Although confidentiality was well rated in terms of responsiveness (patients’ experience when receiving care, as assessed by the mean sores), (Table 2, Figure 1), this domain was considered by respondents as of comparatively low importance for consulting a PHC service (Figure 1). This aligns to other studies which identified confidentiality being a neglected aspect of care in less developed countries, partly due to lower importance given to this domain, mainly attributed to resource limitations and lack of awareness.42 One reason why confidentiality is better perceived in private sector in the present study could be linked to relatively good infrastructural conditions, appropriate space and waiting rooms. Indeed, the private providers in Albania have substantially invested in modern and updated technology and medical devices. At the same time, quality of basic amenities was perceived as an important attribute of quality of care (Figure 1) but were poorly rated by use of governmental services. Public health services in Albania over the last two decades are paradoxically perceived as a mix of poor quality in terms of infrastructure, 5,12,43 yet, with highly satisfied patients44 yielding positive estimations on staff skills in terms of accurate diagnosis and staff readiness to respond on time in a kind and polite way.45
Similar perceptions do prevail when comparing urban and rural PHC experiences with the non -clinical quality of care: patients attending rural PHC were less critical and reported higher levels of agreement with the quality attributes compared to urban patients, reconfirming previous studies of rural patients being more positive about the care environment.29,46 One could argue that the reforms and efforts of the governments of Albania and their partners in improving rural PHC services by (i) refining physical infrastructure of the facilities, (ii) equipping facilities with appropriate medical devices and (ii) fostering staff continuous education activities44 , might have positively impacted rural populations ‘perception. It should be pointed out that efforts towards quality improvement initiatives and UHC have been the focus of the Albanian government. Additionally, since 2009 there has been compulsory accreditation of public and private medical institutions delivering health services (with an exception of laboratories), and the providers are expected to meet minimal standards of quality of care.
The attitudes of the rural patients interviewed within the present study, may also mirror the past communism area positions of the society with strong community ties, where traditionally state-owned institutions, doctors included, were the ultimate and unquestionable authority. The findings may also reflect a lack of awareness of patients’ rights and weak, undeveloped patients’ centeredness concepts. Nevertheless, when compared with urban patients in public facilities, rural patients gave considerably lower mean values on prompt attention (Table 2), perceiving difficulties related to geographic proximity, means and costs of transport and waiting time. However, after adjustments for socioeconomic and health characteristics, these results did not yield a statistical significance when compared to urban public providers (Table 3).
Patient-provider interaction; the path toward informative and participatory decision-making.
Among the eight non-clinical care attributes of quality, patients rated communication and dignity the highest. By contrast the choice of provider, prompt attention and coordination of care were scored lowest (Figure 1). These findings are consistent with previous research where both communication and dignity were highly rated in five central European countries.47 Some authors consider that this pattern can be elucidated by the historical, cultural and social environment36 which formed populations’ expectations when encountering the health providers and health system. Also, in terms of importance of domains, as depicted from patients’ theoretical point of view, our study showed that patients, independent from using a public or private provider, agree that communication and dignity were the most important attributes of quality, followed by prompt attention. This is partly different from the outcomes of a previous study involving 41 countries who selected prompt attention as the most important domain, followed by dignity and communication.17
When averaging total scale (Table 3), patients receiving social or economic aid reported lower dignity and communication mean scores compared to those not receiving it. This aligns to previous research that has found that socio-economically disadvantaged groups are treated with less respect and inadequate communication by health workers.37
The autonomy domain incorporates the concept of patients’ empowerment and their right (including their caregivers’ rights) to medical information and their choice to refuse a medical treatment.22 However, autonomy did not appear to be among the important or even well-rated domains in our study. In fact, it was frequently rated as one of the least important domains (Figure 1). This shows that involvement of patients in treatment choices is still an evolving area, especially in the governmental sector. Some efforts are being invested by private outpatient clinics in giving patients more information about alternative types of treatments and tests; however, in our study there were not any noteworthy differences compared to the public sector. It has been argued that low attention to autonomy can be explained by persistent paternalistic behaviours of both provider and patients regarding their position with each other and within the health system.47 Patients’ voice in healthcare delivery process and community involvement on quality of care improvement initiatives are latent in Albania and have yet to be actively developed in the health system to support health policymaking.5
Prompt attention, choice and coordination of care
When averaging ratings of responsiveness for the total population, domains of ‘ability to choose doctor’, ‘prompt attention’ and ‘coordination of care’ were among the lowest rated, suggesting a poor performance. ‘Prompt attention’ was ranked third by the level of importance and it was the second lowest rating by the level of responsiveness (Figure 1). This indicates that this domain is of high importance to patients but not experienced satisfactorily in the frame of their most recent PHC consultation, especially in rural settings.
