Patient’s perceived quality of care in South Africa’s public health sector: gratitude for access or ideal care experience

Background South Africa strives to close the quality divide between public and private healthcare services. However, it is unclear whether patients’ demands for access to care matches their desire for quality service. Therefore, we sought to determine if patients’ satisfaction with quality of care received in the public healthcare matches their overall care experience. Methods We conducted a mixed-methods cross-sectional survey from February to August 2021, enrolling 40 adult (>18 years) patients/clinics in waiting areas across a proportional sample (10%) of 45 public clinics in the Gauteng province (N=1800). Study participants completed a semi-structured questionnaire. High quality of care was defined as achieving a score>3.5 on a ten-item scale (Cronbach’s alpha= 0.67) measuring agreement with statements about care experiences, including staff communication, attitudes, and clinic amenities. Open-ended questions were analysed thematically and coded as complaints (yes/no). Results Overall, 1788/1800 (99.3%) completed the survey, and 70.2% (95% Confidence Interval (CI): 63.6-76.0) of participants reported high quality of service, equivalent between HIV/TB (73.5, 95%CI: 66.0, 79.9) and non-HIV/TB care seekers (67.8%, 95%CI: 61.0, 73.9). Still, 31.7% of participants reporting high service quality had complaints. Overall, 69.6% (62.3%, 76.0) of participants deeming services low-moderate quality reported complaints. Participants’ complaints included long waiting times, clinic appointment system inefficiencies, staff shortages, and poor staff time management. Additionally, participants reported disrespectful treatment from clinic staff and very poor communication. It appears that the improved access to care compensated for sub-standard experiences, as illustrated by statements like: “I like attending here at this facility as it's closer to my home. Overall experience is good except for long waiting hours and numbering system which is not followed.” “We all know the health care workers are always under pressure as they work with different kinds of people every day, but they need to be very much respectful to some of us who are seeking help politely”. Conclusions Patients’ perception of quality of care is partly driven by gratitude for the widespread access to free care. Still, quality measures must give equal weight to non-clinical experiences of care, such as waiting time and communication, which are essential determinants of improved care-seeking behaviours, particularly among patients in lifelong chronic care.