Integrating Client Experience into PBF Verification Systems: Insights from the Democratic Republic of Congo datasets May 2025 Authors: Esias Bedingar, Louise Tina Day, Supriya Madhavan Global Financing Facility 1 Executive Summary The Democratic Republic of the Congo (DRC) faces some of the highest maternal and newborn mortality and stillbirth rates globally, with persistent challenges in healthcare access, quality, and equity. Improving access to high-quality maternal and newborn healthcare, is a priority to end preventable mortality and morbidity. Health system strengthening is critical to improve quality of care Assessments of health system functioning in high mortality settings typically focus on service coverage and structural quality indicators. Outcome measures have tended to focus on mortality rates and, neglecting morbidity and client perceptions of experience of care. The main data source for tracking improvements in health outcomes over recent decades have been intermittent population-based household surveys but increasingly Routine Health Information Systems (RHIS) data are being used. Neither surveys nor RHIS routinely capture client-centred “experience of care� measures well. World Bank programs using performance monitoring and verification systems, including performance-based financing (PBF) mechanisms provide a potential opportunity to contribute to reducing this gap in capturing client-reported care in high mortality settings. Financed by the World Bank and co-financed by the Global Financing Facility (GFF), the H Health System Strengthening for Better Maternal and Child Health Project (“"PDSS� in French)) had been implemented across 9 provinces in the DRC to improve the utilization of maternal and child health services through performance-based incentives for healthcare facilities. Existing PBF indicators largely focus on process and structural quality measures – such as the availability of medicines, staffing levels, and adherence to protocols. Client experiences, including respect, dignity, communication, satisfaction, are not yet systematically captured in PBF project indicators or evaluations. This presents a missed opportunity to ensure that healthcare services not only meet technical standards but also align with patient needs and expectations. This study was commissioned to explore client-reported measures collected through PDSS project data sources of community survey, heatlh facility exit interviews, and household surveys, to assess the feasibility of incorporating patient experience indicators into PBF verification systems in DRC and beyond. This analysis builds on the High-Quality Health Systems in the SDG Era Framework (HQSS) and the WHO Maternal and Newborn Quality of Care Framework to examine both dimensions of provision of care (technical quality) and experience of care (patient perception). The goal is to generate actionable insights to improve healthcare service accountability and patient-centered care and consider how such measures could be standardized and prospectively used in World Bank projects in the future. This report reveals a complex, yet instructive picture of health facility quality of care Clients reported high satisfaction to questions regarding respectful care and preservation of dignity (WHO QoC domain 5) but were less satisfied with communication, , continuity of care, 2 and safety—domains that are equally fundamental to high-quality, people-centered health systems..This divergence between strong ratings regarding respect and dignity and weaker scores in engagement and communication suggests that while providers may be courteous, they often fail to involve patients meaningfully in their care. We found the two dimensions of quality client experience of care and technical provision quality are related but not aligned in this DRC analysis. High indices of service readiness or adherence to clinical checklists do not necessarily translate into high satisfaction—underscoring the importance of capturing what truly matters to clients: being informed, involved, and confident in the care they receive. Importantly, satisfaction varied across facility types and among population subgroups, but not always as expected. For instance, higher satisfaction was not consistently associated with better facility quality indices, and in some cases, better-resourced facilities reported lower satisfaction— perhaps due to elevated expectations or greater awareness of rights among patients. Such mismatches between measured technical and perceived quality reinforce the value of including client voice as a core part of health system performance measurement. The DRCresults also suggest clear priorities for quality improvement. Domains such as communication and patient engagementconsistently rated low—should be a focus for skill development and peer-to-peer support. . Similarly,an emphasis on safe practices—such as hand hygiene, use of clean equipment, and explanations of procedures—that build patient trust are essential. We found client satisfaction scores were higher in facility-based exit interviews compared to household surveys. The timing and context of data collection can shape how patients report their experiencesThis may reflect social-desirabilty bias immediately after discharge, but in their own community may be able to provide a more reflective perspective, influenced by service outcomes. These findings support the importance of community based surveys, as feasible or even a hybrid model for PBF : using brief exit interviews for rapid feedback and periodic community-based surveys for validation and deeper insights. In summary, this study from the DRC reinforces the need for a more holistic and patient-centered understanding of quality. Listening to patients—and acting on what they report—is not only ethically imperative, but also essential to improving health outcomes and restoring trust in the system. As DRC continues its efforts to expand universal health coverage, embedding patient experience within its quality monitoring architecture will be key to ensuring that care is not just delivered, but truly valued. We recommend client-reported measures are considered a priority for further assessment in maternal and child health PBF programms in in the DRC and beyond. Specifically, we propose testing the robustly developed Patent Centred Maternity Care short score for use in World Bank PBF programs for validity including meaning, measurability, measurement and meaningfulness. 3 Background The Global Financing Facility (GFF) is a trust fund within the World Bank, focused on prioritizing and scaling up evidence-driven investments to improve reproductive, maternal, newborn, child and adolescent health and nutrition through targeted strengthening of primary health care systems – to save lives and as a critical first step toward accelerating progress on Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs). The GFF’s approach includes increasing coverage to high quality care.12 DRC Country context The Democratic Republic of the Congo (DRC) is a vast central African nation bordered by nine countries, including Angola, Zambia, Tanzania, Burundi, Rwanda, Uganda, South Sudan, the Republic of Congo, and the Central African Republic.1 With an estimated population exceeding 90 million, the DRC is characterized by a predominantly rural demographic, where a significant majority of its inhabitants live in remote and hard-to-reach areas.2 Despite its abundant natural resources, the DRC remains classified as a low-income country, with a per capita gross national income (GNI) that lags behind global averages and a Human Development Index ranking that reflects its persistent developmental challenges.1 The country is frequently described as fragile due to ongoing political instability, periodic conflicts, and chronic infrastructural deficiencies that continue to undermine its socioeconomic progress.1,2 Maternal and child health outcomes in the DRC are among the poorest globally, with the nation grappling with alarmingly high maternal and neonatal mortality rates.3 Recent estimates suggest that the DRC ranks as the 4th highest country for total number of maternal and newborn deaths and stillbirths in the world.3,4 These dire outcomes for women and newborns are closely linked to the weak coverage and low quality of reproductive, maternal, neonatal, child and adolescent health services.5,6 Access to healthcare is severely limited by poor road networks and referral linkages as well as by financial access. Widespread shortages of health providers, essential medicines, and life-saving equipment contribute to low quality of care.6 Still, over 80% of births take place in health facilities nationally, with an even higher proportion (90%+) in PDSS- covered areas. Despite increasing utilization of services in the DRC, health outcomes remain poor. The medical causes of maternal mortality in the DRC is driven by complications such as postpartum hemorrhage, hypertensive disorders, obstructed labor, and sepsis.3 Intrapartum stillbirth rate is high due to poor quality intrapartum care.7 Neonatal deaths are predominantly from preterm birth complications, birth asphyxia, and infections.8 These mortality patterns underscore the urgent need for comprehensive strategies that not only expand access to health services but also prioritize the quality of care provided. Addressing these challenges requires a shift from a focus 4 on increasing service coverage to ensuring that every encounter within the health system meets evidence-based standards of care. In this context, the implementation of robust frameworks — such as the WHO Maternal and Newborn Quality of Care Framework—offers a strategic pathway for improving service delivery and ultimately reducing preventable maternal and newborn deaths in the DRC.9 Quality of Care: Conceptual frameworks and context A growing body of evidence underscores the need to shift from focus on coverage to quality of care.10 For these exploratory analyses using available DRC datasets we adopted a broad approach to guide the framing of our analyses and findings, beginning with a rights-based approach then focusing on quality in depth. We touch on 3 frameworks: Availability, Accessibility, Acceptability, and Quality framework (AAA,Q) The availabiltiy, accessibility, accessibility and quality framework (AAA,Q) from 2000 is a rights- based concept based in the context of economic, social, and cultural rights (ESCR) to help ensure that human rights are not just declared but realized in practice.11 Applied to health: Availability: refers to the sufficient quantity of health facilities, doctors, and medicines. Accessibility: has four dimensions: Non-discrimination: Ensuring that everyone, especially vulnerable groups, can access services without discrimination. Physical accessibility: Ensuring that services are within safe and reasonable reach of all Economic accessibility (affordability): Ensuring that services are affordable for all. Information accessibility: Ensuring that people have access to relevant and unbiased information about their rights. Acceptability: refers to the sensitivity of healthcare services to cultural norms, medical ethics, and the specific needs of different groups.including religious beliefs. Quality: means that the services are scientifically and medically appropriate, of good quality, and provide adequate care. For instance, healthcare services should be delivered by qualified professionals using appropriate technologies and following established standards. 