Respondents receiving care from private outpatient clinics provided a low average score on the ‘prompt attention’ domain. This may be related to two facts; first, private outpatient clinics operate during some hours of the day, by inviting several specialist doctors, sometimes from the capital city of Tirana or nearby countries such as doctors from Greece, Italy, or Turkey. Second, the patients attending private clinics frequently do not benefit from health insurance coverage. They may be living in close or distant villages, and they may have gone through different processes and obstacles within the public health care system prior to ending up at the private clinics. Moreover, doctors working at the same time at the public and private health sector (dual practices) and patient juggling are a concerning phenomenon, especially in low- and middle-income countries,48 making private PHC services not constantly available due to limited presences of doctors, hindering thus prompt attention, choice and good coordination of care.
The factors mentioned above might also explain the discontent of patients with their ability to choose the provider they want to consult about their medical condition even when choosing or transiting to the private health providers.
Sociodemographic characteristics and perceived quality of care
Our results showed that being in the possession of a health insurance card, having utilized the health service more recently and being a pensioner, were good predictors of positive quality ratings of the domains of ‘coordination of care’ and ‘involvement in healing options’ (autonomy). At the same, suffering from one or more chronic conditions were good predictors of lower quality ratings on the ‘prompt attention’ domain and higher ratings for coordination of care. Thus, while shaping the new service delivery models, policy makers and public health researchers should emphasis the ways in which to deploy health workers and how to engage patients in treatment choices in order to deliver well-coordinated care. As Albania moves towards a better coordinated health service it will be of importance to build up an electronic medical record system so that different providers can share and exchange relevant patient information.
In the current study, people in good health were overall more critical of the quality of care, especially with the ability to choose a provider, while gender and age were no predictors of quality of care ratings. Previous studies have yielded mixed results between perceived quality and patients’ sociodemographic and health characteristics.25,34,36,47,46,49 Low perceived quality of care has been associated with users in poor health, uninsured people or users that have made fewer visits to providers.25 Other studies associate perceived good quality with older age and higher income,37 self-reported good health status and rural residency.29
Patients’ perceived quality differences may also be explained by variability of the quality instruments and the context on which the instruments have been implemented, factors related to individual characteristics, previous encounters with health care providers and the cultural, historical and geographical environment.
Study limitations
This study has some limitations. The number of respondents who answered each item, varied from one domain to the other (selecting for example the ‘non applicable’ answer option), reflecting variable understanding and sensitivity of respondents to eight domains of WHO responsiveness tool. Therefore, when data was analysed, a condition was set to have at least 75% of the all domains (six out of eight) entirely answered. However, the mean values trend did not change even when we ran the analysis under different domains fulfilled rather than six. The study was conducted applying a widely accepted and validated tool, however, entirely relying on self-reporting perceptions rather than measurements of an impartial observer; therefore, possible variations of the patients’ perceived non-clinical quality may be attributed to differences in patients’ characteristics, cultural aspects, previous experience and expectations rather than actual provider practice. The response rate was quite high (88%), but certain categories of patients, for example younger patients did not give consent to participate. Therefore, a certain response bias cannot be excluded. Further, while all governmental providers in the two regions covered by the study participated, three out of eight private out-patient provides did not consent to participate in the study.
The two regions covered by the study make up around 16% of the territory of Albania and demographically represent around 15.7% of the population. One region (Diber) represents the mountains relatively poor part of the country while the second (Fier) is characteristic for the coastal, partially industrial settings in the country. Thus, the two regions reflect two patterns of Albania but cannot be considered as fully representing the socio-cultural and economic diversity of the country. Consequently, we cannot exclude the possibility that if applied to other regions, namely the urban context of the capital city Tirana, the results would differ.