Promoting equitable and patient-centred care: an analysis of patient satisfaction in urban, rural and remote primary care sites in the Philippines

Abstract

Objectives

This study measured changes in patient satisfaction levels before and after the introduction of primary care system strengthening interventions in urban, rural, and remote sites in the Philippines.

Methods

A previously validated 16-item questionnaire was distributed to 200 patients per site before implementation of interventions and to a different set of 200 patients 1 year after implementation. We compared the percentage change in highly satisfied patients per site before and after implementing interventions using a two-proportion Z-test.

Results

The urban site had a significant increase in patient satisfaction in 13 survey items, which corresponded to the domains of healthcare availability, service efficiency, technical competency and health communication. The rural site had a significant increase in six survey items, which corresponded to the domains of service efficiency, environment, location, health communication and handling. The remote site had a decrease in patient satisfaction in 10 survey items, with a significant increase in only 4 items under the domains of healthcare availability and handling.

Conclusion

Our findings support the ‘inverse equity hypothesis’, where well-resourced urban communities quickly adopt complex health interventions while rural and remote settings experience delays in effectively meeting patient needs and system demands. Extended intervention periods and targeted strategies may be necessary to impact patient satisfaction in underserved areas considerably.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Promoting equitable and patient-centred care through primary care interventions requires the analysis of patient satisfaction. Patient satisfaction is an important predictor of health-seeking behaviour, patient–provider relationships and health improvement, and it is influenced by varied contexts.

WHAT THIS STUDY ADDS

• Changes in patient satisfaction varied across study sites after primary care strengthening interventions were implemented. This may be attributed to differences in baseline resources across research sites, including human resources for health, patient expectations and health system readiness toward primary care adoption.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study ascertains areas of primary care that local organisations and governments must focus on to improve quality care depending on their setting.

Introduction

Health inequities remain prevalent in the Philippines despite advancements gained in the Millennium and Sustainable Development Goals.¹ Inequitable access to quality healthcare, system fragmentation and workforce maldistribution are barriers to achieving nationwide improvement in health outcomes for patients from all regions and economic strata.^{2 3} Service delivery performance and financing are highly dependent on semi-autonomous local government units (LGUs), rendering patient experiences of primary care diverse.³

The Philippine government passed the Universal Healthcare (UHC) Law to address these gaps, expand primary care, improve health service accessibility and promote equitable care for Filipinos.⁴ Patient satisfaction, the degree to which an individual regards their healthcare as useful, effective and beneficial, was identified as a critical indicator of improvement in healthcare delivery and utilisation.⁵ Patient satisfaction is also a predictor of health-seeking behaviour, sustained patient–provider relationships and improved health outcomes.⁶

Patients from different geographic areas in the Philippines have varied experiences with the health system in primary and other aspects of care.^7–10 Introducing new healthcare interventions may have varying results across settings. Patient-centred and equity-based care consider the varying needs and preferences of the communities.⁷

The Philippine Primary Care Studies programme introduced primary care strengthening interventions across urban (University of the Philippines Health Service, Diliman), rural (Municipality of Samal, Province of Bataan) and remote (Municipality of Bulusan, Province of Sorsogon) areas in the Philippines. Interventions on health financing, health information systems, health worker training, and community engagement were introduced. This study aimed to describe patient satisfaction levels in urban, rural and remote sites before and 1 year after the implementation of primary care interventions.

Methodology

Study design

This is an uncontrolled before-and-after study comparing the change in patient satisfaction in three sites. The interventions involved a multisectoral approach, with the main goal of improving primary care in the Philippines. These interventions included a primary care benefit package, the development of an electronic health record (EHR) system, capacity building activities for healthcare workers and community engagement. Context-specific measures such as expanding the healthcare provider network, increasing health human resource capacities and providing transportation assistance were also implemented (table 1). The interventions were implemented in 2016 in the urban site and in 2019 in the rural and remote sites.

Table 1.