2. High-Quality Health Systems in the SDG Era (HQSS) Framework (Figure 1) 5 The HQSS Framework published in 2018 provides a comprehensive structure to improve health system performance.10 It focuses on three core domains: foundations, processes of care, and quality impacts. Processes of care includes competent care—the extent to which providers adhere to evidence-based clinical protocols—and positive user experience, which captures elements such as respectful treatment, clear communication, and patient-centeredness. Figure 1: The High-Quality Health Systems Framework (HQSS). 3. WHO Maternal and Newborn Quality of Care Framework (Figure 2) The WHO quality of care framework from 2015 identifies eight quality domains across two dimensions: provision of care and experience of care.9,10 The framework was initially conceptualized by WHO for maternal and newborn care but has subsequently been adapted by WHO for child, adolescent and small and/or sick newborns and reaffirms the interconnected and cross-cutting domains of quality that are needed to improve health outcomes.9 6 Figure 2: The WHO quality of care framework for maternal and newborn health. Quality of care in the DRC Considering these framings of quality in the context of the DRC, all three conceptualizations are relevant for maternal and child health. Although Availability and Accessibility to health facility care in the DRC has increased, the Acceptability and Quality of services remains uneven, and little attention has been paid to the patient-reported outcomes.11 Therefore, we used the concepts articulated in the AAAQ, HQSS and WHO quality of care frameworks to guide analysis of available datasets to assess not only whether services are delivered technically well, but also the person- centeredness of care ultimately feel satisfied with the care they receive from PDSS-supported facilities.9,10 7 The Health Systems Strengthening Project (“PDSS�) in DRC The Health Systems Strengthening for Better Maternal and Child Health Project (“PDSS� in French) in the DRC, financed by the World Bank and co-financed by the GFF, offered one source of data for this report.13 The main goal of the PDSS project is to improve coverage and quality maternal and child health services in targeted areas through Performance-Based Financing (PBF).13 To achieve this, contracted health facilities receive performance payments according to defined quantity and quality indicators.13 PDSS was implemented across 11 of 26 provinces from 2015-2021, targeting a diverse range of health facilities from primary health centers to first-level referral hospitals.13 A critical component of PDSS was its robust verification mechanism, which included a activities to measure performance against the defined indicators.13 The design of PDSS also reflects lessons learned from previous PBF pilots in the DRC, which underscored the need for systematic verification processes, enhanced community engagement, and the adoption of standardized quality indicators. Financial incentives were disbursed quarterly, following rigorous verification conducted by provincial purchasing agencies and external evaluators.13 This systematic linkage between performance and payment fosters a culture of accountability and continuous quality improvement within health facilities.14 Overall, PDSS represents a pioneering effort in the DRC to improve quality of care by leveraging the innovative financing and verification approaches supported by the GFF and the World Bank, PDSS aims to improve maternal and child health by strengthening the health system across the DRC. Measurement and Data focused on Quality of Care As part of the GFF’s mandate to improve quality of care, the GFF is interested in exploring how to ensure all dimensions of quality are included – both provision and experience of care. Currently verification measures typically focus more on technical provision of care. Including measures of client-report could link verification to a more comprehensive assessment of performance linking to the aim of improving quality of the care. The PDSS project in DRC represents an opportunity to explore data and measurement pertaining to experience of care due to the potential of several data sets: endline survey health facility assessments (observation and client- exit interviews), community client surveys for verification, routine DHIS2 data and DHS surveys. This report presents the initial analyses from datasets available to the GFF by May 2025. Aim The overall aim of this work is to explore quality of care as measured by the PDSS in DRC, to contribute to a proposed set of indicators for measuring client-reported care in results-based health programs that use client verification. 8 Key Objectives In PDSS supported districts in the DRC: 1. Describe health facility assessment of service availability and readiness for provision for antenatal care 2. Describe client-reported experience of health facility antenatal care 3. Compare client-reported experience with health facility assessed service availability and readiness for antenatal care 4. Report “ghost� client rates reported by health facilities Objectives linked to research questions: Objective Research questions 1 Describe health facility • How does the observed PDSS health facility assessment of service availability service availability and readiness compared to and readiness for provision for quality standards? antenatal care 2 Describe client-reported • What is the client-reported outcomes for experience of health facility communication, respect and preservation of antenatal care dignity during health facility antenatal care? • Do user satisfaction and perceptions differ when collected via facility-based exit interviews versus household surveys? • Do respondents provide different responses in community surveys compared to health facilities because in the community, health providers are less likely to hear or find out what they responded to? 3 Compare client-reported • Do user satisfaction and perceptions about experience with health facility facilities/health services correlate with assessed service availability and measures of quality of care obtained through readiness for antenatal care health facility assessments (service readiness and process quality measured through direct observations)? 4 Report “ghost� clients rates • What is the prevalence of “ghost patients� reported by health facilities reported by health facilities? 9 Methodology Study Design and Data Sources We conducted a cross-sectional observational analysis of datasets pertaining to the DRC. We considered five potential data sources and used two as described in Table 1. Given the centrality of both provision and experience of care in determining maternal and child health outcomes, the current analysis was designed to assess how well PDSS was able to meet quality standards, using the endline impact evaluation 2021 survey; health facility assessment for service availability and readiness observations/ checklists for antenatal care (dataset A) and client exit interviews (dataset B) and client household surveys (dataset C). While the original study design anticipated the inclusion of community survey data (dataset D) to enrich insights into client-reported experience, this dataset was ultimately not available for analysis. We considered routine data in DHIS2 (Database E) and the demographic health surveys (Database F) as detailed in Table 1. 10 Table 1: Data sources considered and used in the analysis. Dataset source Type Content focus Purpose in Dataset study A. Health Facility Facility-level Health facility Objective 1 2021 observations/ (prospective census) service availability Objective 3 endline checklists for data observed and readiness for survey - antenatal care during health facility provision of used in assessment maternal and analysis newborn care • Structural indicators: availability of basic equipment, essential medicines, diagnostics • Process quality indicators: provider competence, systematic assessments, counseling, communication, safety, continuity of care B. Client exit interviews Client-level Client-reported Objective 2 2021 after health facility (prospective sample) measures on Objective 3 endline antenatal care data from antenatal care survey - confidential experience including used in interviews with satisfaction, analysis women immediately respectful care, after leaving a PDSS health provider health facility during responsiveness, health facility interpersonal assessment interactions, health provider communication, affordability, waiting times, and privacy C. Client household Client-level Client-reported Objective 2 2021 survey (retrospective measures on Objective 3 endline sample) data from antenatal care survey - confidential experience used in interviews with analysis 11 women interviewed during household survey in PDSS community area D. Community surveys Client-level Client-reported Objective 2 2017-2022 (retrospective semi- measures on