DHS ANALYTICAL 

STUDIES 44

Assessing the Quality of Care in Family 

Planning, Antenatal,and Sick Child 

Services at Health Fac ilities in Kenya,

Namibia,and Senegal

SEPTEMBER 2014

This publication was produced for review by the United States Agency for International Development. It was prepared by 

Wenjuan Wang, Mai Do, John Hembling, and Paul Ametepi.

DHS Analytical Studies No. 44 

Assessing the Quality of Care in Family Planning, Antenatal, 

and Sick Child Services at Health Facilities in Kenya, 

Namibia, and Senegal 

Wenjuan Wang 

 Mai Do 

John Hembling 

 Paul Ametepi 

ICF International 

Rockville, Maryland, USA 

September 2014 

Corresponding author: Wenjuan Wang, International Health and Development, ICF International, 530 

Gaither Road, Suite 500, Rockville, MD 20850, USA; telephone: +1 301-572-0398: fax: +1 301-572-0950; 

email: wenjuan.wang@icfi.com 
3 

Acknowledgment: The authors would like to thank Sohail Agha for reviewing this report and providing 

invaluable comments. 

Editor: Bryant Robey 

Document Production: Natalie La Roche 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (#AID-OAA-C-13-00095). The views expressed are 

those of the author and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about the DHS Program contact: 

DHS Program, ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: 

301-407-6500, fax: 301-407-6501, email: reports@dhsprogram.com, Internet: www.dhsprogram.com. 

Recommended citation: 

Wang, Wenjuan, Mai Do, John Hembling, Paul Ametepi. 2014. Assessing the Quality of Care in Family 

Planning, Antenatal, and Sick Child Services at Health Facilities in Kenya, Namibia, and Senegal. DHS 

Analytical Studies No. 44 Rockville, Maryland, USA: ICF International.
iii 

Contents 

Tables ......................................................................................................................................................... v

Figures ....................................................................................................................................................... vii

Preface ........................................................................................................................................................ ix

Abstract ....................................................................................................................................................... xi

Executive Summary ................................................................................................................................. xiii

1. Introduction .................................................................................................................................... 1

2. Data and Methods .......................................................................................................................... 3

2.1 Data Used in the Analysis ........................................................................................................ 3

2.1.1 Data from facility inventory ............................................................................................ 3

2.1.2 Data from observations and exit interviews ................................................................... 4

2.1.3 Data from providers ........................................................................................................ 4

2.2 Definitions of Variables ............................................................................................................ 4

2.2.1 Structure and process variables ...................................................................................... 4

2.2.2 Client satisfaction ........................................................................................................... 5

2.2.3 Other covariates ............................................................................................................. 5

2.3 Statistical Methods ................................................................................................................... 5

3. Results ...................................................................................................................................................... 7

3.1 Family Planning ....................................................................................................................... 7

3.1.1Distribution of the sample ............................................................................................... 7

3.1.2Description of family planning service quality attributes ................................................ 9

3.1.3Factors associated with family planning client’s satisfaction ....................................... 19

3.2 Antenatal Care ....................................................................................................................... 21

3.2.1Distribution of the sample ............................................................................................. 21

3.2.2Description of ANC service quality attributes ............................................................... 23

3.2.3Factors associated with ANC client’s satisfaction ........................................................ 30

3.3 Sick Child Care ...................................................................................................................... 33

3.3.1Distribution of the sample ............................................................................................. 33

3.3.2Description of sick child service quality attributes ........................................................ 35

3.2.4Factors associated with sick child client’s satisfaction ................................................. 46

4. Discussion and Conclusion ................................................................................................................... 49

References .................................................................................................................................................. 53

Appendix A ................................................................................................................................................ 55

Appendix B ................................................................................................................................................ 57
iv 

Appendix C ................................................................................................................................................ 59

Appendix D ................................................................................................................................................ 61

Appendix E ................................................................................................................................................ 63

Appendix F ................................................................................................................................................ 65

Appendix G ................................................................................................................................................ 67

Appendix H ................................................................................................................................................ 69
v 

Tables 

Table 1. Sample distribution of facilities, provider interviews, and observations/client exit 

interviews in the family planning analysis ................................................................................ 8

Table 2. Attributes of quality of care in family planning services among all facilities and 

providers of family planning services and family planning clients ......................................... 10

Table 3. Factors associated with client satisfaction score related to family planning services ............. 20

Table 4. Sample distribution of facilities, provider interviews, and observations/client exit 

interviews in the ANC analysis ............................................................................................... 22

Table 5. Attributes of quality of care in ANC services among all facilities and providers of ANC 

services, and ANC clients ....................................................................................................... 24

Table 6. Factors associated with client satisfaction score related to ANC services .............................. 32

Table 7. Sample distribution of facilities, provider interviews, and observations/client exit 

interviews in the sick child analysis ........................................................................................ 34

Table 8. Attributes of quality of care in sick child services among all facilities and providers of sick 

child services and sick child clients ......................................................................................... 36

Table 9. Factors associated with client satisfaction score related to sick child services ....................... 47
vi 
vii 

Figures 

Figure 1. Kenya: Percentage of family planning facilities with high structure, process and 

satisfaction score by type of facility ......................................................................................... 11

Figure 2. Kenya: Percentage of family planning facilities with high structure, process and 

satisfaction score by managing authority .................................................................................. 12

Figure 3. Kenya: Percentage of family planning facilities with high structure, process and 

satisfaction score by region ....................................................................................................... 13

Figure 4. Namibia: Percentage of family planning facilities with high structure, process and 

satisfaction score by type of facility ......................................................................................... 14

Figure 5. Namibia: Percentage of family planning facilities with high structure, process and 

satisfaction score by managing authority .................................................................................. 15

Figure 6. Namibia: Percentage of family planning facilities with high structure, process and 

satisfaction score by region ....................................................................................................... 16

Figure 7. Senegal: Percentage of family planning facilities with high structure, process and 

satisfaction score by type of facility ......................................................................................... 17

Figure 8. Senegal: Percentage of family planning facilities with high structure, process and 

satisfaction score by managing authority .................................................................................. 18

Figure 9. Senegal: Percentage of family planning facilities with high structure, process and 

satisfaction score by region ....................................................................................................... 19

Figure 10. Kenya: Percentage of ANC facilities with high structure, process and satisfaction 

score by type of facility ............................................................................................................. 25

Figure 11. Kenya: Percentage of ANC facilities with high structure, process and satisfaction 

score by managing authority ..................................................................................................... 26

Figure 12. Kenya: Percentage of ANC facilities with high structure, process and satisfaction 

score by region .......................................................................................................................... 27

Figure 13. Namibia: Percentage of ANC facilities with high structure, process and satisfaction 

score by type of facility ............................................................................................................. 28

Figure 14. Namibia: Percentage of ANC facilities with high structure, process and satisfaction 

score by managing authority ..................................................................................................... 29

Figure 15. Namibia: Percentage of ANC facilities with high structure, process and satisfaction 

score by region .......................................................................................................................... 30

Figure 16. Kenya: Percentage of facilities providing sick child care with high structure, process and 

satisfaction score by type of facility ......................................................................................... 38

Figure 17. Kenya: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by managing authority .................................................................................. 39

Figure 18. Kenya: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by region ....................................................................................................... 40

Figure 19. Namibia: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by type of facility ......................................................................................... 41
viii 

Figure 20. Namibia: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by managing authority .................................................................................. 42

Figure 21. Namibia: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by region ....................................................................................................... 43

Figure 22. Senegal: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by type of facility ......................................................................................... 44

Figure 23. Senegal: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by managing authority .................................................................................. 45

Figure 24. Senegal: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by region ....................................................................................................... 46 
ix 

Preface 

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services. 

One of the objectives of The DHS Program is to analyze DHS data and provide findings that will be useful 

to policymakers and program managers in low- and middle-income countries. DHS Analytical Studies serve 

this objective by providing in-depth research on a wide range of topics, typically including several countries 

and applying multivariate statistical tools and models. These reports are also intended to illustrate research 

methods and applications of DHS data that may build the capacity of other researchers. 

The topics in the DHS Analytical Studies series are selected by The DHS Program in consultation with the 

U.S. Agency for International Development. 

It is hoped that the DHS Analytical Studies will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries. 

Sunita Kishor 

Director, The DHS Program 
x 
xi 

Abstract 

This study assessed the quality of care at health facilities in providing family planning, antenatal care, and 

sick child care, using data from nationally representative Service Provision Assessment (SPA) surveys in 

Kenya, Namibia, and Senegal. Quality of care was measured in structure, process, and outcome of service 

provision. Associations between the outcome and structural and process attributes were analyzed using 

multiple regressions. 

Health facilities had inadequate infrastructure and supplies that are essential for providing good-quality 

services. Shortage of service-specific guidelines and infection prevention precautions was common across 

service areas and countries. Other structural inadequacies include the limited number of contraceptive 

methods provided by family planning facilities, little use of the Integrated Management of Childhood Illness 

(IMCI) guide in assessing and treating sick children, and poor availability of diagnosis tests to verify 

malaria for children under age 5. Although hospitals and health centers generally possessed better structural 

attributes than clinics and other lower-level health facilities, their performance in adhering to standards of 

care during service delivery was not necessarily superior, and sometimes was poorer than lower-level 

facilities. Long waiting time was a common problem across countries and services, and was more serious 

in hospitals and health centers than in clinics and other facilities. Long waiting time stands out for its 

consistent association with lower levels of client satisfaction. Our analysis also found evidence of more 

client satisfaction in the private sector than in the public sector. 

KEY WORDS: quality of care, client satisfaction, family planning, antenatal care, sick child care, Kenya, 

Namibia, Senegal 
xii 
xiii 

Executive Summary 

Despite remarkable progress in increasing the coverage of reproductive, maternal, and child health 

interventions in the developing world, there has been only limited improvement in health outcomes. One 

reason could be poor quality of care provided in health facilities. Using nationally representative data from 

the Service Provision Assessment (SPA) surveys in Kenya, Namibia, and Senegal, we conducted a 

comprehensive analysis of the quality of care at formal-sector health facilities in providing family planning, 

antenatal, and sick child services. As countries strive to improve healthcare services, assessments of the 

quality of care can identify problems in service delivery and provide information to help guide policies and 

programs. 

Methods 

Data for this study come from SPA surveys conducted in Kenya (2010), Namibia (2009) and Senegal 

(2012-2013). In each country, the analysis included only those facilities providing services of interest—

that is, family planning, antenatal care, and sick child services. Based on the Donabedian quality of care 

framework, we assessed three aspects of quality: structure, process, and outcome. The structural 

characteristics assessed include the facility’s management systems, service availability, physical 

infrastructure, and examination equipment. For this measure of quality, data were collected through the 

facility inventory. The process characteristics comprise both interpersonal and technical aspects of 

provider-client interaction. Data for this component came from direct observation of provider-client 

interactions. The outcome indicator—client satisfaction with services—was an index score based on client 

exit interview responses to a series of questions about service quality. 

We use principal component analysis to construct several indices, including the structural composite score, 

process composite score, and the client satisfaction score for each service within each country. The score 

was computed based on the first principal component, which explained the largest proportion of the total 

variance. The structural attributes were analyzed at the facility level and compared between hospitals/health 

centers and clinics/others. Analysis of the process attributes and client satisfaction was conducted at the 

client level and comparisons were also made between the two groups of facilities. Multiple linear regression 

analysis was used to assess the relationship between the client satisfaction and structural and process aspects 

of quality of care for each group of facilities. 

Results 

In Kenya, the public and private sectors had about equal shares of facilities providing family planning, 

antenatal care, and sick child care. In Namibia and Senegal, the public sector was the primary provider of 

these services. Health workers in hospitals and health centers were more likely to have received servicespecific training in the 2-3 years preceding the survey, but had fewer years of in-service experience 

compared with health workers in clinics and other lower-level health facilities. 

Health facilities at both higher and lower levels of service delivery generally had inadequate infrastructure 

and supplies that are essential for providing good-quality services. Shortage of service-specific guidelines 

and infection prevention precautions was common across service areas and across the countries. Other 
xiv 

structural inadequacies include the limited number of contraceptive methods provided by family planning 

facilities, little use of the Integrated Management of Childhood Illness (IMCI) guide in assessing and 

treating sick children, and poor availability of diagnosis tests to confirm malaria infection in children under 

age 5. In Namibia, guidelines on antenatal care were observed in only 18 percent of the hospitals/health 

centers and 13 percent of the clinics/others. Across countries, of the 14 (or 13 in Senegal) infection 

prevention precautions examined, only one-half of the items were available at health facilities. Hospitals 

and health centers generally showed better structural quality than clinics and other facilities. In Kenya, for 

all three services, hospitals/health centers showed significantly higher measurements than clinics and other 

types of facilities for the most structural indicators studied. Although in Namibia and Senegal the gap was 

less prominent, the majority of structural indicators favored hospitals and health centers when there was a 

significant difference between the two groups. 

Although hospitals and health centers generally possessed better structural attributes than clinics and other 

lower-level health facilities, their performance in adhering to standards of care during the process of service 

delivery was not necessarily superior, and sometimes was poorer than in lower-level facilities. For example, 

in Kenya, clinics/other showed higher measurements in several process attributes, including providing 

injectables to family planning clients, giving iron or/and folate tablets to ANC clients, providing sick child 

care information to the child’s caregiver, using visual aids during consultation, and discussing follow-up 

visits. Long waiting time was a common problem across countries and services, and was more serious in 

hospitals and health centers than in clinics/others. Family planning clients had to wait one hour or longer 

to receive services, and pregnant women waited up to two and half hours for antenatal care services. 

The client satisfaction score was higher at clinics and other types of facilities than hospitals/health centers 

for both family planning and sick child care services in Senegal and for antenatal care in Kenya. While a 

limited number of structure and process attributes were found to be associated with client satisfaction, 

process attributes seem to be more predictive of client satisfaction than structural ones. Long waiting time 

stands out for its consistent association with lower levels of client satisfaction. Our analysis also found 

evidence of more client satisfaction in the private sector than in the public sector. 

