The price of quality care: cross‐sectional associations between out‐of‐pocket payments and quality of care in six low‐income countries

Objective To assess the relationship between out‐of‐pocket (OOP) payments and primary health care quality in six low‐income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania. Methods We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history‐taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non‐profit and private for‐profit facilities controlling for patient, provider, and facility characteristics. Results Across the six countries, an average of 42% of the 29 677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history‐taking and exam items during antenatal care visits, and with counselling in private for‐profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high‐quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality. Conclusion Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.