Objective 3 verification random sample) antenatal care data paper- from PDSS experience including based held community satisfaction, in regions verification survey respectful care, and not data of women affordability, available to interviewed at their provider GFF for homes roughly two communication, analysis weeks after their waiting times, and antenatal health privacy facility visit. The survey is primarily Community samples used to detect “ghost may also include patients� being individuals who reported by PDSS might intentionally facilities not use a specific facility. Community verification of clients reported to Objective 4 2017-2022 have received care from health facility Summary table of “fraud rates� by region E. Routine Health Health facility Reviewed maternal - Not used in Information System reported routine – and newborn analysis (RHIS) data prospective, indicators in DRC aggregate data in DHIS2 dashboard. SNIS2/DHIS2 Few process (coverage) indicators, no quality-of-care indicators F. Demographic Health Population-based General survey - Not used in Surveys (DHS) household surveys – including maternal analysis retrospective data and newborn 2017-18 (2023 yet contract with health published) service for pregnancies in last 5 years 12 Sites and Sampling We conducted analyses using four databases from 11 provinces: • Endline 2021 PDSS health facility assessment (Datasets A and B in Table 1) in 11 provinces in the DRC. These data were collected by trained independent survey workers between July 2021 and June 2022. • The community verification survey (Dataset D in Table 1) was collected by local associations contracted by semi-autonomous purchasing agencies known as Établissements d’Utilité Publique (EUPs), which are responsible for organizing verification that includes household visits to confirm the receipt of reported health services and assess patient satisfaction.15 Data collection started in 2017 and ended in 2022. Variables and Measures We captured domains of quality using the conceptual frameworks of AAAQ, HQSS and WHO QoC. We selected measures of quality based on their theoretical relevance and empirical availability in the dataset, guided by existing literature and the WHO QoC Framework. . I) Objectives 1-3 focused on two main types of variables relating to Antenatal Care: Facility-quality measures of structural and process quality We mapped binary measures in dataset A – (Table 1) for: II) Structural quality topics, (HQSS “Tools�) included service readiness and basic amenities. Basic amenities were measured as the average of items including: electricity, water, any private room, toilet, communication, computer and internet, and ambulance. Service readiness was measured as the average of items of basic equipment, diagnostics, and medication. Process quality topics, (HQSS “Processes of Care�) included items of competent care and systems, and positive user experience III) Client-reported outcomes on experience (Datasets B, C – Table 1) We mapped variables in dataset B and C (Table 2) These included responses to overall satisfaction, perceptions of the general quality of services, and specific measures of respectful care such as whether the patient felt treated with respect, whether their privacy was protected, whether communication was clear, as well as payment experience such as whether consultation fees were affordable, and if any unofficial or extra payments were requested. Client responses to these fifteen closed questions were captured using a 3- point Likert scale (agree, neither agree nor disagree, disagree) and subsequently dichotomized or scaled for use in composite indices. Table 2: Client-reported satisfaction and experience of care questions from health facility exit interview. 13 Number Question Link to Conceptual Frameworks 4.03 Convenience of coming from your home Availability and physical accessibility to the health facility (AAA,Q) 4.04 Health facility is clean Essential Physical resources (WHO QoC, 8) 4.05 Health staff are courteous and respectful Respect and preservation of dignity (WHO QoC, 5) 4.06 Medical staff explained your condition Effective Communication (WHO QoC 4) well 4.07 Easy to get medicines prescribed by Essential Physical resources (WHO health workers QoC, 8) 4.08 Consultation fees are affordable Economic accessibility (AAA,Q) 4.09 Laboratory fees are affordable Economic accessibility (AAA,Q) 4.10 Medication fees for this visit are Economic accessibility (AAA,Q) reasonable 4.11 Transport fees for this visit are Economic accessibility (AAA,Q) reasonable 4.12 Health workers do not ask for additional Economic accessibility (AAA,Q) payments 4.14 You had enough privacy during your visit Respect and preservation of dignity (WHO QoC, 5) 4.15 Health worker spent enough time with Competent Motivated Health Workers you (WHO QoC 7) 4.16 The hours the health facility is open are Essential Physical resources (WHO adapted to your needs QoC, 8) 4.17 Overall quality was satisfactory Quality (AAA,Q), WHO QoC Framework 1-8 Analysis We conducted descriptive analyses of the selected quality measures and constructed composite indices (Table 3) relating to the HQSS and WHO QoC framework: . . Wcompetent care and systems, positive user experience, and foundational inputs, with a focus on processes of care 14 and tools. These domains were operationalized as a composite score using sets of relevant items. For example, provider competence was measured using 18 items on clinical actions such as blood pressure measurement, patient history-taking, standardized and aggregated into a single scale. Each set of indicators was standardized and rescaled to range from 0 to 1, then averaged to produce a domain-specific composite score. We assessed the internal reliability of each index using Cronbach’s alpha.16 To enable comparability across domains of quality, each index score was then scaled to a percentage and interpreted based on distribution (quintiles for descriptive statistics; Tables 7A-C; Tables 8A-B; Table 9) and used in regression models to explore associations with patient satisfaction and other outcomes (Tables 11 and 12). Table 3: Composite score construction and internal consistency. High quality health system domain WHO QoC Number of Cronbach’s Data source framework domain items alpha Measure Element PROCESSES OF CARE: COMPETENT CARE AND SYSTEMS Competent, Provider motivated human 18 𝛼:  0.78 competence resources (7) Evidence- based, Evidence-based effective Systematic practices for routine 27 𝛼:  0.93 Health Facility care assessment care and Assessments management (1) (Dataset A in Counseling and Effective 29 𝛼:  0.93 Table 1) health education communication (4) Evidence-based Safety 1 - practices (1) Capable Prevention and Evidence-based 7 𝛼:  0.67 systems detection practices (1) Continuity and Functional referral 2 𝛼:  0.65 integrity systems (3) PROCESSES OF CARE: POSITIVE USER EXPERIENCE Respect and Dignity preservation of 1 - dignity (5) Client patient Respect and Respect exit interviews Privacy preservation of 1 - after antenatal dignity (5) care (Dataset A Clear Effective 4 𝛼:  0.55 in Table 1) communication communication (4) Patient-voice and Effective User-focus 1 - values communication (4) 15 and emotional support (6) FOUNDATIONS: TOOLS (Equipment, medicines and data) Essential physical Basic equipment 26 𝛼:  0.80 resources (8) Health Facility Service Diagnostic Essential physical assessments 7 𝛼:  0.74 readiness capacity resources (8) (Dataset C in Essential physical Table 1) Medication 23 𝛼:  0.81 resources (8) Notes: This table presents the construction and reliability of composite indices based on the HQSS and WHO QoC frameworks. Data elements are mapped to topics and domains of quality. The number of items included in each index reflects the breadth of measures used. Cronbach’s alpha is reported to assess internal consistency, with values above 0.7 indicating acceptability. All indices were derived from health facility assessments, as noted in the data source column. The exact list of indicators included in each index – by measure and element – is provided in Appendix 1. All analyses were conducted using STATA statistical software and accounted for the clustering of clients within facilities when necessary. Analyses by objective Objectives 1 and 2: Health facility service availability and readiness and client-reported outcomes We summarized the distribution of items from the for different health faciltiy assessment data sources direct observations, client exit interviews Heatlh facility indices were categorized into quintiles (0-0.24, 0.25-0.49, 0.5-0,74, 0.75-0.99 and 1). to facilitate descriptive interpretation across score ranges and cumulative percentages. To explore whether the mode and timing of data collection influence patient-reported satisfaction and experience of care, we conducted a comparative analysis of responses from two survey modalities: health facility patient exit interviews, conducted immediately following antenatal care facility, (Dataset B) and household surveys, administered weeks days or weeks later at the client’s home (Dataset C). We compared seven functionally comparable questions across both datasets and mapped to key domains of the HQSS framework and WHO QoC framework (Appendix 2). The questions reflect different dimensions of client experience of care, ranging from interpersonal treatment and physical conditions to financial accessibility and responsiveness of services. These questions were selected for comparability as they showed high alignment in wording and for the following reasons: (a) framed as general satisfaction measures, minimizing reference bias tied to specific services; (b) asked of recent facility users, For quantitative comparison we aligned the “strongly agree� and “agree� with “satisfied�, and “strongly disagree� and “disagree� as dissatisfied, treating “neutral� consistently across both instruments. 