Conclusion 

Our study provided empirical evidence on the quality of care in providing key health services at health 

facilities of Kenya, Namibia, and Senegal. We highlighted major gaps in the availability of essential 

infrastructure and equipment and in the adherence to standards of good-quality practice. Findings from this 

analysis are expected to inform intervention programs in identifying areas for improving quality of care. 
1 

1. Introduction 

Despite remarkable progress in increasing the coverage of reproductive, maternal, and child health 

interventions in the developing world, there has been only limited improvement in health outcomes. One 

of the important factors contributing to this gap could be the poor quality of care provided in health 

facilities. Studies have found a significant positive association between quality of care and the use of 

maternal and child health services, and the uptake and continuation of family planning methods (Acharya 

and Cleland 2000; Arends-Kuenning and Kessy 2007; Blanc, Curtis, and Croft 2002; Koenig, Hossain, and 

Whittaker 1997; Mariko 2003; Mensch, Arends-Kuenning, and Jain 1996). As many countries strive to 

improve service delivery, there is an increased need to assess the quality of care at health facilities, in order 

to identify problems and to understand the factors that could lead to better client care. 

The concept of quality of health care, in view of its subjective nature, is difficult to define and consequently 

difficult to measure. Different researchers have defined the concept differently. Donabedian defined it as 

“the application of medical science and technology in a manner that maximizes its benefits to health without 

correspondingly increasing the risk” (Donabedian 1980). Ovretveit defined quality care as the “provision 

of care that exceeds patient expectations and achieves the highest possible clinical outcome with the 

resources available”(Ovretveit 1992). Over the years, a number of systems and indicators have been 

proposed and developed for measuring quality of health care. For example, taking a health system 

perspective, the World Health Organization (WHO) has recommended that quality of care should be 

measured in terms of six domains—effective, efficient, accessible, acceptable, equitable, and safe (WHO 

2006). Earlier, Andaleeb had proposed five dimensions for its measurement—communication, cost, facility, 

competence, and demeanor (Andaleeb 2001). Donabbedian’s three-dimension framework measures the 

quality of care in structure, process, and outcome (Donabedian 1988). This approach provides analytical 

advantages in assessing quality of care and has been adopted by many studies. 

A review of the literature reveals inadequacies in the quality of facility-based family planning, maternal, 

and child health services. A quality assessment of newborn care in rural Ghana reported that two-thirds of 

babies were delivered in health facilities without an acceptable level of quality of care (Vesel et al. 2013). 

Another study in Brong Ahafo, Ghana, found that in spite of the high coverage of facility delivery (68 

percent), the “effective” coverage of skilled attendance was low. Only 18 percent of women delivered in a 

facility rated “high” or “highest” quality on all four dimensions of care, including routine delivery care, 

emergency obstetric care, emergency newborn care, and the non-medical component (Nesbitt et al. 2013). 

With the increased focus on client-centered health services, client satisfaction has been considered as an 

important aspect of measuring quality of care. Previous studies that examined client satisfaction linked it 

with the structural and process aspects of quality. For example, studies in Kenya, Tanzania, and Ghana 

found that family planning client satisfaction was higher in the private sector, which showed structural and 

process attributes superior to the public sector (Agha and Do 2009; Hutchinson, Do, and Agha 2011). Other 

studies, however, have found that the interpersonal relationship between provider and client is more likely 

to affect client satisfaction (Mendoza Aldana, Piechulek, and al-Sabir 2001). 

Based on Donabbedian’s framework, this study examines the quality of family planning, antenatal care, 

and sick child services in formal-sector health facilities in three African countries—Kenya, Namibia, and 
2 

Senegal. We focus on these three countries primarily because of the availability of detailed and 

representative data on health services of interest provided in health facilities. The results of this study will 

expand knowledge of the quality of facility-based health care and the relationships between different 

aspects of quality in healthcare delivery. 
3 

2. Data and Methods 

2.1 Data Used in the Analysis 

This study used data from Service Provision Assessment (SPA) surveys conducted in Kenya (2010), 

Namibia (2009), and Senegal (2012-2013). These facility-based surveys, developed by ICF International, 

provide information on the quality and availability of health services, including family planning, antenatal 

care (ANC), and sick child services. Specifically, the SPA surveys collected data on facility infrastructure 

(infection control practices, running water, electricity, privacy, etc.), the availability of resources 

(availability of equipment, supplies, and medicines) and supportive processes and systems (client records, 

supervision, staff training, etc.). The SPA surveys also gauged the extent to which service providers adhere 

to standards of care. 

The SPA comprised four standardized data collection instruments that provided general and service-specific 

information on the availability and quality of health services in a given country. The Facility Inventory 

Questionnaire was used to collect information on the availability of specific family planning, antenatal, and 

sick child services, among others. Additionally it collected information on the general state of infrastructure, 

supplies, medicines, staffing, training, and procedures employed at the facility. The Provider Interview 

Questionnaire collected information on the experience, qualifications, and perceptions of the service 

delivery environment among those health care workers who provided the selected services. The SPA 

included observations of family planning, ANC, and sick child services to assess the extent to which 

providers applied accepted service delivery and quality standards. Finally, exit interviews were conducted 

among the patients whose consultations were observed. The exit interview included questions on the client’s 

understanding of the consultation or examination, recall of instructions received about treatment or 

preventive measures, and perception of the service delivery environment. 

2.1.1 Data from facility inventory 

Data at the facility level were collected through the Facility Inventory Questionnaire with representative 

samples of the facilities in Kenya, Namibia, and Senegal. In each country, a facility sample was selected to 

represent the national and regional levels, by types of facilities and by managing authorities. In Kenya, a 

random selection of facilities was selected from a Master Facility List (MFL) of 6,192 health facilities 

functioning at the time of the survey, and a sample size of 703 facilities was selected. In Namibia, given 

the relatively small number of health facilities, the SPA was conducted among all 446 health facilities 

identified by the Ministry of Health and Social Services. In Senegal, the sample was selected from among 

3,084 health facilities, from which a total of 438 facilities successfully completed the surveys. In this study, 

only facilities providing services of interest were analyzed1

. 

 

1 In Kenya and Namibia, facilities were selected for the analysis of each service based on positive responses to the following 

questions. Family Planning: “Does this facility offer any family planning services, including clinical methods, counselling or 

natural family planning or surgical sterilization?” ANC: “Does this facility offer antenatal (ANC) services, postnatal (PNC) services 

or both?” Sick Child: “Does this facility provide sick child consultations?” For Senegal, facilities were selected for the analysis of 

family planning and sick child services based on a positive response to the question: “Does this facility offer any of the following 

client services: any family planning services, including modern methods, fertility awareness methods (natural family planning),

male or female surgical sterilization? Curative care services for children under age 5, either at the facility or as outreach?”
4 

2.1.2 Data from observations and exit interviews 

In each country the number of clients surveyed was selected systematically based on the number of clients 

visiting the facility that day for each service type and the number of providers providing that service on the 

same day. When many clients were present, observations were conducted among a maximum of five clients 

for each provider of the respective services, with up to 15 observations per service at any one facility. Where 

multiple eligible clients were waiting for family planning or ANC services, interviewers attempted to select 

two new clients for each follow-up client, when possible. Sick child observations were conducted for 

children under age 5 who presented with an illness. An exit interview was attempted with every observed 

family planning and ANC client, as well as with caretakers of observed sick children before they left the 

facility. ANC observations and client exit interviews were not conducted in Senegal. 

2.1.3 Data from providers 

The provider sample was selected from among health service providers who provided the assessed services 

and were present at the sampled facilities on the day of the SPA survey. For each facility, a target of eight 

providers was interviewed. In facilities with fewer than eight providers, all of the providers present were 

interviewed. Where there were more than eight providers, providers whose work was observed were given 

priority and selected for interview. If interviewers observed fewer than eight providers, an additional 

random selection of the remaining providers was interviewed to meet the target. Providers were selected 

for the analysis of each type of services if they responded positively to the question: “In your current 

position and as a part of your work for this facility, do you ever personally provide any family planning 

service (any child health service/child curative care service; any antenatal or postnatal care service)?” 

The distribution of the samples of facilities, providers, and clients for each type of services under study are 

described in the Results section of this report. 

2.2 Definitions of Variables 

Based on Donabedian’s quality of care framework (Donabedian 1988), our study assessed three aspects of 

the quality of care: structure, process, and outcome. The structural characteristics come from the facility 

inventory and provider interview, while the process measurements primarily rely on client observation. The 

outcome indicator is client satisfaction as collected in the exit interview. 

2.2.1 Structure and process variables 

Our selection of the structure and process indicators was guided by the WHO Service Availability and 

Readiness Assessment (SARA) Reference Manual (WHO 2013) and consensus within the literature (Agha 

and Do 2009; Hutchinson, Do, and Agha 2011). A detailed description of these variables is provided in 

Appendices A-D. 

The structural characteristics of quality of care assessed in this analysis include the facility’s management 

systems, service availability, physical infrastructure, and examination equipment, for which data were 

collected through the facility inventory. Several structural variables were combined into one composite 

score using principal component analysis for each service type (family planning, ANC, sick child) within 

each country. 
5 

The process characteristics of quality of care comprise both interpersonal and technical aspects of the 

provider-client interaction. The interpersonal aspects include maintenance of privacy and the handling of 

the client concerns. Technical aspects of the provider-client interaction include observation of the 

performance of specific services, such as physical examinations, patient histories, and procedures provided 

for the relevant family planning, ANC, or sick child services. Waiting time, provider years of related 

experience, and recent training in the service area also served as measures of the technical quality of care. 

Data for this component came from the direct observation of provider-client interactions, provider 

interviews, and client exit interviews. Using factor analysis, multiple process characteristics were 

aggregated into an index for each service type. 

2.2.2 Client satisfaction 

The outcome indicator—client satisfaction with services—was measured using client exit interview 

responses to questions about service quality. The satisfaction variable was rated as an index of problems 

encountered during the visit (none versus any). Clients were asked to report on 12 aspects of their 

perceptions of the quality of the visit. (See Appendix E for the list of questions included in the satisfaction 

index for all three countries.) The responses were aggregated into an index using principal components 

analysis. 

2.2.3 Other covariates 

In the regression analysis for client satisfaction, we controlled for covariates that could affect client 

satisfaction. Facility and provider characteristics adjusted for include: facility managing authority, 

categorized into public and private (private for-profit and private not-for-private); provider’s years of inservice experience; and training experience. We also controlled for client’s age and education level (primary 

education or less versus post-primary or greater). Additionally, for ANC services we controlled for whether 

the client’s pregnancy was her first (binary, yes/no) and a separate variable indicating whether the visit was 

the client’s first to the facility during the current pregnancy (binary, yes/no). For sick child services, in 

addition to child’s age (in months) and sex, we adjusted for whether the visit to the facility was the sick 

child’s first for the same illness (binary, yes/no), and for caregiver’s education level. 

2.3 Statistical Methods 

The Stata Statistical Software Release 12 (StataCorp. 2012) was used to conduct this analysis. The relevant 

facility, provider, and client weights were used to account for selection probabilities. Principal component 

analysis was used to construct several indices including the structural composite score, process composite 

score, and the client satisfaction score for each service within each country. In doing so, we attempted to 

create an index with the highest Cronbach’s alpha possible, while still maintaining the maximum number 

of common variables across countries (See Appendices F-H for a list of the variables included in the 

structure and process composite variables for each service area, by country). The score was computed based 

on the first principle component, which explained the largest proportion of the total variance. In bivariate 

analysis, the differences in the structure and process quality of care indicators and respective composite 

indices were assessed by facility types. Facility types were categorized as hospitals and health centers 

versus all other types of facilities. Hospitals and health facilities were combined into one category due to 

the small number of hospitals in the sample, especially for Namibia and Senegal. The analysis of the 

structure variables by facility type was conducted at the facility level, whereas the analysis of the process 
6 

and client satisfaction by facility type was conducted at the client level. Pearson Chi-squared tests of 

independence were conducted for categorical variables. Differences in continuous variables were assessed 

with a Wald Test. The multivariate analysis to assess the relationship between the outcome measure of 

client satisfaction and structural and process aspects of the quality of care was stratified by facility type. 

Multiple linear regression models were used, given the continuous outcome variable (the score of the first 

principal component of the “problem” index). 
7 

3. Results 

3.1 Family Planning 

3.1.1 Distribution of the sample 

Table 1 shows the distribution of health facilities, providers, and clients interviewed for family planning 

services in each survey. In Kenya facilities were relatively equally distributed between the public and 

private sectors with most facilities being health clinics and others (such as dispensaries, maternity wards, 

and stand-alone VCT clinics). In contrast, 80 percent of the Namibian facilities were in the public sector, 

with the majority being clinics and others. Senegal had the most skewed distribution, where more than 90 

percent of the facilities were in the public sector. As in Kenya and Namibia, clinics and other lower-level 

facilities also accounted for most of Senegalese facilities. 

The distribution of family planning providers interviewed was similar to distribution of health facilities in 

Senegal and Namibia, while in Namibia the proportion of providers in public hospitals/health centers and 

in clinics/others was relatively equal. In Kenya, there were more providers interviewed at private sector 

hospitals (34 percent) and clinics in both public and private sectors (28 percent in both groups); few 

providers (11 percent) were from public sector hospitals. 