Summary of context-specific primary care interventions implemented across sites

Intervention	Urban	Rural	Remote
Health financing: implementation of a primary care benefit package that covered patient consults, medicines and laboratory services of up to PHP2000 or ~US$37 per patient	✓	✓	✓
Health information system: development of an electronic health record (EHR) system that centralised patient records and referral systems	✓	✓	✓
Healthcare worker training: technical training on primary care and clinical practice guidelines, and provision of a clinical decision-making platform	✓	✓	✓
Community engagement: dissemination of print and digital materials to raise public awareness on primary care, provider networks and risk-sharing	✓	✓	✓
Healthcare provider networks: expansion of provider availability through partnerships with private laboratories and pharmacies		✓	✓
Health human resources: augmentation of health workforce by hiring additional physicians		✓	✓
Transportation: subsidised transportation costs to and from the health facility			✓

Study sites

The urban site was a 25-bed facility clinic located within an academic institution in the National Capital Region, the most urbanised and populous region in the Philippines. The facility served a patient population of about 31 000 students, faculty, employees and campus residents. It operated on weekdays, from 08:00 to 17:00, and was serviced by 12 family physicians during the study period. The facility was directly connected to diagnostic and pharmacy services within the university system.¹¹

The rural site was a fourth-class municipality with a population of approximately 36 000 residents.¹² Municipalities in the Philippines are divided into six classes, with first-class municipalities obtaining the highest average annual income and sixth-class municipalities acquiring the lowest.¹³ Different points of care are available for constituents in the rural site, such as the rural health unit (RHU) and barangay (or village) health stations (BHS). These public facilities operated on weekdays, from 08:00 to 17:00. The RHU was supervised by a physician, while the BHS was staffed by midwives or nurses, with a physician remotely managing them.

The remote site was also a fourth-class municipality with a population of approximately 23 000.¹⁴ The country’s Department of Health has identified it as a geographically isolated and disadvantaged area in the Philippines.¹⁵ Due to its mountainous geography, the remote site had inadequate transportation networks and poor internet connectivity. An RHU and various BHS were also available in the remote site, with operations and staffing like the rural site. At baseline, the rural and remote areas only had one family physician employed.¹⁵

Questionnaire development

Patient satisfaction was assessed through a Health Visit Satisfaction Survey developed by the American Academy of Family Physicians (online supplemental appendix A),¹⁶ which was previously piloted at the urban site.¹¹ Since socio-linguistic diversity was present across study sites, the questionnaire was translated and made available in English, Filipino (Tagalog) and Bikolano.

This self-administered questionnaire included two sections. The first section elicited the demographic profile of respondents, including age, sex, education, number of years as a patient and frequency of visits. The second section focused on factors relating to patient satisfaction with health services and facilities. It consisted of 16 items which encompassed eight domains: (1) healthcare availability, (2) service efficiency, (3) technical competency, (4) environment, (5) location, (6) health communication, (7) handling and (8) general perception. Satisfaction was measured through a 5-point Likert scale ranging from 1=‘extremely dissatisfied’ to 5=‘extremely satisfied’ for domains 1–6. The scale for domain 7 ranged from 1=‘extremely uncaring’ to 5=‘extremely caring’, while the scale for domain 8 ranged from 1=‘not definitely’ to 5=‘definitely’.

Sampling and survey distribution

Using consecutive sampling, 200 patients in the outpatient services were given a self-administered questionnaire at baseline for each study site. A different set of 200 patients were consecutively sampled at endline for each study site. Although ideal, we could not survey the same 200 patients from baseline to endline due to logistical and financial constraints. A total of 10 patients were surveyed per working hour at each facility across 4 weeks. Patients were given the questionnaire on arrival in the facility and were asked to complete the questionnaire before leaving the facility.

The baseline survey was conducted in October 2016 at the urban site and the endline survey in September 2017. For rural and remote sites, baseline surveys were conducted in April 2019 and endline surveys in May 2020. Since the interventions were implemented system-wide for all sites, affecting the entire university for the urban site and the entire municipality for the rural and remote sites, all patients who consulted in the outpatient facilities in these three sites experienced the interventions. Written and verbal informed consent were collected from each respondent before survey administration.

