Babar T. Shaikh  ( Department of Community Health Sciences,Aga Khan University Hospital, Karachi, Pakistan. )

Pledging quality in health care services ought to be a priority for any health care system. The notion of quality has emerged more strongly because of the rising costs of treatments, constrained resources in health services and evidence of variations in clinical practice.1 A quality health care system is one which guarantees the continuum of care, not merely for curative services, but for health promotion as well as prevention. Assessment of quality usually focuses on technical concerns as well as the process through which care is delivered. This assessment becomes more authentic and legitimate if based on the application of professional standards integrating the patients' views, experiences and perceptions.2,3 However, an effective system can only function properly, if it operates on a regular assessment of people's perceptions and monitors itself based on their feedback. Researchers have shown that for measuring health care system's performance, the assessment of patient satisfaction is a more sensitive indicator than the traditional measures such as morbidity and mortality patterns and more reliable than other methods such as physician peer review.4 The patient assessment of the health services and the health staff in view of improving the level of quality, is in fact respecting the consumer sovereignty.5 Increasing practice of conducting patients' satisfaction surveys, may be an evidence of the shift from traditional doctor-patient relationship to provider-client attitude.

Dimensions of quality service

World Health Organization in world health report 2000 defined quality of health care through benchmarks of efficiency, cost effectiveness and social acceptability. If the term social acceptability is unpacked, patients' perspective is clearly highlighted. This is not even very different from the corporate sector where consumers are given the prime importance. Reliability, responsiveness, assurance and empathy and tangibles are those attributes which we see being used in all sectors dealing with public goods and services. Health services are also public goods, where there is a definite potential to improve the level of patient satisfaction with the service by tracking these dimensions. Reliability of the service would mean that the patient is seen according to his/her expectations and received the required treatment. A responsive service would be where all patients regardless of their origin, status and background receive prompt attention by the hospital staff with courtesy and cooperation. Waiting time is appropriate and not bothersome. The factor of assurance is reflected from the reliance of the patients on doctor and hospital staff, and the confidence on their qualification and competence. The dimension of empathy could be seen as the individual attention given to the patients, calling by name and showing caring attitude towards them. Tangibles account for the cleanliness in the health facility, use of clean instruments and standard procedures in the facility and lastly the prescription, which should be easy to understand for the patients.

This philosophy of quality of health services, hitherto, may help us finding the answer to the enigma of underutilization of public sector health services in many developing countries and the flourishing private sector. Let's focus on Pakistan for instance. In spite of huge health infrastructure at the primary care level, it is most likely the dearth of quality that only 21% of the patients go to a public health centre for seeking care and 77% per capita health expenditures is incurred in the private sector.6 No doubt, the quality of health service in private sector can also be questioned. Still a higher pattern of utilization of private sector allopathic health facilities is attributed mostly to issues of acceptability such as minimal waiting time, longer and flexible opening hours, all time availability of staff and drugs in the health facilities, better attitude and more confidentiality in socially stigmatized diseases. The attitude of the health provider and patient satisfaction with the treatment play a role in health seeking behaviour. The dissatisfaction with public sector health providers actually make people to do the health care shopping. Also people tend to go to secondary or tertiary level hospitals for minor ailments. This phenomenon has its own repercussions in the form of considerable inefficiency and compromised quality of services in these big hospitals. It is, thus, quite rational to assess patient satisfaction of these public and private health facilities to bring about an overall improvement in quality of services delivered. It is seldom seen that researchers have looked for evaluation of health care services from a consumer perspective. However, satisfaction has been an implicit element in a range of assessments of utilization pattern surveys.

Quality improvement is imperative to development and improvement in health care systems in Pakistan. Although latest national health policy has emphasized on good governance to achieve quality health care, an authentic system of information has always been a flaw in the entire health care system and there is no mechanism on record to check the quality of these services. It is envisaged that through regular tracking of the dimensions of quality of care cited above, health providers and hospitals could receive timely feedback on areas of deficiency and this will stimulate a mechanism to improve patient satisfaction. The efficient delivery of primary health care through the existing health system will lead to improved health conditions by reducing morbidity, reducing mortality-specifically maternal and infant mortality and reducing population growth rate. This will also promote the appropriate use of the health services which will be catering to the very needs and aspirations of the community. The providers must get the first hand information from their clients which should help them to re-orient their services by adopting more client centred approach, moulding their attitude and introducing convivial ambiance at health service outlets based on the feedback of their clients. Gender sensitization of the doctors and the health facility staff is also a pre-condition to make the services more responsive for the women clientele. Understanding the health needs of the women and improving one's interpersonal communication skills of women clients especially would be enviable to bring about a change in the system. More health care is not always better health care. Providing good quality health care is of critical importance for the future economic and overall social well-being of this country.

1. Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci Med 2000;51:1611-25.

2. Haddad S, Potvin L, Roberge D, Pineault R, Remondin M. Patient perception of quality following a visit to a doctor in a primary care unit. Fam Pract 2000;17:21-9.

3. Aharony L, Strasser S. Patient satisfaction: What we know about and what we still need to explore. Med Care Rev 1993;50:49-79.

4. Fitzpatrick R. Surveys of patient satisfaction: important general considerations. BMJ 1991;302:887-9.

5. Grol R. Improving the quality of medical care: Building bridges among professional pride, payer profit and patient satisfaction. JAMA 2001;286:2578-85.

6. Pakistan Medical Research Council. Pattern of health care utilization. National Health Survey of Pakistan. Islamabad: 1998.