In terms of client distribution, Namibia and Senegal were similar in that the majority of clients interviewed 

(63 percent in Namibia and 79 percent in Senegal) were at public sector hospitals and health centers. In 

Namibia few clients (5 percent) were at private sector clinics, and in Senegal very few clients (2 percent) 

were using private sector facilities. The opposite was seen in Kenya, where the majority of clients were 

using private sector services (54 percent at hospitals/health centers and 25 percent at clinics), while only 

about one client in every five used public sector services. 
8

Table 1. Sample distribution of facilities, provider interviews, and observations/client exit interviews in the family planning analysis 

 Kenya Namibia Senegal

% 

(weighted) 

N 

(weighted) 

N

(unweighted) 

% 

(weighted)

N

(weighted) 

N 

(unweighted)

% 

(weighted)

N

(weighted)

% 

(unweighted)

Family Planning FacilitiesPublic

Hospital/Health Centers 4.84 28 94 15.19 55 55 8.34 63 63 Clinics / Others 40.65 234 152 65.75 238 238 83.62 248 248 

Private 

Hospital/Health Centers 13.79 79 223 3.59 13 13 1.90 12 12 Clinics / Others 40.72 234 106 15.47 56 56 6.14 15 15 

Total 100% 575 575 100% 362 362 100% 338 338 

Provider Interviews Public

Hospital/Health Centers 10.80 171 301 38.16 369 287 18.46 136 230 

Clinics / Others 27.60 437 263 40.22 388 503 76.26 560 465 

Private 

Hospital/Health Centers 33.97 438 873 13.30 129 76 2.28 22 23 Clinics / Others 27.63 437 146 8.32 80 100 2.99 17 17 

Total 100% 1,583 1,583 100% 966 966 100% 735 735 

Exit Interviews Public

Hospital/Health Centers 5.87 58 100 22.46 221 185 19.06 184 322 

Clinics / Others 14.79 150 92 63.37 623 705 79.23 767 624 

Private 

Hospital/Health Centers 53.99 542 707 9.14 90 45 0.56 6 12 Clinics / Others 25.34 254 105 5.03 49 48 1.15 11 10 

Total 100% 1004 1004 100% 983 983 100% 968 968 

8 
9 

3.1.2 Description of family planning service quality attributes 

This section describes attributes of family planning service quality by type of facility—hospitals/health 

centers and clinics/others. Percentages are presented for categorical measures while means and standard 

errors are presented for continuous measures. In Kenya, three-quarters of hospitals and health centers were 

in the public sector, while clinics and other facilities were equally distributed between the public and private 

sectors. In both Namibia and Senegal, the majority (at least 80 percent) of both types of facilities were in 

the public sector; few facilities were in the private sector. 

Kenyan providers in clinics/others had significantly more years of experience than their colleagues in 

hospitals/health centers (9.3 versus. 7.5 years, p<.01). There were no differences in the number of years of 

experience between providers in the two types of facilities in Namibia (8.7 versus 9.3). This information 

was not available in Senegal. In both Kenya and Namibia, the proportion of providers who received family 

planning training in the last three years was higher among those at hospitals/health centers than at clinics 

and smaller facilities (p<.001 in Kenya and p<.01 in Namibia). No differences in provider training were 

observed in Senegal. 

Among 12 measures of structural quality, with the exception of two measures, structural quality in Kenya 

was significantly better at hospitals and health centers than at clinics and other types of facilities. The 

number of days that family planning services were provided, on average, was five days at all Kenya 

facilities; the contraceptive storage measure averaged 3.3, across both types of facilities. In Namibia, most 

of the structural quality measures were also higher at hospitals/health centers than at clinics/others, such as 

basic amenities, routine quality assurance activities, and infection prevention (p<.001 in all cases). Several 

quality attributes did not vary by type of facility, including supervision, the availability of family planning 

guidelines, the number of days that family planning services were offered, the number of methods offered, 

the number of visual aids, and the contraceptive storage measure. In Senegal, the results were mixed, as 

some structural quality measures were higher among clinics/other facilities than hospitals and health 

centers. These measures include supervision in the last six months (79 versus 90 percent, p<.05) and the 

number of days family planning services were offered (5.8 versus 6.5, p<.01). 

Compared with structural quality measures, process attributes did not vary as much by type of facility in 

the three study countries. Out of eight process attributes, only two were significantly different between 

hospitals/health centers and clinics/others in Kenya. On average, two family planning methods were 

discussed with each client at hospitals/health centers, while only 1.6 methods, on average, were discussed 

at clinics/others (p<.05). In contrast, nearly half of clients (48 percent) at clinics and other facilities were 

offered or prescribed injectables, compared with one-third of clients at hospitals/health centers (p<.01). 

Similarly, few process measures varied by type of facility in Namibia. Both privacy and confidentiality 

measures were higher among clinics/others than hospitals/health centers in Namibia (p<.01 for privacy and 

p<.05 for confidentiality). The number of family planning methods discussed with clients was the only 

process measure that was higher at Namibian hospitals/health centers than at clinics/others (1.34 versus 

0.90, p<.05). This process attribute also varied significantly between the types of facilities in Senegal, but 

in the opposite direction. An average of 3.2 family planning methods were discussed with each client at 

clinics and other facilities, compared with 2.88 at hospitals/health centers (p<.05). Waiting time 

significantly varied by type of facility only in Senegal, where waiting time at hospitals and health centers 

was about 1.5 times longer than at clinics and other facilities (p<.001).
10 

Table 2. Attributes of quality of care in family planning services among all facilities and providers of family planning services and family planning clients 

 Kenya Namibia Senegal Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

FACILITY / PROVIDER CHARACTERISTICSFacility Managing Authority 

Public 74.02 50.04 0.000 80.88 80.95 0.990 81.45 93.16 0.005 

Private/NGO 25.98 49.96 19.12 19.05 9.07 6.84 

Provider’s years of FP experience 7.53 (.28) 9.29 (.55) 0.005 8.69(.55) 9.27(.37) 0.382 N/A N/A N/A Provider received FP training in past 3 yearsa 49.68 33.83 0.000 32.82 22.12 0.003 39.47 45.82 0.132 

STRUCTURE Monthly meetings for managerial matters 70.95 38.23 0.000 73.53 46.94 0.000 91.87 88.78 0.305 Any system to obtain client opinions about facility 78.19 56.80 0.000 64.71 48.30 0.015 25.33 17.61 0.146 Trained health worker available 79.27 22.58 0.000 70.59 25.51 0.000 97.53 87.36 0.009 Routine quality assurance activities 48.21 21.17 0.000 54.41 25.51 0.000 51.67 22.93 0.000 Supervision visit to facility with in the past 6 months 95.47 84.88 0.000 80.88 72.79 0.170 78.94 89.76 0.044 Guidelines for FP Services at facility 62.31 42.23 0.000 54.41 55.78 0.838 71.44 68.36 0.628 Number of basic amenities at facility 2.50 (.11) 1.36 (.07) 0.000 3.93(.16) 2.50 (.06) 0.000 6.38(.11) 3.78(.10) 0.000 Number of infection prevention precautions 8.39 (.13) 7.47 (.13) 0.000 8.15(.21) 7.35(.09) 0.000 8.52(.27) 8.10(.12) 0.144 

Number of days FP services offered at 4.95 (.10) 5.06 (.13) 0.507 4.51(.22) 4.39(.09) 0.601 5.76(.21) 6.46(.07) 0.002 Number of FP methods offered, available and with valid expiry date 5.18 (.18) 3.52 (.16) 0.000 5.68(.22) 5.51(.08) 0.478 3.70(.42) 3.99(.20) 0.530 

Number of FP visual aids at facility 3.80 (.15) 2.13 (.14) 0.000 2.09(.16) 1.91(.07) 0.317 1.29(.12) 0.87(.06) 0.002 Number of contraceptive storage measures 3.37 (.07) 3.29 (.09) 0.455 3.63(.12) 3.70(.03) 0.595 2.89(.18) 3.20(.08) 0.120 PROCESS Physical examination 2.92 (.06) 2.85 (.09) 0.492 2.92(.12) 2.86(.04) 0.659 2.41(.07) 2.50(.06) 0.307 

Provider ensured visual and auditory privacy 82.78 79.44 0.407 83.25 92.01 0.002 91.86 92.74 0.203 Provider assured client about confidentiality 45.21 49.05 0.420 36.06 48.04 0.016 50.85 54.49 0.312 

Number of FP-related issues discussed 0.83 (.07) 0.73 (.11) 0.428 0.90(.15) 1.11(.06) 0.198 0.26(.04) 0.33(.04) 0.243 

Number of methods discussed with client 1.95 (.08) 1.60 (.12) 0.016 1.34(.21) 0.90(.04) 0.044 2.88(.13) 3.20(.10) 0.046 Information about method provided to client 3.00 (.05) 2.78 (.11) 0.075 2.67(.14) 2.59(.05) 0.608 3.10(.07) 3.12(.06) 0.866 

Injectable contraceptive provided/prescribed 33.25 48.39 0.001 78.33 85.03 0.054 49.59 55.61 0.097 Waiting time (minutes) 65.39 (3.51) 59.17 (7.31) 0.433 67.58(5.92) 76.88(3.31) 0.171 67.61(3.53) 45.99(2.39) 0.000 OUTCOME Satisfaction composite score 0.04 (.03) 0.10 (.06) 0.375 0.17(.06) -0.042(.04) 0.002 -0.24(.07) 0.08(.04) 0.000 

Note: N/A indicates that variable is not available in dataset; numbers in parentheses are standard errors; 

a In Senegal, the variable is provider received FP training in past 2 years. This applies to the same variable in Table 3. 

10 
11 

Outcome, measured by client’s satisfaction score, did not vary by type of facility in Kenya, but in Namibia 

(p<.01) it was significantly higher among clients at hospitals and health centers than clients at clinics/others, 

while the opposite was observed in Senegal (p<.001). Client’s age and education were also reported because 

they were hypothesized to influence client’s expectations of services, and therefore, influence their 

satisfaction. Client’s age did not vary across facilities in any of the three countries; in Kenya and Senegal 

the proportion of clients at hospitals and health centers who had secondary school or more was significantly 

higher than at clinics and other facilities (p<.01 in Kenya and p<.05 in Senegal). 

Figures 1 through 9 present the distribution of facilities in the three study countries with high scores of 

structure, process, and client’s satisfaction by type of facility, managing authority, and region. The 

composite scores were dichotomized at median values to high and low score groups. Figure 1 shows a 

significant difference in the proportion of facilities with a high structure composite score in Kenya, where 

60 percent of hospitals and health centers had a high score (p<.001), compared with 18 percent of clinics 

and other facilities. When stratified by managing facility, the only significant difference in Kenya was in 

the proportion of public versus private sector facilities with high client’s satisfaction score, at 21 percent in 

the public sector compared with 29 percent in the private sector (p<.01). Client’s satisfaction score was also 

the only score that varied by region in Kenya, with Northeastern and Nyanza regions having the highest 

proportions of facilities with high client’s satisfaction score (p<.01). 

Figure 1. Kenya: Percentage of family planning facilities with high structure, process and 

satisfaction score by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

59.76

17.61

48.25

45.46

32.61

36.77

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure***

Process

Satisfaction
12 

Figure 2. Kenya: Percentage of family planning facilities with high structure, process and 

satisfaction score by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

20.73

29.41

50.73

46.08 46.19

31.21

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure

Process

Satisfaction**
13 

Figure 3. Kenya: Percentage of family planning facilities with high structure, process and 

satisfaction score by region 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

In Namibia, as shown in Figures 4 through 6, the structure composite score varied significantly by both 

type of facility and managing authority. Figure 4 shows that 79 percent of hospitals and health centers 

versus 43 percent of clinics and other facilities had a high structure score (p<.001), while Figure 5 indicates 

a similar difference by managing authority: 74 percent of public sector facilities had a high structure score 

compared with 44 percent of private sector facilities (p<.001). Figure 6 shows that all three composite 

scores of structure, process, and client’s satisfaction varied significantly between regions in Namibia. 

Hardap and Omakeke had the highest proportions of facilities with a high structure score (p<.001), and 

Omakeke and Ohangewe had the highest proportions of facilities with a high process score (p<.05). But the 

highest proportion of facilities with a high satisfaction score was found in Oshana, where the proportions 

of facilities with high structure and process scores were very low (p<.05). 

0

10

20

30

40

50

60

70

80

90

100

Percent 

Structure Process Satisfaction*
14 

Figure 4. Namibia: Percentage of family planning facilities with high structure, process and 

satisfaction score by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

79.41

43.2

50.55 50.75 49.91

41.24

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure***

Process

Satisfaction
15 

Figure 5. Namibia: Percentage of family planning facilities with high structure, process and 

satisfaction score by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

73.91

44.37

56.86

48.99 51

43.13

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure***

Process

Satisfaction
16 

Figure 6. Namibia: Percentage of family planning facilities with high structure, process and 

satisfaction score by region 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

Finally Figures 7 through 9 show structure, process, and satisfaction scores in Senegal. Similar to Namibia, 

the structure score in Senegal varied significantly by both type of facility and managing authority. Nearly 

three-quarters (72 percent) of Senegalese hospitals and health centers, compared with 43 percent of clinics 

and other facilities, had a high structure score (p<.001). The public sector facilities also had a much higher 

proportion with a high structure score (49 percent) than the private sector facilities (14 percent) (p<.001). 

In contrast, clients at clinics and other facilities seemed more satisfied than those at hospitals and health 

centers: about half of clinics and other facilities versus one-third of hospitals and health centers had a high 

client’s satisfaction score (p<.001). In Senegal, significant differences in structure, process, and satisfaction 

scores were also observed by region. Kaffrine had the highest proportion of facilities with a high structure 

score (p<.01); it also had the highest proportion of facilities with a high process score, along with 

Ziquinchor (p<.001); yet the highest proportions of facilities with high client satisfaction were found in 

Matam (81 percent) and Sediou (76 percent) (p<.001). 

0

10

20

30

40

50

60

70

80

90

100

Percent 

Structure*** Process* Satisfaction*
17 

Figure 7. Senegal: Percentage of family planning facilities with high structure, process and 

satisfaction score by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

72.14

43.14

48.14

51.09

33.14

50.85

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure***

Process

Satisfaction***
18 

Figure 8. Senegal: Percentage of family planning facilities with high structure, process and 

satisfaction score by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

Results in the private sector is based on n<50.

48.91

14.1

50.53 52.36

47.18

58.43

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure***

Process

Satisfaction
19 

Figure 9. Senegal: Percentage of family planning facilities with high structure, process and 

satisfaction score by region 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level. 

Structure score distribution is based on n<50 in most regions. 

