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Original research
Level of confidence in and endorsement of the health system among internet users in 12 low-income and middle-income countries
  1. Sanam Roder-DeWan1,2,
  2. Anna Gage1,
  3. Lisa R Hirschhorn3,
  4. Nana A Y Twum-Danso4,
  5. Jerker Liljestrand5,
  6. Kwanele Asante-Shongwe6,
  7. Talhiya Yahya7,
  8. Margaret Kruk1
  1. 1Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
  2. 2Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
  3. 3Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  4. 4Maternal and Child Health, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
  5. 5Bill and Melinda Gates Foundation, Seattle, Washington, USA
  6. 6African Organisation for Research and Training in Cancer, Cape Town, South Africa
  7. 7Quality Management Unit, Health Quality Assurance Department, Ministry of Health, Community, Development, Gender, Elderly and Children, Dodoma, Tanzania
  1. Correspondence to Dr Sanam Roder-DeWan; roderdewan{at}mail.harvard.edu

Abstract

Introduction People’s confidence in and endorsement of the health system are key measures of system performance, yet are undermeasured in low-income and middle-income countries (LMICs). We explored the prevalence and predictors of these measures in 12 countries.

Methods We conducted an internet survey in Argentina, China, Ghana, India, Indonesia, Kenya, Lebanon, Mexico, Morocco, Nigeria, Senegal and South Africa collecting demographics, ratings of quality, and confidence in and endorsement of the health system. We used multivariable logistic regression to assess the association between confidence/endorsement and self-reported quality of recent healthcare.

Results Of 13 489 respondents, 62% reported a health visit in the past year. Applying population weights, 32% of these users were very confident that they could receive effective care if they were to ‘become very sick tomorrow’; 30% endorsed the health system, that is, agreed that it ‘works pretty well and only needs minor changes’. Reporting high quality in the last visit was associated with 4.48 and 2.69 greater odds of confidence (95% CI 3.64 to 5.52) and endorsement (95% CI 2.33 to 3.11). Having health insurance was positively associated with confidence and endorsement (adjusted odds ratio (AOR) 1.68, 95% CI 1.49 to 1.90 and AOR 1.34, 95% CI 1.22 to 1.48), while experiencing discrimination in healthcare was negatively associated (AOR 0.67, 95% CI 0.56 to 0.80 and AOR 0.63, 95% CI 0.53 to 0.76).

Conclusion Confidence and endorsement of the health system were low across 12 LMICs. This may hinder efforts to gain support for universal health coverage. Positive patient experience was strongly associated with confidence in and endorsement of the health system.

  • health services research
  • health systems
https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjgh-2019-002205

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    Footnotes

    • Handling editor Eduardo Gómez

    • Twitter @agage93, @mkruk

    • Contributors The study was designed and implemented by MK, SR-D and AG. SR-D and AG wrote and prepared the first draft. All authors interpreted results, revised the manuscript and approved the final manuscript for submission.

    • Funding This study was funded by the Bill & Melinda Gates Foundation.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available in a public, open access repository. Data are available from https://dataverse.harvard.edu/.