Data analysis

Demographic data was summarised as frequencies and percentages for categorical variables. Patient satisfaction scores of 4 (very satisfied) and 5 (extremely satisfied) were categorised as ‘highly satisfied’.¹⁷ A two-proportion Z-test with a 95% CI was used to assess the difference in the proportion of highly satisfied patients between baseline and endline for each item per site. Due to the difference in interventions and the different contexts and sociodemographic characteristics of participants in the three sites, we did not perform inferential statistics to compare the patient satisfaction scores across the three sites. Instead, we described the observed changes in each of the three sites.

Respondent data was encoded using Microsoft Excel and analysed through SPSS Statistics V.25.¹⁸ The statistical test performed in this study was two-tailed and assumed a p value of <0.05 as statistically significant.

Results

This study included 200 participants per site at baseline (before implementation of interventions) and endline (1 year after baseline). Most participants were younger adults (18–39 years old) and females for baseline and endline periods in all three sites. Majority of the participants in the urban site received at least a college level of education for both baseline (78.5%) and endline (92.0%) periods. In the rural and remote sites, less than 30% of the participants received at least a college level of education. Most participants in the urban and remote sites were patients of the facility for 4 years or less, while most participants in the rural site were patients for more than 10 years. Most respondents were returning patients for both baseline and endline periods (table 2).

Table 2.

Summary of respondent demographics

Variables	Urban		Rural		Remote
	Baseline (N=200)	Endline (N=200)	Baseline (N=200)	Endline (N=200)	Baseline (N=200)	Endline (N=200)
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Age
18–39	131 (66)	129 (65)	117 (59)	115 (58)	116 (58)	86 (43)
40–59	53 (27)	48 (24)	43 (22)	55 (28)	55 (28)	65 (33)
60 and above	14 (7)	18 (9)	40 (20)	30 (15)	29 (15)	43 (22)
Sex
Female	117 (59)	117 (59)	118 (59)	147 (74)	174 (87)	134 (67)
Male	83 (41)	83 (41)	82 (41)	53 (26)	26 (13)	66 (33)
Highest education attainment
Elementary school graduate	13 (6)	11 (5)	129 (65)	83 (41)	105 (52)	129 (64)
High school graduate	30 (15)	4 (2)	28 (14)	57 (29)	56 (28)	37 (19)
College level or higher	157 (79)	184 (92)	30 (15)	60 (30)	39 (20)	34 (17)
Not reported	–	1 (1)	13 (6)	–	–	–
Years as patient
Less than a year	64 (32)	130 (65)	58 (29)	56 (28)	126 (63)	73 (37)
1–4 years	89 (45)	39 (20)	49 (25)	43 (22)	74 (37)	108 (54)
5–9 years	30 (15)	6 (3)	26 (13)	23 (12)	0 (0)	6 (3)
10 or above	15 (8)	17 (9)	67 (34)	78 (39)	0 (0)	5 (3)
Frequency of visit
Returning patient	177 (89)	142 (71)	198 (99)	194 (97)	192 (96)	149 (75)

In the urban area, there was an observed increase in patient satisfaction scores in all 16 items at the endline. The increase was statistically significant in 13 of the 16 items (p<0.05). The largest increase in the percentage of highly satisfied patients (>20% increase) was observed in the domains of healthcare availability (Q1, Q2), service efficiency (Q6), technical competency (Q8) and health communication (Q12) (table 3).

Table 3.