3.1.3 Factors associated with family planning client’s satisfaction 

Table 3 presents results from multivariate regression models, by type of facility, where several attributes 

were combined into a structure composite score and a process composite score. The outcome is the client’s 

satisfaction composite score. While results were not consistent across countries, a few should be 

highlighted. First, it was noteworthy that in two of the three countries, Kenya and Namibia, waiting time 

was negatively associated with client’s satisfaction, both at hospitals/health centers and at clinics/others. 

The longer the waiting time, the lower the satisfaction score. Second, there was no strong evidence that the 

structure and process composite scores were associated with client satisfaction. The only significant 

association was between an increased process composite score and increased satisfaction score among 

clients in Kenyan hospitals and health centers (p<.05). 

0

10

20

30

40

50

60

70

80

90

100

Percent 

Structure** Process*** Satisfaction***
20 

Table 3. Factors associated with client satisfaction score related to family planning services 

 Kenya Namibia Senegal Hospitals/ 

Health Centers 

Clinics/ Other 

Facilities 

Hospitals/ 

Health Centers 

Clinics/ Other 

Facilities 

Hospitals/ 

Health Centers 

Clinics/ Other 

Facilities 

Coefficient (SE) Coefficient (SE) Coefficient (SE) Coefficient (SE) Coefficient (SE) Coefficient (SE)

FACILITY / PROVIDER CHARACTERISTICS Government managing authority (ref=private/NGO) -0.08 (.08) -0.28 (.11)* -0.27 (.15) -0.05 (.18) -0.68(.20)** 0.18(.19) 

Provider’s years of FP experience 0.01 (.00) -0.01 (.01) 0.01 (.01) 0.002 (.01) N/A N/A Provider received FP training in past 3 years (ref=no) -0.09 (.07) -0.14 (.12) -0.10 (.13) -0.10 (.11) -0.02(.13) 0.05(.08) 

STRUCTURE Structure composite score 0.10 (.05) -0.06 (.06) -0.12 (.10) -0.01 (.08) -0.09(.11) -0.01(.06) 

Supervision visit to facility with in the past 6 months (ref=no) -0.08 (.13) -0.03 (.11) -0.09 (.11) 0.27 (.12)* 0.83(.32)** -0.12(.10) Number of FP commodity storage measures b -0.07 (.06) -0.04 (.09) -0.33 (.19) 0.16 (.10) -- -- 

Number of days FP services provided -0.04 (.03) -0.02 (.04) -0.06 (.05) -0.041 (.019)* -0.13(.07) -0.14(.04)*** 

Number of FP methods offered, available and with valid expiry datea -- -- -0.05 (.05) -0.01 (.03) -0.03(.02) -0.01(.01) 

Number of FP visual aids at facility a,b -- -- 0.04 (.04) -0.06 (.03)* -- -- 

PROCESS Process composite score 0.09 (.04)* 0.11 (.09) 0.09 (.06) 0.08 (.04) 0.12(.13) 0.01(.05) 

Provider ensured visual and auditory privacyc

(ref=no) -- -- -- -- 0.06(.31) 0.11(.16) Injectable provided/prescribed (ref=no) 0.12 (.06) 0.47 (.12)*** 0.01 (.14) -0.05 (.11) 0.10(.13) 0.01(.8) Waiting time (minutes) -0.01 (.00)*** -0.00 (.00)* -0.01 (.01)** -0.01 (.01)** 0.01(.00) -0.01(.00) 

R-squared .09 .17 .21 .05 .09 .03

Note: All models controlled for client’s characteristics, including age and education. 

a These variables are included in the structure composite score in Kenya; b These variables are included in the structure composite score in Senegal. c These variables are included in the process composite score in Kenya and Namibia; 

*p<0.05; **p<0.01; ***p<0.001 

20 
21 

In Kenya, no individual structure and process measure was found associated with client’s satisfaction, while 

in Namibia and Senegal, very few were. For example, among clients of clinics and other facilities in 

Namibia, client’s satisfaction score was higher in facilities receiving a supervision visit in the last six 

months, compared with those that did not receive a supervision visit in the last six months (p<.05). 

However, Namibian clinics and other facilities with more days when family planning services were 

provided and with more family planning visual aids had a lower client’s satisfaction score (p<.05 in both 

cases). In Senegal, results were also inconsistent between the two types of facilities. At hospitals and health 

centers, receiving supervision within the last six months was associated with increased client’s satisfaction 

(p<.01), but at clinics and other facilities client’s satisfaction score was negatively associated with the 

number of days when family planning services were offered (p<.001). 

Among process attributes, as mentioned earlier, waiting time and process composite score were associated 

with client’s satisfaction at hospitals and health centers in Kenya. At clinics and other types of facilities, 

providing or prescribing injectables was strongly associated with an increased satisfaction score (p<.001). 

No process attributes were found to be associated with client satisfaction in Senegal, and waiting time was 

the only factor associated with it in Namibia. 

Finally, there was no strong evidence of differential client’s satisfaction between managing authorities. 

Client’s satisfaction score was lower only among public sector clinics/others in Kenya (p<.05) and public 

sector hospitals/health centers in Senegal (p<.01), compared with their private sector counterparts. Family 

planning provider’s experience and training also did not seem to affect client’s satisfaction. 

3.2 Antenatal Care 

As mentioned in the Methods section, information on ANC service process and outcome was not available 

in the SPA survey of Senegal. Consequently, we present results from Kenya and Namibia in this section.

3.2.1 Distribution of the sample 

Table 4 shows that the majority of facilities in both Kenya and Namibia were in the public sector (60 percent 

in Kenya and 86 percent in Namibia); most of facilities were also clinics and other types of facilities in both 

countries (75 percent in Kenya and 84 percent in Namibia). With regard to ANC providers interviewed in 

Kenya, 36 percent were from public sector hospitals and health centers, 24 percent from private sector 

clinics and other facilities, another 22 percent from public sector clinics and other facilities. Only 18 percent 

were from private sector hospitals/health facilities. The distribution of Namibian providers interviewed was 

more skewed toward the public sector—38 percent of providers were from public hospitals/health centers 

and 40 percent from clinics/others. Just 13 percent were from private sector hospitals/health centers, and 

even fewer (8 percent) were from private sector clinics and other facilities. 

In terms of the distribution of ANC clients, the majority of ANC clients interviewed in both countries were 

using services in the public sector. In Kenya, however, half of all clients (50 percent) were at public sector 

hospitals and health centers, whereas in Namibia, nearly two-thirds (63 percent) were at services at public 

sector clinics and other types of facilities. Few clients in Kenya were interviewed at private sector clinics 

and other facilities (11 percent), and even fewer in Namibia (4 percent). 
22 

Table 4. Sample distribution of facilities, provider interviews, and observations/client exit interviews 

in the ANC analysis 

 Kenya Namibia 

 % 

(weighted) 

N

(weighted) 

N

(unweighted) 

% 

(weighted) 

N 

(weighted) 

N

(unweighted) 

ANC 

Facilities 

Public

Hospital/Health Centers 17.02 44 225 13.20 40 40 

Clinics / Others 42.89 181 97 73.27 222 222 

Private 

Hospital/Health Centers 7.88 96 115 3.63 11 11 

Clinics / Others 32.21 242 127 9.90 30 30 

Total 100.00 564 564 100.00 303 303 

Provider Interviews 

Public 

Hospital/Health Centers 35.95 323 930 38.16 369 287 

Clinics / Others 21.77 422 128 40.22 388 503 

Private 

Hospital/Health Centers 18.32 633 451 13.30 129 76 

Clinics / Others 23.95 383 252 8.32 80 100 

Total 100.00 1,761 1,761 100.00 966 966 

Exit Interviews 

Public

Hospital/Health Centers 49.56 193 874 23.46 201 174 

Clinics / Others 26.00 152 154 63.05 542 576 

Private 

Hospital/Health Centers 13.47 701 257 9.37 81 49 

Clinics / Others 10.98 357 118 4.12 35 60 

Total 100.00 1,403 1,403 100.00 859 859 
23 

3.2.2 Description of ANC service quality attributes 

Table 5 compares structural and process attributes of ANC service quality between types of facilities, in 

Kenya and Namibia. As mentioned earlier, most facilities in both countries were in the public sector. ANC 

providers at clinics and other types of facilities in Kenya had significantly more years of experience 

compared with their colleagues in hospitals and health centers (p<.01), while there were no differences in 

provider’s experience in Namibia. The proportion of Namibian providers who received ANC training in 

the last three years was higher at hospitals and health centers than at clinics and other facilities. 

In Kenya, most of the 14 structural quality attributes varied significantly between the types of facilities. In 

most cases, hospitals and health centers scored higher on these measures than did clinics and other facilities. 

For example, significantly larger proportions of hospitals and health centers maintained a system to collect 

client opinions on service quality, had routine quality assurance activities, had health workers available at 

all times, and had ANC service guidelines, compared with clinics and other facilities. In contrast, only 69 

percent of hospitals and health centers had iron or folic acid on hand, compared with 82 percent of clinics 

and other facilities (p<.05). A few structural quality attributes did not vary by type of facility, including 

supervision, infection prevention measures, the number of days per week when ANC services were offered, 

the number of ANC services offered, and whether ITNs were routinely distributed to ANC clients at the 

facility. 

Most of the structural quality measures also differed between the two types of facilities in Namibia. Like 

Kenya, in most cases structural quality seemed better at Namibian hospitals and health centers than at clinics 

and other facilities. For example, hospitals and health centers in Namibia had more basic amenities, ANC 

specific equipment, and better infection prevention measures compared with clinics and other facilities. 

There were no differences between the two types of facilities in a number of structural quality attributes, 

including facility supervision, the number of days per week that ANC services were offered, the numbers 

of ANC services and tests offered, iron and folic acid availability, the availability of ANC guidelines, and 

ITN distribution to ANC clients. None of the attributes were higher among clinics and other facilities than 

among hospitals and health centers. 

In terms of process attributes of quality, few measures varied by type of facility in both countries. In 

addition, unlike structural quality measures, these measures were generally higher at clinics and other 

facilities than at hospitals and health centers. In fact, in Kenya, there was only one measure that differed 

between the two types of facilities: 19 percent of ANC clients at clinics and other facilities had received 

iron or folic acid compared with 14 percent of ANC clients at hospitals and health centers (p<.05). In 

Namibia, ANC providers at clinics and other facilities scored higher than their colleagues at hospitals and 

health centers with regard to asking clients about signs and problems with the index pregnancy (p<.05) and 

discussing delivery preparation (p<.01). Waiting time, although quite long across facilities, was 

significantly shorter at clinics and other facilities (128 minutes on average) than at hospitals and health 

centers (162 minutes, p<.01). Despite these differences, client’s satisfaction score was significantly higher 

at Namibian hospitals and health centers than at clinics and other facilities (p<.01), while it did not vary by 

type of facility in Kenya. 
24 

Table 5. Attributes of quality of care in ANC services among all facilities and providers of ANC services, and ANC clients 

Kenya Namibia

Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

FACILITY / PROVIDER CHARACTERISTICSFacility Managing Authority 

Public 68.36 57.12 0.039 78.43 88.1 0.067 

Private/NGO 31.65 42.88 21.57 11.9 

Provider’s years of ANC experience 7.53 (0.28) 9.18 (.52) 0.005 8.68(.55) 9.26(.37) 0.382 

Provider received ANC training in past 3 years 69.69 64.24 0.156 37.15 28.08 0.016 

STRUCTURE Monthly meetings for managerial/ administrative issues 67.78 39.56 0.000 68.63 48.63 0.005 Any system to obtain client opinions 75.39 56.10 0.001 62.75 47.62 0.050 

Routine quality assurance activities 48.98 23.13 0.000 47.06 24.60 0.001 

Supervision visit to facility with in the past 6 months 94.18 88.01 0.054 92.35 76.59 0.370 

Number of basic amenities at facility 2.62 (.11) 1.43 (.08) 0.000 3.57(.18) 2.35(.06) 0.000 Number of infection prevention precautions 7.83 (.18) 7.39 (.17) 0.083 7.96(.25) 7.40(.09) 0.038 

Health workers always available 79.64 26.61 0.000 64.71 26.98 0.000 

Number of days per week that ANC services are offered 4.45 (.14) 4.26 (.19) 0.448 2.94(.22) 2.52(.10) 0.085 

Number of services provided to ANC clients 5.49 (.06) 5.47 (.09) 0.845 4.98(.14) 5.00(.06) 0.896 Number of equipment for ANC services, excluding iron and folate 6.95 (.22) 6.21 (.21) 0.016 7.98(.24) 7.16(.10) 0.002 Facility has iron or folic acid 68.85 81.46 0.013 100.00 94.05 0.070 

Facility routinely distributes ITN to ANC clients 64.20 57.41 0.226 68.63 64.68 0.590 

Number of test for ANC clients 4.84 (.15) 2.42 (.24) 0.000 4.92(.16) 4.63(.10) 0.122 

Guidelines for ANC services at facility 79.27 57.77 0.000 17.65 13.10 0.392 

PROCESS Number of ANC procedures 10.72 (.12) 10.65 (.24) 0.798 6.76(.17) 6.58(.09) 0.331 

Number of ANC client’s history discussed 3.49 (.13) 3.09 (.23) 0.120 3.68(.28) 3.55(.17) 0.686 Provider asked about signs and problems with pregnancy 2.77 (.10) 2.78 (.19) 0.956 2.04(.16) 2.41(.09) 0.041 Issues with delivery preparation discussed 2.41 (.09) 2.31 (.15) 0.589 1.22(.15) 1.73(.09) 0.003 Client received iron/folate tablets or both at this or previous visit 13.57 19.24 0.037 92.13 96.08 0.077 

Client received tetanus toxoid vaccine at this or previous visit 43.64 46.35 0.510 81.25 84.80 0.355 

Waiting time (minutes) 71.88 (2.86) 75.79 (7.11) 0.610 162.44(10.39) 127.93(5.34) 0.003 

OUTCOME Satisfaction score 0.06 (.03) 0.03 (.06) 0.570 0.18(.05) -0.01(.05) 0.005 

Note: Numbers in parentheses are standard errors. 