16 Objective 3: Comparison between client experience and health facility readiness We compared exit survey client-reported measure of satisfaction (Q4.17) as a tracer experience of care outcomes with health facility-observed quality measures of structural and process quality. Our hypothesis was that facilities with higher service readiness percentages would have higher proportions of “satisfied� clients. To examine associations between client reported experience of care and health facility service availability and readiness measures, we conducted univariate and multivariable regression analyses, to control for potential confounders. Because client satisfaction was often measured on an ordinal scale (very satisfied to very dissatisfied) or binary (satisfied vs not), we employed appropriate models – ordinal logistic regression for ordinal outcomes and logistic regression for binary outcomes. In these models, the key independent variables were the facility quality indicators (structural and process scores). We included patient-level covariates such as age, education, and whether the visit was for maternal health or child health services, to adjust for differences in expectations or needs. We also controlled for facility type or size if available (e.g., hospital vs health center) and province fixed effects to account for unobserved regional differences. The regression produced estimates of the effect of facility quality on the odds of a patient reporting high satisfaction. For example, we estimated the odds ratio (OR) for client satisfaction per unit increase in facility quality score. A significantly positive odds ratio would suggest better facility quality is associated with higher likelihood of patient satisfaction, while a null or negative finding would indicate little association. We ran separate models for different aspects of quality (testing the influence of structural readiness vs. clinical process quality vs. experience domains like provider communication). For all statistical tests, a significance level of α=0.05 was used. Results are reported with p-values or confidence intervals where relevant. All analyses were reviewed to ensure alignment with the HQSS and WHO Quality of Care conceptual frameworks – e.g., interpreting findings in terms of domains of quality (clinical care vs user experience) and considering how the measurement context (facility vs home interview) might influence the responses. Objective 4: Report “ghost� client rates reported by health facilities To assess the integrity of reported service delivery at PDSS supported health facilities in the DRC, we reviewed data from community verification surveys conducted between 2017 and 2022 across 14 provincial health divisions. These surveys were designed to independently verify whether individuals recorded as having received services at the health centers actually existed and received those services. —to identify Patients reported but not found in follow-up verification are, hereafter called “ghost patients�. For each province and year, the proportion of fraudulent cases was presented by dividing the number of unverifiable or fictitious patients by the total number of sampled patient records under verification. These proportions were then aggregated by province-year pairs. 17 Results Background Characteristics The background characteristics of the endline PDSS program impact health facility dataset , in 11 districts in DRC in 2021 are shown in Tables 5 and 6. Observed antenatal care visits women and health provider characteristics are shown in Table 5. Among 576 women directly observed for health facility antenatal care (ANC), only 14% attended 4 or more ANC visits, with a mean age of pregnancy at 21.8 weeks (Table 5). Most of the health providers (83%) were female, and nurses (67.9%) were the most represented health worker type, with only 9% identifying as midwives. Table 5: Background Frequency Percentage characteristics of women and health providers for observed ANC visits from health facility assessments, DRC endline survey 2021 Women characteristics (n = 576) Number of ANC visits attended 1 143 26.7 2 210 39.2 3 102 19.0 4 76 14.2 More than 4 5 0.94 Mean pregnancy age (in week) 21.75 (0.16) Health provider characteristics (n = 2321) Gender of the provider Female 1928 83.07 Male 393 16.93 Cadre Doctor 29 1.25 Nurses 1575 67.86 Midwife 200 8.62 Other* 517 22.27 Notes: *The “Other� category under provider cadre (n = 517, 22.27%) includes a diverse set of health workers who do not fall under the classifications of doctor, nurse, or midwife. This group is composed primarily of matrons, including various levels of formal and informal training. 18 Client exit interview background characteristics are shown in Table 6, The sample comprised 2321 women (Table 4) drawn from six provinces in DRC, with the highest representation from Kwilu (34.6%) and Kwango (23.3%). The mean age of women was 25 years, and women in the “15-34� years age category represented 87.8% of the sample. Women were mostly interviewed in public health facilities (81.8%), at the primary care level (69.6%) and in in rural areas (95.8%). Table 6: Background characteristics of women and health facilities for client exit interviews from health facility assessments, DRC endline survey 2021. Frequency Percentage Women characteristics Province Kwango 540 23.27 Kwilu 802 34.55 Mai-Ndombe 414 17.84 Haut-Katanga 84 3.62 Haut-Lomami 349 15.04 Lualaba 132 5.69 Mean age (in years) 25.35 (0.14) Age (in years) 15-19 471 20.38 20-24 728 31.50 25-29 511 22.11 30-34 318 13.76 35-39 224 9.69 40-44 53 2.29 45-49 6 0.26 Level of education None 779 33.71 Primary 207 8.96 Secondary 1282 55.48 Tertiary 43 1.86 Marital status Married, monogamous 1684 72.87 Married, polygamous 262 11.34 Open relationship 188 8.14 Single 170 7.36 Divorced 5 0.22 Widow 2 0.09 19 Health facility characteristics Health facility type Referral general hospital 392 16.96 Referral health facility 311 13.46 Primary Health facility 1608 69.58 Health facility status Public 1890 81.78 Private-for-profit 19 0.82 Private-not-for profit - Religious 103 4.46 Private-not-for profit (NGO) 4 0.17 Mixed, public/religious, 295 12.77 public/private Health facility location Urban 98 4.24 Rural 2213 95.76 Language spoken French 41 1.77 Lingala 877 37.95 Kikongo 802 34.70 Swahili 351 15.19 Other 240 10.39 Objective 1: Describe health facility assessment of service availability and readiness for provision for antenatal care The indices are presented by HQSS domains of quality: competent care and systems, and tools. HQSS PROCESSES OF CARE: competent care and systems We assessed six indices, including provider competence, systematic assessment, counseling and health education, prevention and detection, safety, and continuity and integration (Tables 7A, 7B, 7C). Presented in Table 7A: • Provider competence was moderately rated, with a mean of 0.59. Most (70.6%) health facilities were within the 0.40-0.79 range. Approximately 52.6% of facilities received scores below 0.60, suggesting variability in clinical skill and adherence to protocols. • Systematic assessment index was reported to be lower with a mean of 0.42. Nearly 53% of responses falling below 0.40. Only 15.8% of assessments scored 0.80 or higher, indicating a general need for improving the consistency and completeness of clinical evaluations. 20 • Counseling and health education index was also reported to be low with a mean of 0.39 Approximately 31% of health facilities were below 0.20, and nearly 53% rated it below 0.40. • Prevention and detection index showed a moderate rating with a mean of 0.52. Most (73.2%) health facilities were within the 0.40-0.79 range Table 7A: Quality-of-care indices for Competent Care and Systems HQHS domain Mean (SE) 0.00-0.19 0.20-0.39 0.40.0.59 0.60-079 0.80-0.99 1.00 Provider 0.58 (0.004) 2.3% 16.3% 33.9% 35.7% 8.8% 3.0% competence Systematic 0.42 (0.006) 24.0% 28.6% 22.0% 11.1% 9.5% 4.8% assessment Counselling and health 0.39 (0.006) 31.4% 21.3% 23.0% 14.6% 6.7% 3.0% education Prevention and 0.52 (0.005) 10.7% 10.2% 41.5% 31.8% 3.7% 2.1% detection Presented in Table 7B • Safety was measured as a binary variable and results were polarized: approximately half of facilities scored 0, and the remaining half reported a full score, suggesting that safety varied substantially across settings and clients. This polarization signals the need for greater attention towards of safety practices, including hygiene protocols and infection prevention. Table 7B: Quality-of-care indices for Competent Care and Systems HQSS domain Mean (SE) 0.00 1.00 Safety 0.50 (0.01) 49.9% 50.1% Presented in Table 7C • Continuity and integrity emerged as a very weak area with a mean of 0.22. Nearly 68% of facilities scored 0 Table 7C: Quality-of-care indices for Competent Care and Systems HQSS domain Mean (SE) 0.00 0.50 1.00 Continuity and 0.22 (0.007) 67.6% 19.9% 12.5% integration • 21 HQSS FOUNDATIONS: Tools (equipment, medicines and diagnostics) We assessed four indices, including basic equipment, diagnostic capacity, and availability of essential medications (Table 9). Presented in Table 8 • Basic equipment had a mean of 0.67 component, only 22.2% of facilities scored between 80-99%, and nearly half scored in the 60-79% range. • Diagnostic capacity ranked lowest in this domain with a mean of 0.49 and 68% of facilities scored below 60%. • Medication availability ranked highest in this doman with a mean of 0.73 and 73.8% of facilities scoring 60% or above. Table 8: Quality-of-care indices for Tools HQSS domain Mean 0.01-0.19 0.20-0.39 0.40.0.59 0.60-079 0.80-0.99 1.00 (range) Basic 0.67 (0.003) 0.6% 4.4% 24.2% 48.3% 22.2% 0.3% Equipment Diagnostic 0.49 (0.006) 17.9% 22.8% 27.5% 10.3% 16.1% 5.4% capacity Medication 0.73 (0.004) 0.9% 3.4% 16.4% 40.0% 33.8% 5.5% availability Service 0.63 (0.003) 0.2% 7.0% 36.8% 32.7% 23.3% 0.0% readiness 22 Objective 2: Describe client-reported experience of health facility antenatal care Client exit interviews Analyses of individual questions showed high levels of satisfaction across most aspects of care (Figure 1). The proportion of respondents who agreed with the positive statements in questions 4.03 through 4.17 was overwhelmingly dominant. This included satisfaction with overall quality (4.17) of 92.7%. Agreement approached or exceeded 90% for most questions, including respect (4.03), cleanliness (4.04), courteous care (4.05), clear communication by health providers (4.06), privacy (4.14), health workers spending enough time (4.15). However, areas related to payment and cost transparency revealed greater variability and with only between 8.9% and 63.4% of respondents in agreement including affordable consultation fees (Q4.08), affordable laboratory fees (Q4.09), reasonable medication fees (Q4.10), reasonable transport fees (Q4.11). Notably responses to whether health workers not asking for additional payments Q4.12—which may reflect perception of overall cost fairness—recorded one of the highest levels of disagreement, with roughly approximately one-quarter of respondents expressing dissatisfaction. Figure 1: Client-reported experience of care responses, exit survey responses, PDSS endline survey DRC, 2021, n = 2321 women. Notes: The figure displays the distribution of responses to patient satisfaction and service experience items, grouped into “Agree� in green, “Neutral� in blue, and “Disagree� in red. 23 Indices of positive user experience based on HQHS PROCESSES OF CARE included clear communication, dignity, privacy, and patient voice and values Presented in Tables 9A • Clear communication, was moderately rated with a mean of 0.53. 