Comparison of baseline and endline proportions of highly satisfied patients within sites

Domain and Item	Urban			Rural			Remote
	Baseline (%)	Endline (%)	P value	Baseline (%)	Endline (%)	P value	Baseline (%)	Endline (%)	P value
I. Healthcare availability
Q1: Setting appointments for check-ups	34	68	<0.01*	75	76	0.84	70	63	0.25
Q2: Setting appointments for sickness	31	69	<0.01*	77	74	0.56	78	61	<0.01*
Q3: Contacting physician during off-hours	23	41	<0.01*	77	53	<0.01*	36	51	0.03*
Q4: Contacting physician during office hours	38	49	0.06	48	51	0.71	64	56	0.42
II. Service efficiency
Q5: Responding to emergencies	39	51	0.03*	48	56	0.22	71	54	0.07
Q6: Waiting time at the office	32	54	<0.01*	72	58	<0.01*	54	54	0.93
Q7: Obtaining follow-up information and care	46	64	<0.01*	72	81	0.04*	75	71	0.32
III. Technical competency
Q8: Medical care with doctor	49	70	<0.01*	85	91	0.06	75	76	0.82
IV. Environment
Q9: Office appearance	49	66	<0.01*	78	88	<0.01*	89	77	<0.01*
V. Location
Q10: Office convenience	50	65	<0.01*	75	84	0.02*	77	76	0.72
VI. Health communication
Q11: Improving health	45	63	<0.01*	85	94	0.01*	85	78	0.06
Q12: Involving other HCWs in providing care	43	64	<0.01*	85	88	0.36	86	79	0.13
VII. Handling
Q13: Physician	59	70	0.02*	88	94	0.04*	73	86	<0.01*
Q14: Medical staff	57	68	0.03*	86	92	0.05	75	85	0.01*
Q15: Office staff	55	64	0.09	53	92	<0.01*	68	83	<0.01*
VIII. General perception
Q16: Recommendability	87	89	0.58	97	97	0.78	96	92	0.09

*Statistically significant at p<0.05.

In the rural area, patient satisfaction scores increased in 12 of the 16 items, but only 6 of these were statistically significant. These six items were in the domains of service efficiency (Q7), environment (Q9), location (Q10), health communication (Q11) and handling (Q13, Q15). The largest increase in the percentage of highly satisfied patients (>20% increase) was observed in the handling of office staff. Patient satisfaction decreased for three items, of which two were statistically significant. These two items were contacting the physician during office hours, which decreased by 24% (p<0.01), and waiting time at the office, which decreased by 14% (p=0.01).

In the remote site, patient satisfaction scores increased in only 5 of the 16 items. Of the five items, only four items had a statistically significant increase: healthcare availability (Q3) and all items under handling (Q13–Q15). Satisfaction levels decreased for 10 items, of which 2 were statistically significant. These to items were setting appointments for sickness, which decreased by 17% (p<0.01), and office appearance, which decreased by 12% (p=0.01).

Overall recommendability, which corresponds to whether patients would recommend the healthcare facility to their family or friends, remained high across all sites. At endline, 89% in the urban site, 97% in the rural site and 92% in the remote site would recommend their respective facilities. No significant difference was found for this item between baseline and endline periods for each site.

Discussion

This study assessed the impact of primary care interventions on patient satisfaction in urban, rural and remote settings in the Philippines. The greatest increase in the proportion of highly satisfied patients between baseline and endline periods was observed in the urban site (all 16 items increased, 13 of which were statistically significant), followed by the rural site (six items significantly increased, two items significantly decreased). The least favourable results were observed in the remote site (four items significantly increased, two items significantly decreased).

Urban site

The urban site had significant improvement in patient satisfaction 1 year after the implementation of interventions in the domains of healthcare availability, service efficiency, technical competency and health communication. The EHR system that managed appointment-setting and referrals, integrated health systems, and centralised medical information may have contributed to this study result, especially in relation to the domains of service efficiency and healthcare availability. Liu et al reported increased patient satisfaction associated with the use of EHR systems.¹⁹

Healthcare worker capacity-building initiatives, which encompassed training on primary care and clinical practice guidelines, could have improved physician-patient rapport and quality of clinical care and resulted in better patient satisfaction in the domains of technical competency and handling.²⁰ The primary care training initiatives also emphasised the need for coordinated care, which may have contributed to increased patient satisfaction in health communication.¹¹

Expanding healthcare coverage through a primary care benefit package encouraged patients to adhere to long-term treatment plans. The urban site also allowed a seamless patient experience by providing free and immediate access to diagnostic and pharmacy services. Improved access to comprehensive services could have contributed to increased satisfaction levels in service efficiency.