24 
25 

Finally, Table 5 also shows no differences in ANC client’s characteristics between the two types of facilities 

in Namibia. In Kenya, ANC clients at hospitals and health centers were more likely to have secondary 

school education or more, and to have a first pregnancy (p<.01 and p<.05, respectively). 

Figures 10 to 15 show the distribution of ANC structure, process, and client’s satisfaction scores in Kenya 

and Namibia by type of facility, managing authority, and region. In each country, these ANC-related 

composite scores were dichotomized at median values to high and low scores. Figures 10 and 11 indicate 

that in Kenya the structure score varied by both facility type and managing authority. A higher proportion 

of hospitals and health centers had a high structure score, compared with clinics and other facilities (56 

versus 10 percent, p<.001), and the same proportion was also higher among public sector facilities than 

private sector facilities (29 versus 16 percent, p<.01). The satisfaction score also appeared higher among 

public sector ANC clients (53 percent of facilities had a high score) than clients of the private sector (41 

percent of facilities) (p<.01). When stratified by region, the structure score did not vary between regions 

but the highest proportion of facilities with a high process score was found in Nyanza (62 percent) and 

Central (61 percent) regions, while Coastal region had the highest proportion of facilities with a high 

satisfaction score (67 percent) (p<.001 in both cases). 

Figure 10. Kenya: Percentage of ANC facilities with high structure, process and satisfaction score 

by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

55.97

9.48

52.93 51.77

44.31 41.96

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure***

Process

Satisfaction
26 

Figure 11. Kenya: Percentage of ANC facilities with high structure, process and satisfaction score 

by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

28.74

15.92

49.78

52.69 53.38

40.45

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure**

Process

Satisfaction**
27 

Figure 12. Kenya: Percentage of ANC facilities with high structure, process and satisfaction score 

by region 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

0

10

20

30

40

50

60

70

80

90

100

Percent 

Structure Process*** Satisfaction***
28 

Figure 13. Namibia: Percentage of ANC facilities with high structure, process and satisfaction score 

by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

70.59

45.63

49.89

46.01

39.69

42.82

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure**

Process

Satisfaction
29 

Figure 14. Namibia: Percentage of ANC facilities with high structure, process and satisfaction score 

by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

45.42

78.05

47.52 45.75

40.91

47.44

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure***

Process

Satisfaction
30 

Figure 15. Namibia: Percentage of ANC facilities with high structure, process and satisfaction score 

by region 

As in Kenya, the ANC structure score in Namibia also varied by facility type and managing authority. In 

Figure 13, 71 percent of hospitals/health centers versus 46 percent of clinics/others in Namibia had a high 

ANC structure score (p<.001), while Figure 14 shows that 78 percent of private sector facilities had a high 

structure score compared with 45 percent of public sector facilities (p<.001). Both structure and process 

scores varied significantly by region in Namibia, while client’s satisfaction did not. Figure 15 shows that a 

few regions, such as Hardap and Khomas, had 100 percent of facilities with a high structure score, while 

others including Caprivi and Ohangewe had just 12 percent and 14 percent of facilities, respectively, with 

a high structure score (p<.001). Similarly, Oshitoto and Omakeke had the highest proportions of facilities 

with a high process score, while the proportion was lowest in Caprivi (p<.001). 

3.2.3 Factors associated with ANC client’s satisfaction 

Table 6 shows several facility, process, and client characteristics that were associated with ANC client’s 

satisfaction score in Kenya and Namibia. Results varied by type of facilities within each country, with the 

exception of managing authority, which indicates that the satisfaction score was significantly lower among 

public sector facilities than among private sector facilities in three of the four models. 

At Kenyan hospitals and health centers, increased client’s satisfaction was found at facilities with a higher 

structure composite score (p<.05). In terms of service delivery process, receiving iron/folic acid and tetanus 

toxoid vaccine was important to client’s satisfaction (p<.05 and p<.01, respectively). Shorter waiting time 

was strongly associated with increased client’s satisfaction (p<.001). Clients also reported being more 

satisfied with providers who had more experience providing ANC services (p<.05). Clients with more 

0

10

20

30

40

50

60

70

80

90

100

Percent

Structure*** Process*** Satisfaction
31 

education reported being less satisfied compared with clients with no more than primary schooling 

(p<.001). 

Among ANC clients at clinics and other facilities in Kenya, few factors in addition to managing authority 

were found to be associated with client’s satisfaction. The only facility-level factor associated with client’s 

satisfaction was supervision. ANC clients had higher levels of satisfaction at facilities that received 

supervision within the last six months compared with clients at other facilities (p<.05). Clients with a first 

pregnancy reported being more satisfied with ANC services than those with one or more previous 

pregnancies (p<.01). 
32 

Table 6. Factors associated with client satisfaction score related to ANC services 

Kenya Namibia

Hospitals/ Health 

Centers 

Clinics/ Other 

Facilities 

Hospitals/ Health 

Centers 

Clinics/ Other 

Facilities 

Coefficient (SE) Coefficient (SE) Coefficient (SE) Coefficient (SE)

FACILITY / PROVIDER CHARACTERISTICS Government managing authority (ref=private/NGO) -0.15 (.06)* -0.39 (.13)** -0.34 (.12)** 0.09 (.11) Provider’s years of ANC experience 0.01 (.00)* 0.01 (.01) -0.01 (.01) 0.01 (.00)*** 

Provider received ANC training in past 3 years (ref=no) 0.00 (.06) 0.23 (.13) -0.16(.08)* 0.07 (.09) STRUCTURE Structure composite score 0.13 (.06)* 0.01 (.10) -0.10 (.06) -0.13 (.05)* 

Supervision visit to facility with in the past 6 months (ref=no) 0.20 (.25) 0.36 (.15)* -0.10(.14) 0.42 (.17)* 

Number of days per week that ANC services are offered 0.01 (.02) -0.04 (.02) 0.01 (.04) -0.03 (.03) Number of equipment for ANC services, excluding iron and folatea -- -- 0.03 (.03) 0.02 (.24) 

Number of test for ANC clientsa -- -- 0.04 (.03) 0.01 (.04) 

Facility has iron or folic acid (ref=no) -0.03 (.06) -0.17 (.12) Omitted 0.15 (.12) 

Facility routinely distributes ITN to ANC clientsb (ref=no) 0.08 (.05) -0.02 (.13) -- -- 

PROCESS Process composite score 0.01 (.04) 0.01 (.13) 0.07 (.11) -0.04 (.08) 

Client received iron/folate tablets or both at this or previous visit (ref=no) 0.15 (.06)* 0.07 (.12) -0.19 (.18) 0.21 (.02) Client received tetanus toxoid vaccine at this or previous visit (ref=no) 0.30 (.10)** 0.14 (.14) 0.08 (.12) 0.03 (.13) 

Waiting time (minutes) -0.01 (.00)*** -0.01 (.00) -0.00 (.00) -0.01 (.00)*** 

R-squared .12 .14 .10 .09

Note: All models controlled for client’s characteristics, including age, education, whether it was her first pregnancy, and whether it was her first visit to the facility for the index pregnancy. 

a Variable included in Kenya structure composite score b Variable included in the Namibia structure composite score 

*p<0.05; **p<0.01; ***p<0.001 Note: All hospitals/health centers in Namibia have iron or folic acid. This variable was omitted from the analysis. 

32 
33 

In Namibia, few factors were found to be associated with ANC client’s satisfaction score. Among clients 

at hospitals and health centers, in addition to managing authority, provider’s ANC training was the only 

factor associated with client’s satisfaction. Surprisingly, the association was negative: ANC clients reported 

being less satisfied with providers who had received training in the last three years compared with clients 

of other providers (p<.05). Among ANC clients at clinics and other facilities, the satisfaction score did not 

depend on the managing authority, but was lower at facilities with a higher structure composite score 

(p<.05). Increased client’s satisfaction was found at clinics and facilities with supervision in the last six 

months (p<.05), shorter waiting time (p<.001), and providers who had more experience providing ANC 

services (p<.001). 

3.3 Sick Child Care 

In this section, we present results of the analysis of sick child service quality and factors associated with 

client’s satisfaction in the three study countries.

3.3.1 Distribution of the sample 

Table 7 shows the distribution of the sample of facilities, providers, and clients of sick child services. In 

Kenya, more than two facilities in every five (43 percent) included in the survey were private sector clinics 

or other facilities; clinics and other facilities in the public sector accounted for 37 percent of the sample, 

while less than 20 percent of facilities were hospitals and health centers in either the public or private sector. 

The distributions of facilities in Namibia and Senegal were similar: the majority of facilities (68 percent in 

Namibia and 80 percent in Senegal) were public sector clinics and other facilities. In both countries private 

sector hospitals and health centers accounted for the smallest proportion of the sample (4 percent in Namibia 

and 2 percent in Senegal). 

Among providers interviewed in Kenya, those from public sector hospitals and health centers accounted 

for the largest proportion (32 percent), followed by providers from clinics and other facilities in the private 

sector (28 percent) and the public sector (24 percent), while the proportion of providers in private sector 

hospitals/health centers was 16 percent. The distributions of providers in Namibia and Senegal were more 

skewed. In Namibia, nearly 80 percent of the providers were in the public sector; about one provider in 

every seven was at a private sector hospital or health center, while only 6 percent of the providers 

interviewed were at private sector clinics or other facilities. In Senegal, 70 percent of providers interviewed 

were from clinics and other facilities in the public sector and another 18 percent were from hospitals/health 

centers in the public sector. Few were from the private sector: 9 percent from clinics/other facilities and 3 

percent from hospitals/health centers. 

Finally, Table 7 shows that in all three countries the majority of sick child clients interviewed were using 

services in the public sector. In Kenya, public sector sick child clients were relatively equally distributed 

between the two types of facilities, while in the other two countries most of them were at clinics and other 

facilities. Approximately 18 percent of clients were using sick child services from private sector clinics and 

other facilities in Kenya and Senegal, while only 8 percent were using services from these sources in 

Namibia. Few clients were using services at private sector hospitals and health centers, especially in 

Namibia (5 percent) and Senegal (3 percent). 
34 

Table 7. Sample distribution of facilities, provider interviews, and observations/client exit interviews in the sick child analysis 

 Kenya Namibia Senegal % 

(weighted) 

N

(weighted) 

N

(unweighted)

% 

(weighted)

N

(weighted) 

N

(unweighted)

% 

(weighted)

N

(weighted) 

N

(unweighted)

Sick Child FacilitiesPublic

Hospital/Health Centers 13.22 40 228 17.58 61 61 8.00 73 73 Clinics / Others 37.12 278 106 68.30 237 237 79.56 291 291 

Private 

Hospital/Health Centers 6.30 85 124 3.75 13 13 2.14 16 16 Clinics / Others 43.37 238 183 10.37 36 36 10.29 33 33 

Total 100% 641 641 100% 347 347 100% 413 413 Provider Interviews Public

Hospital/Health Centers 31.82 341 1,082 42.44 448 359 17.66 201 342 Clinics / Others 23.85 595 159 35.96 380 517 70.12 799 671 

Private 

Hospital/Health Centers 16.16 672 523 15.68 166 102 3.07 35 53 Clinics / Others 28.17 504 349 5.93 63 79 9.15 104 73 

Total 100% 2,113 2,113 100% 1057 1057 100% 1139 1139 Exit Interviews Public

Hospital/Health Centers 35.26 180 1,055 21.17 327 293 14.30 187 365 Clinics / Others 37.64 348 355 66.40 1025 1083 65.21 850 753 

Private 

Hospital/Health Centers 9.20 701 291 4.51 70 48 2.48 32 59 Clinics / Others 17.91 728 256 7.92 122 120 18.01 235 127 

Total 100% 1,957 1,957 100% 1544 1544 100% 1304 1304 

34 
35 

3.3.2 Description of sick child service quality attributes 

Table 8 presents the description and comparisons of sick child service quality attributes across types of 

facilities in each of the study countries. In Kenya, hospitals and health centers scored higher than clinics 

and other facilities in all of the 13 structural quality attributes. Marked differences were seen, for example, 

in the proportion of facilities that had routine quality assurance activities (49 versus 21 percent, p<.001), 

the availability of health workers (80 versus 22 percent, p<.001), and the availability of the Integrated 

Management of Childhood Illness (IMCI) mother’s card (36 versus 18 percent, p<.001). Results in Namibia 

and Senegal in terms of structural quality were mixed. Several attributes varied significantly by type of 

facility, while others did not. In Namibia, for example, hospitals and health centers scored higher than 

clinics and other facilities in having monthly meetings (p<.001), a system to collect client’s opinions 

(p<.01), the availability of health workers (p<.001), and the number of days per month when sick child 

services were offered (p<.001). In Senegal, hospitals and health centers scored higher than clinics and other 

facilities in terms of basic amenities (p<.001), health workers’ availability (p<.001), and infection 

prevention measures (p<.05). Differences between types of facilities were also observed with other 

structural quality attributes in Senegal, such as routine quality assurance activities (p<.001) and supervision 

(p<.01). 

Comparisons of measures of service delivery process were mixed across the three study countries. In Kenya, 

four of the seven process measures were found to be significantly better at clinics and other facilities than 

at hospitals and health centers. These include information provided to caregivers (p<.001), whether the 

provider discussed return visits (p<.01), waiting time (p<.001), and whether the provider used visual aids 

during the consultation (p<.05, although caution should be exercised because of the small number of clinics 

and other facilities). In Namibia, only two of the seven process measures varied by type of facility, including 

information provided to caregivers and whether the provider discussed return visits. Both measures were 

higher at clinics and other facilities than at hospitals and health centers (p<.001 and p<.01, respectively). 

In Senegal, the pattern was not consistent across process measures. Some were better at clinics and other 

facilities, while others were better at hospitals and health centers. Clinics and other facilities scored higher 

than hospitals and health centers in measures of symptoms discussed by providers and caregivers (p<.001) 

and information provided to caregivers (p<.001). Hospitals and health centers were better than clinics and 

other facilities in measures of physical exam of the sick child (p<.05), whether the provider used visual aids 

during the consultation (p<.001), whether the provider discussed returned visits (p<.01), and waiting time 

(p<.01). 