40% with an index 0.75 or more including 11.7% with a perfect index of 1.0. Table 9A: Quality-of-care indices for Positive User Experience HQSS domain Mean (range) 0.00-0.24 0.25-0.49 0.50.0.74 0.75-0.99 1.00 Clear 0.53 (0.006) 13.4% 14.4% 31.5% 29.0% 11.7% communication Presented in Table 9B • Dignity. Almost all clients (99.9%) reported being treated with dignity • Privacy was also highly rated with a mean 0.92 with 91.6% reporting their privacy was respected during care. • Patient-voice and values emerged as a weak area as 40% of clients reported a score of 0, indicating that they did not feel heard or involved in decision-making. Table 9B: Quality-of-care indices for Positive User Experience HQSS domain Mean (range) 0.00 1.00 Dignity 0.53 (0.006) 0.1% 99.9% Privacy 0.92 (0.001) 8.4% 91.6% Patient voice 0.60 (0.01) 39.9% 60.1% and values 24 Household survey The results of the comparison between health facility exit interviews and household surveys are presented in Table 10. Table 10: Comparison of satisfaction responses by survey mode. Mode Satisfied (%) Neutral (%) Dissastified (%) Household 68.8 27.3 3.9 Staff respectful Exit interview 97.3 2.0 0.7 Convenience of Household 63.6 19.2 17.2 access Exit interview 94.1 3.0 2.9 Facility Household 60.9 28.3 10.8 cleanliness Exit interview 88.9 6.1 5.0 Medication Household 41.7 31.8 26.5 availability Exit interview 87.3 9.9 2.9 Consultation Household 35.0 34.1 30.9 affordability Exit interview 78.5 10.5 11.0 Medication Household 27.1 34.0 38.9 affordability Exit interview 62.9 19.2 17.9 Opening hours Household 76.0 20.2 3.8 availability Exit interview 92.5 6.5 1.0 In all cases, Kruskal-Wallis and chi-square tests confirmed statistically significant differences across modes (p < 0.001). • Respectful treatment by staff: 97.3% of exit patient interviews reported satisfaction with how they were treated by staff, compared to 68.8% of household respondents. While most clients rated staff positively in both groups, household respondents were more likely to report neutral (27.3%) or dissatisfied (3.9%) responses. • Convenience of access: 94.1% of exit patient interviews rated access as satisfactory, whereas only 63.6% of household respondents did. • Cleanliness and comfort: 88.9% of exit clients were satisfied with the cleanliness of the facility compared to 60.9% in the household group. • Availability of medicines: While 87.3% of exit clients reported satisfaction with (easy) access to medicines, only 41.7% of household respondents did. • Consultation affordability: Satisfaction with affordability of services was reported by 78.5% of exit respondents, but only 35.0% of household respondents. • Medication affordability: Just 27.1% of household respondents expressed satisfaction with the cost of medications, compared to 62.9% of exit clients. • Opening hours availability: Satisfaction with facility hours was reported by 92.5% of exit respondents, versus 76.0% of household respondents. 25 Across all items, the exit interview modality systematically yielded higher satisfaction scores, while household surveys revealed more nuanced perspectives—particularly in domains related to cost and access. These findings are consistent with numerous other studies that attest to the positive bias of exit interviews versus interviews at the household [ref]. 26 Objectives 3: Compare client-reported experience of care with health facility observed service availability and readiness provision of care. Associations between health facility assessment data and client overall satisfaction (Q4.17), adjusted for potential confounders are presented in Tables 11 and 12. Focusing on the composite quality indices (Tables 7A-C; Table 8; Table 9A-C), the results from ordered logistic regression models identified several significant predictors of patient satisfaction. In this context, “ordered� refers to the ordinal nature of the satisfaction outcome, where responses are ranked (e.g., dissatisfied, neutral, satisfied) rather than treated as purely categorical or continuous. Table 11: Ordered logistic regression results: Predictors of patient satisfaction. AOR 95% CI p-value Satisfied with service (satisfied, neutral, dissatisfied) COMPETENT CARE AND SYSTEMS Provider competence 0.37 0.14 – 1.01 0.052 Systematic 0.33 0.12 – 0.93 0.036 assessment Counseling 0.52 0.16 – 1.68 0.271 Safety 0.61 0.35 – 1.07 0.083 Prevention and 0.38 0.15 – 0.95 0.039 detection Continuity and 0.35 0.16 – 0.74 0.006 integration POSITIVE USER EXPERIENCE Privacy 0.83 0.38 – 1.85 0.656 Clear communication 0.54 0.20 – 1.41 0.206 Patient-voice and 0.90 0.56 – 1.43 0.653 values TOOLS Basic equipment 0.07 0.01 - 0.44 0.005 Diagnostic capacity 0.69 0.25 - 1.75 0.463 Medication 0.10 0.02 - 0.43 0.002 Notes: The outcome variable in this table is Q4.17 user satisfaction, defined as whether the overall quality of the services provided were satisfactory, and measured using a 3-Likert scale (agree, neutral, disagree). All specifications are estimated using an ordered logistic regression and include province fixed effects to control for unobserved regional factors such as health system strength, as well as cluster robust standard errors by health center. All estimations control for contextual and patient characteristics (e.g., health facility status, health facility residence, health worker sex, health worker cadre) likely to influence satisfaction 1 Lower performance in indices for— systematic assessment, prevention and detection, continuity and integration of care, basic equipment, and medication availability—was significantly associated with decreased odds of reporting high satisfaction levels. For example, poor basic equipment was linked to an 93% reduction in the odds of being satisfied (AOR = 0.07; p = 0.005), while weak performance in continuity and integration was associated with a 65% reduction in the odds of client-reported satisfaction (AOR = 0.35; p = 0.006). (Table 11) Using summary indices across the three domains of the HQSS framework revealed distinct patterns (Table 12) Facilities scoring lower on competent care and systems had significantly reduced odds of their clients reporting satisfaction with services. Specifically, patients attending facilities in the lowest performing quartile on this domain were about 83% less likely to report being satisfied with their care (AOR = 0.17; p = 0.006). The association between satisfaction and positive user experience (such as being listened to, respected, and receiving clear communication) was not statistically significant (AOR = 0.51; p = 0.496) suggesting that while important, this domain alone may not be the strongest determinant when model. Table 12: Ordered logistic regression results: for summary HQSS domain in indices of patient satisfaction. AOR 95% CI p-value Satisfied with service (satisfied, neutral, dissatisfied) Competent care and 0.17 0.05 - 0.61 0.006 systems Positive user 0.51 0.07 - 3.56 0.496 experience Tools (Service 0.11 0.15 - 0.79 0.028 readiness) Notes: The outcome variable in this table is user satisfaction Q4.17, defined as whether the overall quality of the services provided were satisfactory, and measured using a 3-Likert scale (agree, neutral, disagree). All specifications are estimated using an ordered logistic regression and include province fixed effects to control for unobserved regional factors such as health system strength, as well as cluster robust standard errors by health center. All estimations control for contextual and patient characteristics (e.g., health facility status, health facility residence, health worker sex, health worker cadre) likely to influence satisfaction Objective 4: Assess “ghost� client rates reported by health facilities The proportion of ghost patients identified (health facility reporting “fraud�) by DRC provincial health division and year (2017-2022) is shown in Figure 2. Fraud rates varied between 0 to 61.8% across all years and divisions. Equateur and North Kivu had minimal or no proportion of fraud across all years. The province with the highest fraud was Haut Katanga with peaks in 2017, 2021 and 2022. Tshuapa saw a substantial rise of identified ghost patients in recent years, with the highest proportion in 2022 (51.3%). Identification of fraud in Kinshasa only appears after 2021. 1 Figure 2: Proportion of “ghost patients� identified by provinces and year (2017-2022) from the PDSS project. 