Urban baseline scores were relatively low compared with rural and remote sites, which can explain the higher magnitude of improvement in patient satisfaction on this site. A possible explanation for low patient satisfaction at baseline would be the discontinuity in care in urban settings, a central component impacting patient satisfaction and health outcomes.²¹ In our study, 3 in 10 were patients of the facility for only a short period (ie, less than a year). Additionally, urban patients have more choices for providers and facilities and may use them as reference points when providing their satisfaction scores.

Rural site

Patient satisfaction in the rural site significantly increased in the domains of service efficiency, environment, location, health communication and handling. Like the urban site, EHR implementation and healthcare worker training may have contributed to increased patient satisfaction in service efficiency and handling. Additional site-specific interventions relating to establishing healthcare provider networks and recruiting additional health human resources can also support this development.

Prior to the study intervention, access to diagnostic and pharmacy providers proved challenging for the rural site. While laboratory tests and medicines were offered at the RHU, the available medicines and services were limited. This made it difficult for patients to adhere to treatment plans and to access continued care. The expansion of provider networks was conducted through partnerships with private laboratories and pharmacies. These engagements boosted the accessibility of diagnostic and pharmacy services and could explain the improvement in patient satisfaction in service efficiency and handling.

Only one physician supervised the RHU at baseline in the rural site. Three additional physicians were hired to augment health human resources. This allowed for additional supervision and support for medical and office staff. Alongside the healthcare worker capacity building activities, the community health workforce was able to advance their primary care competencies, contributing to improved patient satisfaction in health communication and handling. Perry et al demonstrated that training community health workers facilitates health promotion for underserved communities.²² The highest increase in patient satisfaction was seen in the handling of office staff, which may have been influenced by expanded supervision and training.

In contrast, patient satisfaction significantly decreased for contacting physicians during off-hours. Most endline rural respondents have been patients of the facility for over 10 years. It is likely that the rural site patients have close personal relations with their existing physician.⁷ It is probably an existing behaviour for rural patients to contact their physician outside of working hours.²³ With the addition of new physicians in the facility, relationships between patients and the new physicians may have been too premature to support contact outside office hours. This may explain the decrease in satisfaction for this item.

Satisfaction towards patient wait times also significantly decreased. The introduction of primary care interventions led to increased service utilisation.¹⁵ While this is a noteworthy outcome, the growth in the number of consultations may have contributed to longer waiting times at the RHU. This suggests that increased patient demand for primary care services necessitates rolling interventions, consistent systems strengthening, and continued service expansion to address patient needs.²⁴

Remote site

Patient satisfaction in the remote site generally declined, with a decrease in the proportion of highly satisfied patients for 11 of 16 items. Two of these items, setting appointments for sickness and office appearance, were statistically significant. Patient satisfaction significantly increased for contacting physicians during off-hours and in handling of physicians, medical staff, and office staff.

The remote site experienced widespread challenges in internet connectivity. Although the site was provided with routers, laptops and printers to enable the implementation of the EHR system, intermittent internet connection remained an issue. Poor internet access significantly limited some service functions, such as appointment setting (Q2). This result may be of a transient nature, given that the optimal implementation of the EHR system in the remote site has yet to be achieved. Once the platform is optimised through better internet connectivity, appointment and referral management through EHR systems is expected to increase patient satisfaction levels, like the urban and rural sites.

The significant decrease in patient satisfaction with office appearance can be explained by differences in patient expectations. Tièche et al explained that office appearance, specifically the interior of primary care facilities, contributes to patients’ overall satisfaction.²⁵ In our study, there were more new patients during endline (25.5%) as opposed to baseline (4.0%), which suggests more first-time clinic goers after implementation of interventions. It is likely that the expectations of the new patients towards the facility are higher. Ali Jadoo et al reported that patients may have higher expectations towards new interventions.²⁶ This may also explain the decrease in patient satisfaction in the other domains.