Client’s satisfaction score varied significantly by type of facility in Kenya and Senegal. Sick child clients 

at clinics and other facilities reported being more satisfied than those at hospitals and health centers (p<.001 

in both cases). The difference in client’s satisfaction across facility types in Namibia did not reach the 

statistical significance level of .05. 
36 

Table 8. Attributes of quality of care in sick child services among all facilities and providers of sick child services and sick child clients 

 Kenya Namibia Senegal Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

Hospitals/ 

Health 

Centers 

Clinics/ 

Others P 

FACILITY / PROVIDER CHARACTERISTICS Facility Managing Authority 

Public 67.73 46.12 0.000 82.43 86.81 0.339 21.11 11.46 0.031 Private/NGO 32.27 53.88 17.57 13.19 78.89 88.54 

Provider’s years of SC care experience 7.79 (.26) 10.12 (.53) 0.000 9.28(.52) 9.85(.42) 0.397 N/A N/A

Provider received SC care training in past 3 yearsa 29.85 23.18 0.034 40.45 41.23 0.829 33.2 40.88 0.021 

STRUCTURE Monthly meetings for managerial/ administrative issues 68.03 39.56 0.000 74.32 47.25 0.000 83.82 85.12 0.776 

Any system to obtain client opinions 75.51 56.80 0.001 67.57 47.62 0.003 26.09 17.20 0.071 

Routine quality assurance activities 48.98 20.94 0.000 56.76 24.18 0.000 47.98 21.60 0.000 

Supervision visit to facility with in the past 6 months 94.04 81.37 0.000 82.43 75.46 0.208 70.06 85.74 0.001 Number of basic amenities at facility 2.64 (.11) 1.45 (.07) 0.000 4.01(.16) 2.37(.06) 0.000 5.22 (.11) 2.64(.09) 0.000 Health workers always available 79.66 22.10 0.000 70.27 26.01 0.000 98.87 83.76 0.000 

Number of infection prevention precautions 7.71 (.18) 6.92 (.16) 0.000 7.28(.29) 7.39(.08) 0.717 8.31(.25) 7.74(.13) 0.045 

Number of SC services provided at facility 2.35 (.17) 1.73 (.17) 0.011 3.34(.26) 3.42(.13) 0.783 3.39 (.25) 3.43(.15) 0.877 Number of equipment available for SC services 3.66 (.10) 2.86 (.10) 0.000 2.95(.11) 2.84(.06) 0.395 3.10(.10) 3.09(.05) 0.939 IMCI guide always used in assessing/treating sick child 80.36 62.39 0.000 55.41 51.65 0.567 36.28 44.26 0.189 

Number of days per month that SC services are provided 25.64 (.34) 22.99 (.23) 0.000 22.97(.51) 20.72(.20) 0.000 25.80(.62) 26.32(.39) 0.457 Blood test to verify malaria always available for children under age 5 29.94 19.43 0.017 55.41 59.34 0.543 58.77 54.96 0.537 

IMCI mother’s card available 36.42 18.34 0.000 12.16 6.59 0.114 45.25 41.24 0.514 

PROCESS Number of symptoms that provider asked about or caregiver mentioned 3.54 (.05) 3.51 (.07) 0.713 3.92(.12) 3.83(.05) 0.534 2.81(.06) 3.14(.04) 0.000 Physical exam of sick child 8.11 (.15) 8.17 (.21) 0.819 8.78(.25) 9.28(.12) 0.073 5.08(.13) 4.72(.10) 0.027 

Information provided to caregiver 1.69 (.06) 2.04 (.08) 0.000 1.31(.11) 1.82(.05) 0.000 0.45(.04) 0.65(.04) 0.000 

Provider used visual aids 4.37 7.26 0.036 5.81 7.81 0.374 15.32 10.22 0.000 

Provider recorded on child’s health card/booklet 93.35 94.66 0.378 98.01 87.43 0.552 51.54 47.45 0.189 

Provider discussed follow-up visit 56.39 65.11 0.002 45.99 56.92 0.003 69.46 60.39 0.002 Waiting time (minutes) 69.34 (2.56) 51.57 (3.02) 0.000 111.56(6.34) 107.91(2.97) 0.603 51.08(2.69) 64.08(3.00) 0.001 OUTCOME Satisfaction score 0.12 (.02) 0.26 (.03) 0.000 -0.01(.05) 0.10(.03) 0.081 -0.24(.06) 0.02(.04) 0.000 

a In Senegal, the variable is provider received sick child care training in past 2 years. This applies to the same variable in Table 9. 

36 
37 

Finally, Table 8 shows that the characteristics of providers and clients differ somewhat between the two 

types of facilities in all three countries. In Kenya, hospitals and health centers were more likely to be in the 

public sector, while clinics and other facilities were more likely to be in the private sector (p<.001). 

Providers at Kenyan hospitals and health centers had less experience providing sick child services than 

those at clinics and other facilities (p<.001), but were more likely to have received training in the last three 

years (p<.05). Clients of sick child services at hospitals and health facilities were more highly educated 

than those at clinics and other facilities (p<.01). In Namibia, there were no differences in facility and 

provider characteristics, but children brought to hospitals and health centers tended to be younger than those 

brought to clinics and other facilities (p<.05). In Senegal, there were differences in the distribution of 

facilities across managing authorities (p<.05) but they were based on small numbers of hospitals and health 

centers. The proportion of providers who received training in the last two years was higher at clinics and 

other facilities than at hospitals and health centers (p<.05). In terms of client’s characteristics, caregivers 

who brought children to clinics and other facilities appeared to be less educated (p<.001) and were more 

likely to have repeat visits to the same facility for the same sickness episode (p<.01) compared with 

caregivers who brought children to hospitals and health centers. 

Figures 16 through 24 show the distribution of sick child structure, process, and satisfaction scores, 

dichotomized at median values, in the three study countries, by facility type, managing authority, and 

region. Kenya presents an interesting scenario, in which all three scores varied significantly by type of 

facility but not by managing authority. In Figure 16, although the sick child structure score was much higher 

in Kenya among hospitals and health centers (68 percent) than clinics and other facilities (17 percent) 

(p<.001), the opposite pattern was observed with service delivery and client’s satisfaction. Higher 

proportions of clinics and other facilities had high process and satisfaction scores (59 and 53 percent, 

respectively) than hospitals and health centers (50 and 39 percent, respectively) (p<.01 and p<.001). These 

two scores also varied significantly by region, but while Nyanza showed the highest proportion of facilities 

with a high process score (77 percent), Northeastern showed the highest client’s satisfaction, with 75 

percent of facilities having a high score in this regard (p<.001 in both cases). 
38 

Figure 16. Kenya: Percentage of facilities providing sick child care with high structure, process and 

satisfaction score by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

68.2

16.83

50.4

58.93

39.98

52.49

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure***

Process**

Satisfaction***
39 

Figure 17. Kenya: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

25.8 27.9

59.87

53.38

50.51

45.9

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure

Process

Satisfaction
40 

Figure 18. Kenya: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by region 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

In Namibia (Figures 19-21), the sick child structure score was different between both types of facilities and 

managing authorities. A much higher proportion of facilities with a high score was seen among 

hospitals/health centers compared with clinics/others (84 versus 41 percent, p<.01) and among public sector 

compared with private sector facilities (76 versus 46 percent, p<.001). When stratified by region (Figure 

21), all three scores were significantly different between regions, where Omakeke had the highest 

proportion of facilities with high scores in all three aspects of service delivery (p<.001 in all cases). 

 

0

10

20

30

40

50

60

70

80

90

100

Percent 

Structure Process*** Satisfaction***
41 

Figure 19. Namibia: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

83.78

40.66

44.44

48.04

42.75

48.59

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure**

Process

Satisfaction
42 

Figure 20. Namibia: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

75.51

45.64

37.9

50.94

42.14

47.79

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure***

Process

Satisfaction
43 

Figure 21. Namibia: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by region 

Figures 22-24 show the distribution of these scores in Senegal. Figure 22 indicates that while the sick child 

structure score appeared higher among hospitals and health centers (with a higher proportion of facilities 

with a high score) than among clinics and other facilities (63 versus 45 percent, p<.01), the opposite was 

observed with client’s satisfaction: 50 percent of clients at clinics and other facilities reported being highly 

satisfied compared with 42 percent of clients at hospitals and health centers (p<.05). There were no 

differences between the public and private sectors with regard to these three scores, as shown in Figure 23. 

Figure 24, however, shows regional differences in the process and satisfaction scores. Kaffrine and Diourbel 

had the highest proportions of facilities with a high process score (72 and 62 percent, respectively), while 

clients in Louga, Saint Louis, and Matam were most likely to be satisfied (89, 86, and 85 percent, 

respectively) (p<.001 for both scores). 

 

0

20

40

60

80

100

Percent

Structure*** Process*** Satisfaction***
44 

Figure 22. Senegal: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by type of facility 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

62.8

45.09

50.37 50.79

41.85

49.69

0

10

20

30

40

50

60

70

80

90

100

Hospitals/Health centers Clinics/Others

Percent 

Structure**

Process

Satisfaction*
45 

Figure 23. Senegal: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by managing authority 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level

Results in the private sector is based on n<50. 

47.5

42.55

50.97 49.9 49.75

42.49

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percent 

Structure

Process

Satisfaction
46 

Figure 24. Senegal: Percentage of facilities offering sick child care with high structure, process and 

satisfaction score by region 

*p<.05; ** p<.01; *** p<.001 

Structure score was calculated at the facility level, while process and satisfaction scores were calculated at the client level. 

Structure score distribution is based on n<50 in most regions 

3.2.4 Factors associated with sick child client’s satisfaction 

Table 9 presents results of multivariate models regressing client’s satisfaction score against service delivery 

factors, and characteristics of the facility, provider, and client, by type of facility. A few results were 

consistent across models. Increased waiting time was found to be significantly associated with a lower 

client’s satisfaction score in four of the six models. The process composite score was also consistently 

associated with increased client’s satisfaction in all four models in Namibia and Senegal. The structure 

composite score was positively associated with client’s satisfaction at clinics and other facilities in Kenya, 

but the association was negative at hospitals and health centers in both Namibia and Senegal. 

0

10

20

30

40

50

60

70

80

90

100

Percent 

Structure Process*** Satisfaction***
47 

Table 9. Factors associated with client satisfaction score related to sick child services 

 Kenya Namibia Senegal

Hospitals/ 

Health Centers 

Clinics/ Other 

Facilities 

Hospitals/ 

Health Centers 

Clinics/ Other 

Facilities 

Hospitals/ 

Health Centers 

Clinics/ Other 

Facilities 

Coefficient (SE) Coefficient (SE) Coefficient (SE) Coefficient (SE) Coefficient (SE) Coefficient (SE)

FACILITY / PROVIDER CHARACTERISTICS Government managing authority (ref=private/NGO) -0.26 (.06)*** -0.07 (.06) -0.18(.14) 0.19(.13) -0.20(.14) .16(.12) 

Provider’s years of SC experience 0.00 (.00) 0.00 (.00) 0.01(.00) 0.01(.00)* N/A N/A Provider received SC training in past 3 years (ref=no) 0.11 (.04)* -0.02 (.06) -0.18(.11) -0.06(.05) -0.31(.11)** -0.11(.05)* STRUCTURE Structure composite score 0.03 (.04) 0.10 (.04)* -0.27(.08)** 0.05(.04) -0.30(.09)** 0.05(.04) Number of infection prevention precautions a -- -- -0.03(.02) -0.01(.01) -- -- 

Number of SC services provided at facility a -- -- 0.05(.03) 0.02(.01) -- -- 

Number of equipment available for SC servicesa -- -- -0.09(.06) -0.02(0.02) -- -- 

Supervision visit to facility with in the past 6 monthsa -- -- 0.18(.11) 0.16(.06)* -- -- 

Number of days per month that SC services are provided 0.03 (.04) 0.00 (.01) -0.01(.01) -0.03(.01)** -0.01(.02) -0.03(.01)** 

Blood test to verify malaria always available for children under age 5 -0.03 (.05) -0.12 (.08) -0.07(.09) 0.01(.05) -0.08(.08) 0.03(0.05) 

IMCI mother’s card available -0.09 (.05)* -0.06 (.05) -0.28(.08) -0.04(.07) -0.32(.15)* 0.01(.07) 

IMCI guide always used in assessing/treating sick childa -- -- -0.15(.09) -0.11(.05)* -- -- 

PROCESS Process composite score -0.03 (.03) -0.02 (.03) 0.13(.06)* 0.07(.03)* 0.14(.06)* 0.06(.03)* 

Provider used visual aids -0.01 (.09) -0.04 (.08) -0.28(.21) 0.14(.07)* -0.26(.20) 0.12(.06) Provider recorded on child’s health card/booklet 0.21 (.09)* 0.43 (.21)* -0.34(.23) 0.01(18) -0.30(.20) 0.02(.18) 

Provider discussed follow-up visit 0.01 (.04) 0.15 (.07)* 0.35(.09)*** 0.04(.05) 0.32(.09)*** 0.04(.05) 

Waiting time -0.01 (.00)*** -0.00 (.00)*** -0.00(.00) -0.00(.00)*** -0.00(.00) -0.00(.00)*** R-squared .13 .14 .21 .09 .20 .07

Note: All models controlled for the sick child’s characteristics (including, age, and whether it was his/her first visit to the facility for the same sickness episode) and the caregiver’s education. 

a These variables are included in the structure composite score in Kenya and Senegal; 

*p<0.05; **p<0.01; ***p<0.001; a b These variables are included in the structure composite score in Namibia and Senegal 

47 
48 

Concerning other factors found to be associated with the outcome—sick child client’s satisfaction—within 

each country, in Kenya clients of sick child services at public sector hospitals and health centers appeared 

to report a lower satisfaction score than those at private sector hospitals and health centers (p<.001). 