2 Discussion Our study presents measures of quality for maternal and child care in the PDSS project in 9 districts in the DRC. We based our analyses on existing frameworks: the rights-based AAA,Q approach to conceptualize availability andaccessibility of care and quality explored using the HQSS and WHO Quality of Care Frameworks to explore quality in depth Using 2021 endline survey data, wecompared client-reported of experience of care at exit from health facility with community survey responses. We explored associations between health facility assessments of service availability and readiness with client-reported satisfaction with care. We calculated novel quality indices using the HQSS framework domain of across competent care and systems and tools (equipment, medicines and data), finding substantial gaps across all dimensions of antenatal care service availability and readiness. Observed health facility care and systems showed low indices of competence and diagnostic and clinical assessment processes. The index for counselling and health education was especially low, indicating that patients are likely frequently leaving health facilities without adequate information about their condition, treatment, and preventive care—a critical shortcoming in patient engagement and informed decision-making. Major gaps also existed in safety, prevention and detection and continuity of care. We also identified gaps in equipment which impact the timeliness and effectiveness of services, alongside limited diagnostic infrastructure which poses a barrier to early and accurate detection of health conditions. While medications were generally more available than diagnostics, stock-outs and gaps were also an issue. Our analyses of client-reported outcomes after antenatal care explored individual measures of experience of care and affordability as well as an index of “positive user experience�. Overall, antenatal clients reported very high agreement rates regarding provider interaction, trust, and satisfaction and interpersonal aspects of care, particularly in relation to provider respect and overall satisfaction with the visit. While most patients rated dignity and privacy highly, the high ceiling effect suggests this could be used as a sentinel indicator—if scores drop, it signals a serious issue, because dignity and privacy are fundamental aspects of respectful, people-centered care. Effective communication is needed for client-health provider trust and understand their condition, treatment, and next steps. The results showed low ratings for communication quality and significant negative correlations with satisfaction, indicating it is a key driver of poor experience. Lowest satisfaction was reported by clients for measures of affordability and reasonability of cost of care. These measures also showed the largest differences when comparing health facility exit surveys with community surveys. Divergence in satisfaction between exit interviews and community surveys was consistent across all measures of experience of care highlighting the risk of depending on exit surveys as survey context shapes client response. 1 While clients reported being treated respectfully and with dignity during antenatal care, significant deficits remain in both clinical process quality and structural readiness. A central question was whether patients’ reported satisfaction aligns with the objectively measured quality of care provided at health facilities. In other words, do facilities that perform well on structural and clinical quality metrics also have more satisfied clients? Our analyses showed that an association exists, but it is modest and often inconsistent across domains. While these findings suggest that technical and system-level quality play a meaningful role in shaping client perceptions, further work is needed to explore these relationships once community validation of exit survey responses are available and across intrapartum and postnatal care in addition to antenatal visits. In summary, these findings suggest that while objective health facility service availability/ readiness quality of antenatal care metrics matter, they do not strongly or uniformly predict client- reported satisfaction. This reinforces the need for client interviews to complement structural and process quality assessments to capture experience of care including respect and dignity, communication and shared decision-making. Our analyses validate the need to monitor both experience and provision-based indicators to holistically measure and improve quality of care in the DRC. Utility of client-reported measures in PBF verification We found the client reported measures collected through both client exit interviews and community surveys offered valuable insights into service quality that could complement existing verification mechanisms of health facility assessments (i.e., largely paper-based reports, registers, drug logs, HMIS) in PBF programs. By integrating both technical and experiential metrics into PBF verification systems, health programs like PDSS can better reflect a more comprehensive perspective on quality of care. driving people-centered improvements in service delivery. This study provides evidence that integrating client-reported measures into performance-based financing (PBF) verification systems—such as PDSS in the DRC—can significantly enhance the ability of these systems to capture dimensions of quality that traditional facility assessments often miss. While the current PDSS verification framework focuses largely on structural and process indicators (e.g., infrastructure, equipment, and adherence to clinical protocols), our findings show that patient experience is both measurable and meaningfully associated with overall satisfaction and therefore should be considered in the performance equation. The value of client-reported measures lies in its ability to detect gaps in the dimension of experience of care. Communication, engagement, and payment transparency, which were consistently identified as areas of weaknesses in the DRC data analysed. Notably, process and structural quality indicators, were found to be only variably correlated with satisfaction in bivariate analyses highlighting they are poor proxies of comprehensive quality of care. Importantly, client- centered indicators—such as communication quality, respectful treatment, patient engagement, and payment transparency—are not abstract ideals but have already been measured for 2 antenatal care in the DRC in endline survey exit interviews and household surveys. Although the community verification survey data were not available for our study, nonetheless we propose client-reported measures have potential in the context of DRC and beyond to be utilized for improving accountability and, if validated even as potential for PBF disbursements. Individual component indicators of the PCMC indicators and the composite score could be tracked from exit interview at the facility level quarterly or biannually and compared against historical trends and peer facilities. These could be supplemented by anonymous phone or SMS follow-up surveys to reduce courtesy bias. High quality data to ensure the integrity and credibility of condifidential client feedback is important. Our study used independent trained survey data collectors. While client exit interviews are efficient for near-real-time feedback the community survey responses were less positive, demonstrating the value for triangulating results. The feasibility of this integration is high: the PDSS community survey infrastructure already exists, and routine exit interviews are widely implemented. The next step is to shift from using this data solely for verification (e.g., identifying "ghost patients") to a broader quality improvement and accountability tool that places the patient at the center of the health system’s performance metrics. Their use could drive both accountability and improvement by: • Rewarding facilities that demonstrate high levels of patient-centered care • Highlighing health facilities with consistently poor client-reported performance, • Triggering follow-up support or quality improvement plans, and • . • Our analyses showed variable responses across experience of care questions, highlighting the importance of capturing multiple domains. This aligns with sentinel work by Afulani et al. to develop a person-centered-maternity-care (PCMC) scale which serves as a full 30-item scale with three sub-scales to measure dignified and respectful care, communication and autonomy and supportive care.17 The PCMC scale was designed using robust methodology including literature review, content validity with testing for cognitive, construct and criterion validity and reliability in multiple contexts.17 Importantly they tested the Likert scale finding that for experience of care, a four-point scale was optimal (“no, never�, “yes, a few times�, “yes, most of the time� and “yes many/ all of the time�).18 Subsequent work has generated a shorter 13-item PCMC scale with domains of dignity/ respect, privacy/confidentiality, autonomy, communication, supportive care and trust.19 These PCMC scales form the basis of the revised Service Provision Assessment (SPA) exit interviews for antenatal care (Appendix 3) and could be adopted in the context of World Bank programs. 3 Next steps for client-reported measures to improve quality of care in World Bank PBF program We recommend client-reported measures are considered a priority for further assessment in maternal and child health PBF programs in the DRC and beyond. Their use would strengthen person-centered care and contribute to a comprehensive measurement of quality of care. The Patient Centred Maternity Care (PCMC) short scale recently adapted for the revised SPA survey (Appendix 3) instruments demonstrates a commitment to using a robustly developed and tested standardized index. World Bank PBF programs could consider testing the PCMC in PBF programs. If successful, alignment could enable comparable data across multiple settings in DRC and beyond.20 Validating use of patient-centred indicators such as the PCMC in World Bank programs could take a broad approach including assessing meaning (is this what we want to measure?), measurability (is it practical to measure the PCMC in verification processes?), measurement (is the estimate good enough?) and meaningfulness (what can be achieved through its use?).20 , In conclusion, exploring how best to include client-reported experience measures in world bank programs including but not limited to PBF programs is essential to drive improving health service quality. This will enable the DRC and health systems in other geographies move closer to the goal of people-centered, responsive, and equitable care, leaving no citizen behind. 4 References 1. Interactive Country Fiches. Democratic Republic of the Congo. Available from: https://dicf.develop.unepgrid.ch. 2. World Bank. Democratic Republic of Congo Overview. 2025. Available from: https://www.worldbank.org/en/country/drc/overview. 