Readiness and Client Satisfaction with Maternal and Child Health in LMICs: A Multi-Country Study Using Service Readiness Index Domains

Purpose: Client satisfaction is a critical determinant of health service utilization and adherence to treatment regimens, particularly for maternal and child health in low- and middle-income countries (LMICs). Structural quality, as conceptualized by Donabedian's framework—encompassing structure, process, and outcome—is often measured with the Service Readiness Index (SRI). However, its composite nature may obscure the contribution of individual domains. This study examines the relationship between disaggregated SRI domains and client satisfaction for antenatal care (ANC) and sick-child care across several LMICs, specifically Afghanistan, Haiti, Malawi, Nepal, and Tanzania. Methods: This study used exit interviews from a total of 9,373 antenatal care clients and 12,688 sick child caregivers collected as part of Service Provision Assessment. Bayesian logistic regression models were employed to analyze satisfaction as a binary outcome, adjusted for facility-, provider-, and client-level characteristics in each country. The independent variables of interest were the five SRI domains (basic amenities, basic equipment, infection prevention, diagnostic capacity, and essential medicines), evaluated separately by care type (ANC and sick-child care). Results: Variation was observed in the contribution of SRI domains to client satisfaction across countries and by care type. For ANC, basic equipment was strongly associated with higher satisfaction in Nepal (OR = 1.29, 95% CrI: [1.13, 1.48]) and Malawi (OR = 1.13, 95% CrI: [1.01, 1.27]). For sick-child care, diagnostic capacity had a positive association in Afghanistan (OR = 1.25, 95% CrI: [1.11, 1.43]) but a negative association in Tanzania (OR = 0.94, 95% CrI: [0.91, 0.97]). Consistent positive associations were observed for the essential medicines domain, and were highly certain in Malawi and Tanzania. In contrast, infection prevention measures showed inconsistent effects across contexts. Discussion: These findings highlight the importance of identifying country-specific drivers of client satisfaction within the SRI framework. While essential medicines consistently influenced satisfaction, other domains varied, likely reflecting differing expectations and needs. Conclusion: Disaggregating SRI domains provides a nuanced understanding of structural drivers of client satisfaction, enabling targeted quality improvements. Policymakers should prioritize domain-specific monitoring to inform the targeted implementation of interventions to enhance maternal and child health outcomes in diverse LMIC settings.