Surprisingly, the availability of the IMCI mother’s card at hospital and health centers was negatively 

associated with client’s satisfaction (p<.05). However, clients seemed more satisfied if sick child providers 

recorded on the child’s health card, whether clients were receiving services at hospitals/health centers or 

clinics/others (p<.05 in both cases). Among Kenyan clinics and other facilities, sick child clients also 

reported being more satisfied if providers discussed return visits with them (p<.05). Only a few client 

characteristics were associated with the satisfaction score. If the sick child was a boy, clients of 

hospitals/health centers tended to report a lower satisfaction score than if the sick child was a girl (p<.001). 

Among sick child clients at hospitals/health centers, caregivers with higher levels of education also 

appeared to report being less satisfied (p<.01). Among sick child clients at clinics and other facilities, firsttime visitors reported being more satisfied with services than return visitors (p<.05). 

In Namibia, in addition to the factors already mentioned, a few other factors were associated with sick child 

client’s satisfaction. Among clients of hospitals and health centers, those who discussed return visits with 

the provider reported a higher satisfaction score than those who did not (p<.05). Discussion of follow-up 

visits was the only factor associated with client’s satisfaction at these facilities, besides the structure and 

process scores. Among clients of clinics and other facilities, a higher satisfaction score was reported at 

facilities that were supervised within the last six months (p<.05), but an increased number of days when 

sick child services were provided and consistent use of the IMCI guide were both associated with clients 

being less satisfied with services (p<.01 and p<.05, respectively). Among process attributes, in addition to 

process score and waiting time, mentioned previously, the use of visual aids was the only factor important 

to client satisfaction: clients reported being more satisfied if providers used visual aids during consultations 

(p<.05). Clients were also more satisfied if providers had more years of experience (p<.05). None of the 

client’s characteristics were found associated with the outcome in Namibia. 

In Senegal, as mentioned, the process score was associated with increased satisfaction across types of 

facilities, while the structure score was negatively associated with client’s satisfaction at hospitals and 

health centers. In addition, among sick child clients at hospitals and health centers, higher satisfaction was 

reported if providers discussed follow-up visits with caregivers (p<.001), but the availability of the IMCI 

mother’s card was associated with a lower satisfaction score (p<.05). Across facilities, provider’s training 

in sick child services in the last two years was negatively associated with client satisfaction (p<.01 and 

p<.05, respectively). Clients of sick child services at clinics and other facilities also reported being less 

satisfied at facilities that offered these services more often during the month (p<.01). As in Namibia, none 

of the client’s characteristics appeared to be important to client satisfaction with sick child services in 

Senegal. 

 
49 

4. Discussion and Conclusion 

This study assessed the quality of care at formal-sector health facilities in providing family planning, 

antenatal care (ANC), and sick child services, using data from the nationally representative Service 

Provision Assessment (SPA) surveys of health facilities in Kenya, Namibia, and Senegal. Quality of care 

was measured in structure, process, and outcome of the service provision. Associations between the 

outcome and structural and process attributes were analyzed using multiple regressions. 

Higher-level facilities—hospitals and health centers—generally showed better structural quality than 

lower-level facilities, including clinics and other types of health facilities. In Kenya, for all three services, 

hospitals/health centers had significantly higher measurements for most of the structural indicators studied 

compared with clinics and other facilities. Although in Namibia and Senegal the gap was less prominent, 

the majority of structural indicators favored hospitals and health centers when there was a significant 

difference between the two groups. This finding is to be expected. Because there is greater demand for 

services provided in hospitals and health centers, more resources are allocated to them than to clinics and 

other facilities. The greater differences observed in Kenya compared with Namibia and Senegal could be 

because family planning, antenatal, and child health services in Kenya were offered by a large percentage 

of private clinics and others, which are commonly found to lack essential infrastructure and equipment. 

Among the facilities offering each of the three services, in Kenya more than 40 percent were private 

clinics/others compared with 6-15 percent in Namibia and Senegal. 

When looking at individual structural attributes, health facilities at both higher and lower levels had 

inadequate infrastructure and supplies that are essential for providing good-quality services. In Namibia, 

for example, among facilities offering ANC services, service guidelines that detail how to manage 

pregnancy-related problems were observed in only 18 percent of the hospitals/health centers and 13 percent 

of the clinics/others. Another area of concern is the shortage of items for infection-prevention. Of the 14 

(or 13 in Senegal) infection prevention items examined, only one-half were available at health facilities. 

Availability of some service-specific structural attributes was also of concern, such as the limited number 

of contraceptive methods provided by family planning facilities, lack of regular distribution of ITNs to 

ANC clients, little use of the IMCI guide in assessing/treating sick children, and poor availability of 

diagnosis tests to verify malaria for children under age 5. 

The observation of provider-client interaction in SPA surveys provides opportunities to assess whether the 

service provision process follows standards of acceptable content and quality. Although hospitals and health 

centers generally possessed better structural attributes than clinics and other lower-level health facilities, 

their performance in adhering to standards of care during the process of service delivery was not necessarily 

superior, and sometimes was poorer than at lower-level facilities. This finding suggests that enhanced 

structural attributes might improve the process of service delivery but not ensure its quality (Brook, 

McGlynn, and Shekelle 2000). Compared with structural measurements, process indicators did not vary as 

much by type of facility across service areas in all three countries. Moreover, lower-level facilities 

sometimes outperformed hospitals and health centers in providing some of the services. In Namibia, for 

example, family planning clinics/others were more likely than hospitals/health centers to ensure visual and 

auditory privacy for clients and assure client’s confidentiality; clinics offering ANC services also were 
50 

more likely to discuss with clients signs and problems related to pregnancy and delivery preparation. In 

Kenya, clinics/other also showed higher measurements in several process attributes, including providing 

injectables to family planning clients, giving iron or/and folate tablets to ANC clients, providing sick child 

care information to the caregiver, using visual aids during consultation, and discussing follow-up visits. 

The weak relationship between the structural and process attributes leads to a different question: what 

factors influence providers’ performance during service delivery, if not the infrastructure environment of 

the facility? Human resource management including supervision and training may be associated with 

provider’s performance in service delivery. Our comparisons between two groups of facilities, however, 

indicate that health providers in hospitals and health centers are more likely to have received servicespecific training in the past three years and to have received supervision visits within the past six months. 

Also, in a study exploring how human resource management affects family planning providers’ 

performance in service delivery, the authors found that having a job description was significantly associated 

with better quality of family planning delivery after controlling for other covariates, but not supervision 

and training (Thatte and Choi 2014). Another important factor is client volume. With a large number of 

clients, which can be the case in hospitals and health centers, quality of care is likely to be compromised. 

Results on service-specific process indicators show that family planning providers rarely counselled clients 

on important family planning issues such as risk of STIs, or condom use for dual protection, as well as 

partner’s attitudes towards contraceptive use. In all three countries, while family planning providers tended 

to discuss major issues related to the specific contraceptive method provided to clients, they did not seem 

to counsel about other family planning methods. For ANC, interventions like giving pregnant women 

iron/folate tablets and tetanus toxoid were not commonly observed in Kenya, whereas in Namibia the 

majority of consultations prescribed iron/tablets and tetanus toxoid vaccine to clients. For sick child care, 

poor practice was observed in adhering to the IMCI guidelines. Providers are expected advise caregivers 

about sick child care at home, such as giving information about feeding/breastfeeding, advising intake of 

extra fluids during sickness, advising continued feeding during sickness, naming the illness for the 

caregivers, and teaching them about symptoms requiring immediate return for medical care (WHO 2005). 

However we found that such consultation was rarely offered to caregivers of sick children in all three 

countries. 

Waiting time is an important component of quality of care and of client satisfaction. Long waiting time has 

been found to be associated with increased client dissatisfaction and to have a negative impact on use of 

health services and on health outcomes (Pizer and Prentice 2011; Prentice and Pizer 2007). Our analysis 

indicates that prolonged waiting time was a common problem across service areas and countries. Family 

planning clients had to wait one hour or longer to receive services—twice as long as the recommended 

waiting time of 30 minutes (O’Malley et al. 1983). The average waiting time was unbearably long for 

antenatal care, as long as over two and half hours at hospitals/health centers in Namibia. Clients waited 

longer at hospital and health centers generally than at clinics and other types of facilities. Our results 

confirmed the findings from previous research that long waiting time is a serious problem at health facilities 

in developing countries (Mendoza Aldana, Piechulek, and al-Sabir 2001; Oche and Adamu 2013). The 

major problems causing long waiting time reported in the literature include lack of health workers, large 

patient load, and inefficient registration process (Oche and Adamu 2013). 
51 

The outcome aspect of the quality of care was only measured through client satisfaction due to data 

availability. When comparing higher- and lower-level health facilities, we found that higher-level facilities 

do not necessarily have greater client satisfaction. To the contrary, the satisfaction score was higher at 

clinics and other types of facilities than at hospitals/health centers for both family planning and sick child 

care services in Senegal, and for antenatal care in Kenya. Within each type of facility, we further examined 

how structural and process attributes are associated with client satisfaction after controlling for variables 

that could potentially affect client satisfaction. 

A limited number of structural and process attributes were identified as associated with client satisfaction. 

Process attributes seem to be more predictive of client satisfaction than structural ones. In both Namibia 

and Senegal, the process composite score was positively associated with satisfaction of clients seeking sick 

child services, irrespective of facility type. A study in three African countries also found client satisfaction 

to be associated more with process quality than structural quality (Hutchinson, Do, and Agha 2011). 

Waiting time showed consistent negative effects on client satisfaction. This finding agrees with findings of 

previous research in both developed and developing countries that waiting time is an important factor 

influencing client satisfaction (Mendoza Aldana, Piechulek, and al-Sabir 2001; Pizer and Prentice 2011; 

Tafese, Woldie, and Megerssa 2013). A few other service-specific process attributes, especially those 

indicating receipt of tangible services (i.e. injectables for family planning clients, iron/folic acid and tetanus 

toxoid vaccine for ANC clients) also appeared to affect client satisfaction. This finding is comparable to 

that of several previous studies in which not being able to get prescribed drugs and supplies was a major 

cause of client dissatisfaction (Mitike, Mekonnen, and Osman 2002; Tafese, Woldie, and Megerssa 2013). 

We did not find much evidence of a significant relationship between the structural quality and client 

satisfaction. Among the list of structural attributes, the composite structural score showed positive effects 

on client satisfaction with ANC services at hospitals and health centers and with sick child services at clinics 

and other types of facilities in Kenya. Having a supervision visit within the past six months stands out as 

positively associated with client satisfaction in several models. Some structural attributes showed negative 

effects on client satisfaction in several models. For example, the structure composite score was negatively 

associated with client satisfaction with ANC services at clinics/others in Namibia and with sick child 

services at hospitals and health centers in both Namibia and Senegal. The number of days when family 

planning services were provided was negatively associated with client satisfaction in lower-level facilities 

in Namibia and Senegal. Another unexpected finding is that provider’s receipt of training in the past three 

months was negatively associated with client satisfaction. 

We acknowledge that apart from quality of care client satisfaction can also be affected by many other 

factors, including previous experience with health services, client expectations for the provider, as well as 

the client’s socio-demographic characteristics and cultural background. When judging the service received, 

due to the limited knowledge about technical aspects of the care, clients tend to give more weight to the 

interpersonal relationship with the provider. Several studies have confirmed that client satisfaction is more 

likely to be predicted by the provider’s interpersonal relationship with the client rather than technical 

capability and the facility’s infrastructural environment (Lei and Jolibert 2012; Mendoza Aldana, 

Piechulek, and al-Sabir 2001). 

Our results provided some evidence that client satisfaction was greater in the private sector than in the 

public sector. After controlling for variables that could potentially affect client satisfaction, family planning 
52 

clients at private clinics/others in Kenya and private hospital/health centers in Senegal reported greater 

satisfaction with the service received than their counterparts at public sector facilities. Antenatal clients in 

the public sector were also more likely to be satisfied than in the private sector for all facilities in Kenya, 

and for hospitals and health centers in Namibia. Such private-public disparity was also observed in client 

satisfaction with sick child services at hospitals and health centers in Kenya. Our findings accord with an 

assessment based on the 2004 Kenya SPA data, which showed that the odds of family planning clients 

being satisfied at private sector facilities were three times higher than at public sector facilities (Agha and 

Do 2009). Hutchinson and colleagues also reported significantly higher levels of client satisfaction with 

family planning services provided in private facilities than in public facilities in Ghana, Kenya, and 

Tanzania (Hutchinson, Do, and Agha 2011). The private sector was generally reported to have greater 

timeliness and hospitality to patients compared with the public sector (Basu et al. 2012), which may in part 

explain the higher level of client satisfaction. 

While the observations of actual process of service delivery in SPA surveys provide direct evidence of 

quality of care, it should be noted that the presence of an observer could possibly make providers adjust 

their behavior; what was observed may not be the daily practice. We measure client satisfaction based on 

client’s responses to a series of questions. While this approach may be less subjective than asking a single 

question about whether the client was satisfied with the service received, clients may respond to the series 

of questions with answers deemed social acceptable, depending upon their expectations and cultural 

background. 

In conclusion, through a comprehensive assessment of the structure, process, and outcomes of key maternal 

and child health services in three African countries, our study has provided empirical evidence on the 

quality of care and highlighted major gaps in the availability of essential infrastructure and equipment, and 

in adherence to standards of quality practice. Findings from this analysis are expected to inform intervention 

programs in identifying areas for improving quality of care. 