3. Ramazani IB, Ntela SD, Ahouah M, Ishoso DK, Monique RT. Maternal mortality study in the Eastern Democratic Republic of the Congo. BMC pregnancy and childbirth. 2022 May 31;22(1):452. 4. World Health Organization. Improving maternal and newborn health and survival and reducing stillbirth: progress report 2023. World Health Organization; 2023 May 9. 5. Marthias T, Anindya K, Saputri NS, Putri LP, Atun R, Lee JT. Effective coverage for reproductive, maternal, neonatal and newborn health: an analysis of geographical and socioeconomic inequalities in 39 low-and middle-income countries. BMJ Global Health. 2025 Feb 17;10(2). 6. Duff R, Patel F, Dumouza A, Brown L, Embeke N, Fataki J, Haile M, Conners A, Pickett C. Facilitators and barriers to supply-side maternal, newborn, and child health service availability in DRC: a systematic review and narrative synthesis. Journal of Global Health Economics and Policy. 2024 May 16;4:e2024001. 7. Mukherjee A, Di Stefano L, Blencowe H, Mee P. Determinants of stillbirths in sub�Saharan Africa: A systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 2024 Jan;131(2):140-50. 8. Matendo RM, Engmann CM, Ditekemena JD, Gado J, Tshefu A, McClure EM, Moore J, Boelaert M, Carlo WA, Wright LL, Bose CL. Challenge of reducing perinatal mortality in rural Congo: findings of a prospective, population-based study. Journal of health, population, and nutrition. 2011 Oct;29(5):532. 9. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. 2016. Available from: https://www.who.int/publications/i/item/9789241511216. 10. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, Adeyi O, Barker P, Daelmans B, Doubova SV, English M. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet global health. 2018 Nov 1;6(11):e1196-252. 11. Heckman C, Rastigi S. Availability, Accessibility, Acceptability and Quality framework. tool to identify potential barriers to accessing services in humanitarian settings. UNICEF. UNICEF, Nov. 2019. 12. The Global Financing Facility. Protecting, promoting, and accelerating health gains for women, children, and adolescents: Global Financing Facility 2021-2025 strategy. 2020. Available from: https://www.globalfinancingfacility.org/sites/gff_new/files/documents/GFF- Strategy-2021-2025.pdf. 1 13. World Bank. Health system strengthening for better maternal and child health results project (PDSS). Available from: https://projects.worldbank.org/en/projects-operations/project- detail/P147555. 14. Rowe JW. Pay-for-performance and accountability: related themes in improving health care. Annals of internal medicine. 2006 Nov 7;145(9):695-9. 15. Witter S, Bertone MP, Namakula J, Chandiwana P, Chirwa Y, Ssennyonjo A, Ssengooba F. (How) does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo. Global health research and policy. 2019 Dec;4:1-20. 16. Cronbach LJ. Coefficient alpha and the internal structure of tests. psychometrika. 1951 Sep;16(3):297-334. 17. Afulani PA, Phillips B, Aborigo RA, Moyer CA. Person-centred maternity care in low-income and middle-income countries: analysis of data from Kenya, Ghana, and India. The Lancet Global Health 2019; 7(1): e96-e109. 18. Afulani PA, Diamond-Smith N, Golub G, Sudhinaraset M. Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reproductive health. 2017 Dec;14:1-8. 19. Afulani PA, Feeser K, Sudhinaraset M, Aborigo R, Montagu D, Chakraborty N. Toward the development of a short multi�country person�centered maternity care scale. International Journal of Gynecology & Obstetrics. 2019 Jul;146(1):80-7. 2 Appendices Appendix 1A: Indicators used for Competent Care and Systems composite indices by HQHS domains. Element Number of items Indicator codes Cronbach’s alpha f3_207c to f3_207v (excluding Provider competence 18 0.78 207a, 207b, 207s, 207t) f3_205a–f3_205g, f3_206a– Systematic assessment 27 0.93 f3_206t f3_210a–210b, f3_211a– f3_211a5, f3_211b–f3_211b2, Counseling and health 29 f3_211d, f3_212a–f3_212e, 0.93 education f3_213a–f3_213c, f3_214a– f3_214d, f3_215a–f3_215e Safety 1 f3_207b - f3_208a, 208e, 208g, 208l, Prevention and detection 7 0.67 208m, 209a, 209b Continuity and integration 2 f3_207s, f3_207t 0.65 Appendix 1B: Indicators used for Positive User Experience composite indices by HQHS domains. Element Number of items Indicator codes Cronbach’s alpha Dignity 1 f3_222_1 - Privacy 1 f3_207a - Clear communication 4 f3_203a–203c, f3_217 0.55 Patient voice and values 1 f3_216 - Appendix 1C: Indicators used for Tools composite indices by HQHS domains. Element Number of items Indicator codes Cronbach’s alpha 1 equipment_8, equipment_9, equipment_10, equipment_6, equipment_7, equipment_14, equipment_24, equipment_2, 0.80 Basic equipment 26 equipment_4, equipment_5, equipment_3, equip_1–3, equip_7–10, equip_20, equip_23, equip_38, equip_41, equipment_26–29 diagnostic_95 to Diagnostic capacity 7 0.74 diagnostic_101 medication_2, _3, _4, _5, _6, _7, _10, _11, _15, _16, _22, Medication availability 23 _23, _36, _39, _42, _43, _44, 0.81 _45, _46, _79, equipment_1, equipment_12 2 Appendix 2: Mapping of the patient-reported experience questions across data sources to HQHS and WHO QoC framework domains. Exit Patient Interviews Household Surveys HQHS Domain WHO QoC Domain Indicators Questions Indicators Questions Convenience of coming hh504_3 The distance to from your home to the Foundations – Inputs – Cross- 4.03 reach the health health facility Access cutting hh510_3 facility hh502_2 The cleanliness and Foundations – Health facility is clean Inputs – Facility- 4.04 comfort of the rooms Physical hh508_2 level environment environment hh503_3 Health staff are Respect toward Processes – Experience – 4.05 courteous and respectful hh509_3 patients Respectful care Respect and dignity Easy to get medicines hh502_5 prescribed by health Availability of Foundations – Inputs – Essential 4.07 workers medicines Tools medicines hh508_5 Costs of services Consultation fees are hh504_1 and other Quality impact – Cross-cutting – 4.08 affordable procedures Economic benefit Financial barriers hh510_1 hh504_2 Medication fees for this Quality impact – Cross-cutting – 4.10 visit are reasonable Costs of medicines hh510_2 Economic benefit Financial barriers The hours of the health hh502_1 Foundations – facility is open are Opening hours of Inputs – 4.16 Access ; adapted to your needs the health facility Availability ; Access hh508_1 Responsiveness 1 Appendix 3: SPA ANC exit interviews THE DHS PROGRAM SERVICE PROVISION ASSESSMENT ANTENATAL CARE EXIT INTERVIEW EAN INTRODUCTION AND CONSENT READ THE FOLLOWING CONSENT STATEMENT Good day! My name is . We are here on behalf of the [IMPLEMENTING AGENCY] conducting a survey of health facilities to assist the government in knowing more about health services in [COUNTRY]. This facility was selected to participate in the study. I would like to ask you some questions about your experiences here today to better understand how ANC services are provided in this facility. These questions usually take about 10-15 minutes. We are not evaluating the [NURSE/DOCTOR/PROVIDER] or the facility. Information from this interview is confidential and will not be shared with anyone other than members of our survey team. The information acquired during this interview may be used by the [IMPLEMENTING AGENCY], other organizations or researchers, for planning service improvements or further studies of services. Neither your name nor the date of service will be provided in any shared data, so your identity and any information about you will remain completely confidential. Please know that the decision to participate in this interview is completely voluntary and that your decision will not affect the services you receive. If at any point you would prefer to end the interview please feel free to tell me. There is no penalty for refusing to participate, however, we hope you will choose to participate. In case you need more information about the survey, you may contact the in-charge manager of this health facility. Do you have any questions for me at this time? Do I have your permission to interview you? SIGNATURE OF INTERVIEWER DATE 2 0 2 DAY . . . . . . . . . . . . . MONTH . . . . . . . . . . . YEAR . CLIENT AGREES CLIENT DOES NOT AGREE TO BE INTERVIEWED . 1 TO BE INTERVIEWED . . . . 2 END AN 1. INFORMATION ABOUT VISIT - ANTENATAL CARE NO. QUESTIONS CODING CLASSIFICATION SKIP A101 RECORD THE TIME THE INTERVIEW STARTED. HOURS . . . . . . . . . . . . . . . . . . . . . . . . . . . . USE 24-HOUR FORMAT. MINUTES . . . . . . . . . . . . . . . . . . . . . . . . . A102 What time did you arrive at the facility today? HOURS . . . . . . . . . . . . . . . . . . . . . . . . . . . . USE 24-HOUR FORMAT. IF CLIENT DOESN'T KNOW THE EXACT MINUTES . . . . . . . . . . . . . . . . . . . . . . . . . TIME, ASK HER TO APPROXIMATE. IF SHE CAN'T GIVE AN APPROXIMATE TIME, DON'T KNOW HOURS AND MINUT ................................ 98 SELECT THE CODE ‘98’ FOR 'DON’T KNOW HOURS AND MINUTES'. A103 What time did you see the provider? HOURS . . . . . . . . . . . . . . . . . . . . . . . . . . . . USE 24-HOUR FORMAT. IF SHE DOESN'T KNOW THE EXACT TIME, MINUTES . . . . . . . . . . . . . . . . . . . . . . . . . ASK HER TO APPROXIMATE. IF SHE CAN'T GIVE AN APPROXIMATE TIME, SELECT THE DON'T KNOW HOURS AND MINUT ................................ 98 CODE ‘98’ FOR 'DON’T KNOW HOURS AND MINUTES'. A104 Do you have an antenatal care card/book, or a YES ......................................................................................... 1 vaccination card or TT card with you today? NO, CARD KEPT WITH FACILITY ..................................... 2 NO, LEFT CARD/BOOK AT HOME .................................... 3 IF YES: ASK TO SEE THE CARD/BOOK. A106 LOST CARD/NO CARD/BOOK USED AT THIS FACILITY................................................................. 4 A105 CHECK THE ANC CARD, BOOK, OR TT YES, 1 TIME .......................................................................... 1 CARD OR VACCINATION CARD. INDICATE YES, 2 TIMES........................................................................ 2 WHETHER THERE IS ANY NOTE OR YES, 3 TIMES ........................................................................ 3 RECORD OF THE CLIENT HAVING YES, 4 TIMES........................................................................ 