On the other hand, increased satisfaction for domains of healthcare availability and handling can be associated with the augmentation of health human resources and healthcare worker training. Like the rural site, only one physician supervised the RHU at baseline. At endline, there were three physicians in the remote site. Expanding the workforce and providing primary care training may have resulted in significantly better patient satisfaction levels for these domains.

While results for overall recommendability did not significantly change after interventions were implemented, the proportion of highly satisfied patients remained high at endline despite the decrease in satisfaction in the other domains. Considering the geographical and structural barriers to accessing care beyond the municipality, patients likely consider the RHU as the most convenient healthcare facility available to them and have no other recourse but to recommend it.

Implications on establishing patient-centred and equitable primary care

Patient satisfaction varied across study sites after implementing primary care interventions. This disparity may be attributed to (1) communities’ baseline level of engagement with health facilities and (2) existing structural differences across research sites, particularly human resources for health.

Rural and remote communities solely rely on publicly run RHU and BHS and have limited access to care beyond their municipality. In contrast, the urban area has a higher density of healthcare services; thus, multiple points of care are available for the community. This suggests that rural and remote constituents have higher levels of engagement with their existing health facilities, to begin with. Much of their patient expectations are rooted in these long-established health systems. Therefore, additional engagements and informational activities are integral for rural and remote communities to establish trust and manage expectations toward new primary healthcare systems.²⁷

Existing structural differences across research sites highlight variations in health system readiness toward primary care adoption. Health system fragmentation has led to widescale disparities in facility capabilities and human resource availability in the Philippines. This has inhibited the capacity of LGUs to meet the demands of implementing the UHC Law.^{3 28} Studies suggest that these system-level conditions continuously moderate and influence determinants of patient satisfaction.^{7 29} Constituents from localities who are less prepared to adopt primary care may be less satisfied with a new health system as it unfolds.

The results of this study are consistent with the ‘inverse equity hypothesis’, which states that when efforts to expand national health coverage are implemented, well-supported urban communities can immediately adopt complex health interventions.³⁰ In contrast, underserved settings are expected to expand services without the resources to support increased demand. This results in the delayed impact of systems interventions and increased structural inequalities for a transitory period.³⁰ Targeted approaches that address supply and demand challenges can ultimately become essential in ensuring equitable access to care.^{8 30 31} This includes expanding supply and infrastructure, strengthening management and coordination, and boosting community participation.^{15 30 31}

Limitations

This study is limited to patient experiences with outpatient services provided in each of the three sites. External generalisability of the results may be limited. Patients who participated in the baseline survey differed from those in the endline survey, making this an uncontrolled before and after study. Differences between individuals may also have impacted the patient satisfaction scores. Other external factors, including change in the political, social and economic context, could also have affected the observed change in the outcome. Due to logistical and financial constraints, we could not conduct a controlled before and after study, or an interrupted time series. Thus, the results of this study are exploratory in nature, and may be used to guide future research. It was also beyond the scope of the study to adjust for the effect of sociodemographic factors (eg, educational status, income level, family size) and other potential confounders that may affect patient satisfaction. Finally, due to the difference in interventions and context across sites, we did not perform inferential statistics to compare patient satisfaction across sites.

Conclusion

Patient satisfaction varied across sites after the implementation of primary care interventions, with the urban site having the greatest improvement in patient satisfaction, followed by the rural site. The remote site had the least improvement. Baseline scores in the urban site were relatively lower than in the rural and remote sites. Improvement in patient satisfaction in the urban site can be attributed to interventions relating to health financing, health information systems and the adequacy of human health resources. While the rural and remote sites received additional interventions, these remained insufficient to improve patient satisfaction at the same magnitude as observed in the urban site. Targeted interventions and extended observation periods may be necessary to observe a significant impact of systems strengthening in underserved areas. Resolving existing barriers will improve patient satisfaction and, subsequently, other health outcomes such as health-seeking behaviour and utilisation.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and ethics approval for the study was granted by the University of the Philippines Manila Research Ethics Board (UPMREB) under the code 2015-489-0. Participants gave informed consent to participate in the study before taking part.