 
53 

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55 

Appendix A Definitions of common structural attributes for family planning, ANC, and sick child care services 

Variable Definition Variable typeManaging authority Public sector: government sector facilities 

Private sector: all private for profit, non-profit and faith-based facilities 

Binary 

Structural attributes 

Infrastructure and equipment 

Basic amenities Number of amenities at facility: water, electricity, generator, telephone, email, ambulance Out of 6 Infection prevention precautions Number of infection prevention measures at facility: sharps containers, gloves, disinfectant, 

disposable needles, autodestruct syringes, disposable syringes, waste bin with plastic liners, hand disinfectant, electric dry heat stabilizer, autoclave, waste disposal of sharps, waste disposal of hazards 

Kenya: Out of 14 Namibia: Out of 14 Senegal: Out of 13 

Management 

Routine management meetings Where there are monthly meeting to discuss management issues Binary 

Quality assurance system Whether the facility has a routine quality assurance system Binary System to collect client opinion Whether the facility has a system to obtain clients’ opinions regarding services Binary Supervision Whether the facility reported that the last supervision visit was in the last 6 months Binary 

55 
56 
57 

Appendix B Definitions of family-planning-specific structural and process attributes of service quality 

Variable Definition Variable typeStructural Attributes Service availability 

Days FP services available Number of days the facility provides family planning services Out of 7 FP methods offered, in stock and valid 

Number of family planning methods, in stock at time of visit and valid: combined pills, progestin 

only pills (2 month, 3 month), combined injectables (1 month), implants, male condoms, female condoms, IUDs, emergency contraceptive pills, diaphragm, male sterilization, female sterilization 

Kenya: Out of 13 items Namibia: Out of 13 items Senegal: Out of 12 items 

Contraceptive storage measures 

Number of measures in place to store contraceptive methods safely: Contraceptive methods organized by expiration date, protected from water, protected from sun, protected from rodents/pests 

Out of 4 

Health care provider always available 

Whether a trained health care provider was always available at the facility Binary 

Counseling 

FP visual aides Number of family planning visual aids available: Samples of methods, male condom model, 

female condom model, posters, teaching aids 

Kenya: Out of 8 Namibia: Out of 5 Senegal: Out of 3 

FP guidelines/protocols Whether the facility had family planning guidelines or protocols available on the day of the visit Binary 

Process Attributes

Physical examinations performed 

Number of family planning physical examinations performed during consultation: blood pressure, weighed, asked about smoking, asked about symptoms of sexually transmitted infections, reviewed client health card 

Out of 5 

Visual and auditory privacy Whether the provider ensured both visual and auditory privacy for client during consultation Binary Confidentiality Whether the provider assured the client orally of confidentiality during consultation Binary FP-related issues discussed Number of issues related to family planning discussed during consultation: partner’s attitude 

toward family planning, partner status, risk of STIs, use of condoms to prevent STIs, use of condoms with other methods to avoid STIs 

Out of 5 

FP methods discussed Number of methods discussed with client: combined pill, progestin-only pill, injectable (1 month), 

injectable (2-3 months), implant, male condom, female condom, IUD, emergency contraception, spermicide, diaphragm, vasectomy, female sterilization 

Kenya: Out of 12 Namibia: Out of 12 Senegal: Out of 13 

Information about FP methods provided 

Number of types of information provided about family planning explained during consultation: how to use method, possible side effects, what do if problems occurred, told to return for followup 

Out of 4 

Injectable prescribed Whether the client was provided or prescribed an injectable method by the provider Binary 

57 
58 
59 

Appendix C Definitions of ANC-specific structural and process attributes of service quality 

Variable Definition Variable typeStructure Attributes Service availability Days ANC services available Number of days the facility provides ANC services Out of 7 Routine ANC services Number of routine ANC services: HIV counseling, HIV testing/results, STI testing/referral, preventive 

antimalarial treatment, delivery preparations, FP counseling 

Out of 6 

ANC equipment available Number of ANC equipment available at facility: Vaginal speculum (small, medium, large), individual infant 

chart/record, vitamin K, vitamin A, fetal stethoscope, thermometer, infant scale, adult weighing scale 

Out of 11 

Availability of iron or folate tablets 

Whether the facility had iron or folate tablets Binary 

Routine ANC-related tests Number of routine ANC-related tests available at facility: Anemia (blood test), syphilis (blood test), urine 

protein, rh factor, urine glucose, blood group

Out of 6 

Tetanus toxoid vaccine available 

Whether tetanus toxoid vaccine offered on all days that ANC services are offered Binary 

Insecticide Treated Nets (ITN) available 

Whether ITNs are distributed to ANC clients Binary 

Counseling 

Guidelines for ANC Whether the facility had ANC guidelines or protocols available on the day of the visit Binary Process Attributes

Number of ANC procedures performed 

Number of ANC procedures performed during consult: blood pressure, palpate abdomen for fetal presentation, palpate abdomen for uterine height, listen abdomen for fetal heartbeat, anemia test, urine test, syphilis test, counseled/referred for HIV test, tested for HIV/referral, looked at client health card, weighed client, examined palms for anemia, examined feet for edema, examined client’s breast, vaginal exam 

Out of 15 

ANC client history Number of types of client history information requested during consult: age, current medication, date of 

last menstruation, number of prior pregnancies, prior stillbirth, infants who died in first week, heavy bleeding during or after delivery, previous assisted delivery, previous abortions, multiple pregnancies, prolonged labor, hypertension, convulsions 

Kenya: Out of 13 Namibia: Out of 9 

Signs and problems with current pregnancy 

Number of signs or problems with current pregnancy discussed during consultation: Bleeding, fever, headache/blurred vision, swollen face or hands, tiredness/breathlessness, felt the baby move, other 

symptoms/problems in pregnancy, persistent cough, HIV status 

Kenya: Out of 9 Namibia: Out of 7 

Delivery preparation Number of delivery-related issues about which the health care provider advised/counseled: place of 

delivery, use of skilled health worker for delivery, items to have for home delivery, importance of newborn immunization, delivery preparation, care of newborn, early initiation of breastfeeding 

Kenya: Out of 7 Namibia: Out of 5 

Client received iron or folic acid tablets 

Whether client received iron or folic acid tables during consultation Binary 

Client asked about tetanus toxoid 

Whether client received tetanus toxoid vaccine Binary 

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Appendix D Definitions of sick-child-specific structural and process attributes of service quality 

Variable Definition Variable typeStructure Attributes Service availability Days SC services available Number of days the facility provides sick child services in the month Out of 31 Routine SC services Number of routine sick child services provided: Weigh child, plot weight on graph, take child’s 

temperature, assess immunization status, group health education, administer 

paracetamol/sponge for fever 

Kenya: Out of 7 Namibia: Out of 6 Senegal: Out of 7 

SC equipment available Number of pieces of sick child equipment available at facility: Infant scale, child scale, 

thermometer, timer/watch or clock with second hand 

Kenya: Out of 6 Namibia: Out of 4 Senegal: Out of 4 

Malaria blood test Whether the facility always has malaria blood tests available for children under age 5 Binary IMCI mother’s card Whether IMCI mother’s card are available at facility Binary Insecticide Treated Nets (ITN) available 

Whether ITNs are distributed to ANC clients Binary 

Counseling IMCI guide followed Whether the facility always follows guide for integrated management of childhood illness (IMCI) 

when assessing/treating sick child 

Binary 

Process Attributes

Number of symptoms checked Number of symptoms that the provider asked for or that the caregiver mentioned: Cough or 

difficulty breathing, diarrhea, fever or body hotness, ear problems, unable to drink/breastfeed, 

vomiting everything, convulsions, blood in stools 

Kenya: Out of 7 Namibia: Out of 8 Senegal: Out of 7 

Physical exams for sick child Number of types of sick child exams performed: Temperature by thermometer, feel for fever or 

hotness, count respirations, ausculate child, check skin turgor for dehydration, check for pallor by looking at palms, check for pallor by looking at conjunctiva or mouth, look in ear, feel behind ear, undress child to examine, press feet to check for edema, assess for HIV symptoms, weigh the child, plot weight on growth chart, compare weight to standard weight, check mouth and throat, check for neck stiffness, offered breast or drink, normal feeding when not ill, normal breastfeeding when not ill, feeding or breastfeeding during this illness, discuss weight/growth/growth chart, review immunization card or asked about vaccination history, asked if child received vitamin a, looked at health card during visit 

Kenya: Out of 24 Namibia: Out of 24 Senegal: Out of 16 

Information provided to caregiver 

Number of pieces of information given to caregiver during consultation: provide general information about feeding/breastfeeding, advise extra fluids during this sickness, advise continued feeding during sickness, name the illness for the caretaker, describe symptoms requiring immediate return for care 

Out of 5 

Visual aids Whether provided used visual aids during consultation Binary Child’s health card Whether provider recorded on child’s health card/booklet Binary Follow-up Whether the provider discussed follow-up visit during consultation Binary 

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Appendix E 

Questions that were used to construct the client satisfaction score (the same for all services): whether each 

of the followings was a major problem (1=no, 0=yes) 

1. Time you waited 

2. Ability to discuss problems or concerns about your health with the provider 

3. Amount of explanation you received about the problem or treatment 

4. Quality of the examination and treatment provided 

5. Privacy from having others see the examination 

6. Privacy from having others hear your consultation discussion 

7. Availability of medicines/methods at this facility 

8. The hours of services at this facility 

9. The number of days services are available to you 

10. The cleanliness of the facility 

11. How the staff treated you 

12. Cost for services or treatments 

13. Any problem you had today that I did not mention 

Internal reliability coefficients of the satisfaction index by type of service and country 

Kenya Namibia Senegal 

Family planning services 0.85 0.72 0.72 

ANC services 0.86 0.75 N/A 

Sick child care 0.90 0.84 0.71 

 
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Appendix F Variables included in the structure and process composite indices in family planning, by country 

Variable type Country

 Categorical Continuous Kenya Namibia SenegalSTRUCTURE COMPOSITE INDEX Monthly meetings for managerial/ administrative issues Yes / No --- X X X 

Any system to obtain client opinions Yes / No --- X X X 

Routine quality assurance activities Yes / No --- X X X 

Supervision visit to facility with in the past 6 months Yes / No --- --- X --- 

Number of basic amenities at facility --- 0-6 X X X 

Number of infection prevention precautions (out of 14) --- 0-14 X X X Number of FP methods offered, available and with valid expiry date --- 

0-13 (Kenya and Namibia) 0-12 (Senegal) X --- --- 

Number of FP visual aids at facility --- 

0-8 (Kenya) 0-5 (Namibia) 0-3 ( Senegal) 

X --- X 

Guidelines for FP Services at facility Yes / No --- X X X 

Cronbach’s Alpha .66 .51 .51 

PROCESS COMPOSITE INDEX Physical examinations --- 0-5 X X X 

Provider ensured visual and auditory privacy Yes / No --- X X Provider assured client about confidentiality Yes / No --- X X X 

Number of FP-related issues discussed --- 0-5 X X X Number of methods discussed with client --- 0-12 (Kenya and Namibia) 0-13 (Senegal) X X X 

Information about method provided to client --- 0-4 X X X 

Cronbach’s Alpha .51 .53 .51 

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Appendix G Variables included in the structure and process composite indices in antenatal care (ANC), by country. 

Variable type Country

Categorical Continuous Kenya Namibia

STRUCTURE COMPOSITE INDEX Monthly meetings for managerial/ administrative issues Yes / No --- X X Any system to obtain client opinions Yes / No --- X X Routine quality assurance activities Yes / No --- X X 

Supervision visit to facility with in the past 6 months Yes /No --- --- --- 

Number of basic amenities at facility --- 0-6 X X Number of infection prevention precautions --- 0-14 X X 

Health workers always available Yes/No --- X X 

Number of days per week that ANC services are offered --- 0-7 --- --- 

Number of services provided to ANC clients --- 0-6 X X 

Number of equipment for ANC services, excluding iron and folate --- 0-11 X --- 

Facility has iron or folic acid Yes / No --- --- --- Facility routinely distributes ITN to ANC clients Yes / No --- --- X 

Number of tests for ANC clients --- 0-6 X --- Guidelines for ANC services at facility Yes / No --- X X Cronbach’s Alpha .61 .53 

PROCESS COMPOSITE INDEX ANC procedure --- Kenya: 0-17 Namibia: 0-15 X X 

ANC client’s history is taken --- Kenya: 0-13 Namibia: 0-9 X X 

Provider asked about signs and problems with pregnancy --- Kenya: 0-9 Namibia: 0-7 X X 

Issues with delivery preparation discussed --- Kenya: 0-7 Namibia: 0-5 X X 

Client received iron/folate tablets or both at this or previous visit Yes / No --- --- --- Client received tetanus toxoid vaccine or both at this or previous visit Yes / No --- --- --- 

Cronbach’s Alpha .70 .75 

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Appendix H Variables included in the structure and process composite indices in sick child care, by country. 

Variable type Country

 Categorical Continuous Kenya Namibia SenegalSTRUCTURE COMPOSITE INDEX Monthly meetings for managerial/ administrative issues Yes / No --- X X X 

Any system to obtain client opinions Yes / No --- X X X 

Routine quality assurance activities Yes / No --- X X X 

Supervision visit to facility with in the past 6 months Yes /No --- X --- X 

Number of basic amenities at facility --- 0-6 X X X 

Health workers always available Yes / No --- X X X Number of infection prevention precautions (out of 14) 

--- 

0-14 (Kenya and Namibia) 0-13 (Senegal) X --- X 

Number of SC services provided at facility --- 0-7 (Kenya and Senegal) 0-6 (Namibia) X --- X 

Number of equipment available for SC services --- 0-6 (Kenya) 0-4 (Namibia and Senegal) X --- X 

IMCI guide always used in assessing/treating sick child Yes / No --- X --- X 

Number of days per month that SC services are provided --- 0-31 --- --- --- 

Blood test to verify malaria always available for children <5 Yes / No --- --- --- --- 

IMCI mother’s card available Yes / No --- --- --- --- 

Cronbach’s Alpha .60 .45 .55 

PROCESS COMPOSITE INDEX Number of symptoms that provider asked about or caregiver mentioned --- 

0-7 (Kenya and Senegal) 0-8 (Namibia) X X X 

Physical exam of sick child --- 0-24 (Kenya and Namibia) 0-16 (Senegal) X X X 

Information provided to caregiver --- 0-5 X X X Provider used visual aids Yes / No --- --- --- --- 

Provider recorded on child’s health card/booklet Yes / No --- --- --- --- Provider discussed follow-up visit Yes / No --- --- --- --- Cronbach’s Alpha .61 .59 .26* 

*No combination of variables resulted in an alpha of greater than .40. The variables for this process index were chosen based the variables included in the index 

for Namibia and Kenya. 

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