4 RECEIVED TETANUS TOXOID. Yes, 5 TIMES ......................................................................... 5 YES, 6 TIMES OR MOR....................................................... 6 NO RECOR ............................................................................ 7 A106 Have you received any doses of the COVID19 YES, 1 DOSE ............................ 1 (FN1) vaccine? [COUNTRY SPECIFIC] YES, 2 OR MORE DOSES ................ 2 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 IF YES: How many doses? A107 Have you ever been pregnant, regardless of the FIRST PREGNANCY . . . . . . . . . . . . . . . . . . . . . . . 1 duration or outcome, or is this your first NOT FIRST PREGNANCY . . . . . . . . . . . . . . . . . . . . . 2 pregnancy? A108A Is this your first antenatal visit at this facility for YES, FIRST VISIT ....................... 1 A109 this pregnancy? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 A108B How many times have you visited this antenatal clinic for this pregnancy? # OF VISITS ....................... A109 Have you had antenatal care at any other YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 facilities for this pregnancy? NO ........................................................................................... 2 A111 DON’T KNOW ........................................................................ 8 A110 How many antenatal care visits have you had at other health facilities? # OF VISITS ....................... AINS1 A provider may have talked with you about things to do in preparation for delivery. One of those things is having enough money to pay for transportation or any unplanned costs of delivery. AN NO. QUESTIONS CODING CLASSIFICATION SKIP A111 Do you have money set aside for the delivery? YES, ENOUGH...................................................................... 1 YES, BUT NOT ENOUGH ................................................... 2 IF YES, ASK: Do you think you have enough? NO ........................................................................................... 3 A112 Have you decided where you will go for the AT THIS HEALTH FACILITY ............................................... 1 A201 delivery of your baby? OTHER HEALTH FACILITY................................................. 2 AT HOME ............................................................................... 3 IF YES PROBE FOR WHETHER THE PLAN IS AT TBA's HOME .................................................................... 4 A114 TO DELIVER IN A FACILITY OR AT HOME OTHER LOCATION _______________________________ 6 SPECIFY NO/DON’T KNOW ................................................................. 8 A201 A113 What is the main reason you do not plan to INCONVENIENT OPERATING HOURS ........................... 01 deliver at this facility? LOCATION (ACCESS OR TRANSPORTATION)......................................................02 IF CLIENT MENTIONS SEVERAL REASONS, BAD REPUTATION ..............................................................03 PROBE FOR THE MOST IMPORTANT, OR BAD PREVIOUS EXPERIENCE AT THE FACILITY . 04 MAIN REASON NO MEDICINE ......................................................................05 PREFERS TO REMAIN ANONYMOUS ............................ 06 A201 IT IS MORE EXPENSIVE .................................................... 07 WAS REFERRED TO OTHER FACILITY ......................... 08 FACILITY DOESN'T PROVIDE DELIVERY SERVIC. 09 OTHER 96 SPECIFY DON’T KNOW ....................................................................... 98 A114 What is the main reason you do not plan to INCONVENIENT OPERATING HOURS ...........................01 deliver at a facility? LOCATION (ACCESS OR TRANSPORTATIO ................02 DELIVERING AT FACILITY IS UNNECESSARY FOR IF CLIENT MENTIONS SEVERAL REASONS, CHILDBIRTH ...................................................................03 PROBE FOR THE MOST IMPORTANT, OR BAD PREVIOUS EXPERIENCE AT HEALTH MAIN REASON FACILITIES ......................................................................04 AFRAID OF BEING CUT.....................................................05 LACK OF PRIVACY AT FACILITIES .................................06 COST .....................................................................................07 LACK OF SUPPORTIVE ATTENDANCE AT FACIL . 08 OTHERS MADE THE DECISION FOR ME . 09 OTHER 96 SPECIFY DON’T KNOW .......................................................................98 2. ANTENATAL EXPERIENCE OF CARE AINS2 Thank you for answering my questions about your antenatal care. Now I am going to ask you about specific services that you received in your antenatal care visit today. I know some of these are difficult to remember, so it is ok if you don't remember, but do try to tell me what you remember as it will be very useful in checking the quality of antenatal care provided in the facilities around here. A201 Thinking about your antenatal care visit today: 01 Did you feel the doctors, nurses or other staff YES, ALL OF THE TIME ...................................................... 1 treated you with respect? YES, MOST OF THE TIME.................................................. 2 YES, A FEW TIMES ............................................................. 3 IF YES, PROBE : Would you say this was all NO, NEVER ........................................................................... 4 the time, most of the time, or a few times? DON'T KNOW/CAN'T REMEMBER.................................... 8 02 Did you feel the doctors, nurses or other staff YES, ALL OF THE TIME ...................................................... 1 treated you in a friendly manner? YES, MOST OF THE TIME.................................................. 2 YES, A FEW TIMES ............................................................. 3 IF YES, PROBE : Would you say this was all NO, NEVER ........................................................................... 4 the time, most of the time, or a few times? DON'T KNOW/CAN'T REMEMBER.................................... 8 AN NO. QUESTIONS CODING CLASSIFICATION SKIP 03 Did you feel you could discuss your problems YES, ALL OF THE TIME ...................................................... 1 with the doctors, nurses or other providers, YES, MOST OF THE TIME.................................................. 2 without others not involved in your care YES, A FEW TIMES ............................................................. 3 overhearing your conversations? NO, NEVER ........................................................................... 4 DON'T KNOW/CAN'T REMEMBER.................................... 8 IF YES, PROBE : Would you say this was all the time, most of the time, or a few times? 04 Did you feel you understood the purpose of any YES, ALL OF THE TIME ...................................................... 1 tests you were asked to do? YES, MOST OF THE TIME.................................................. 2 YES, A FEW TIMES ............................................................. 3 IF YES, PROBE : Would you say this was all NO, NEVER ........................................................................... 4 the time, most of the time, or a few times? DON'T KNOW/CAN'T REMEMBER.................................... 8 NOT APPLICABL .................................................................. 9 IF CLIENT SAYS THEY DID NOT HAVE ANY TESTS, CIRCLE 9 05 Did you feel you understood the purpose of any YES, ALL OF THE TIME ...................................................... 1 medicines you were given? YES, MOST OF THE TIME.................................................. 2 YES, A FEW TIMES ............................................................. 3 IF YES, PROBE : Would you say this was all NO, NEVER ........................................................................... 4 the time, most of the time, or a few times? DON'T KNOW/CAN'T REMEMBER.................................... 8 NOT APPLICABL .................................................................. 9 IF CLIENT SAYS THEY DID NOT HAVE ANY MEDICINES, CIRCLE 9 06 Did you feel you could ask the doctors, nurses YES, ALL OF THE TIME ...................................................... 1 or other staff at the facility any questions you YES, MOST OF THE TIME.................................................. 2 had? YES, A FEW TIMES ............................................................. 3 NO, NEVER ........................................................................... 4 IF YES, PROBE : Would you say this was all DON'T KNOW/CAN'T REMEMBER.................................... 8 the time, most of the time, or a few times? 07 Did the doctors, nurses or other staff at the YES, ALL OF THE TIME ...................................................... 1 facility ask you if you had any questions? YES, MOST OF THE TIME.................................................. 2 YES, A FEW TIMES ............................................................. 3 IF YES, PROBE : Would you say this was all NO, NEVER ........................................................................... 4 the time, most of the time, or a few times? DON'T KNOW/CAN'T REMEMBER.................................... 8 08 Did you feel the health facility environment, YES, ALL OF THE TIME ...................................................... 1 including the washrooms were clean? YES, MOST OF THE TIME.................................................. 2 YES, A FEW TIMES ............................................................. 3 IF YES, PROBE : Would you say this was all NO, NEVER ........................................................................... 4 the time, most of the time, or a few times? DON'T KNOW/CAN'T REMEMBER.................................... 8 09 Did you feel that during private exams (such as YES, ALL OF THE TIME ...................................................... 1 vaginal exams) that occurred during your YES, MOST OF THE TIME.................................................. 2 consultation, no other clients or patients at the YES, A FEW TIMES ............................................................. 3 facility could see you? NO, NEVER ........................................................................... 4 DON'T KNOW/CAN'T REMEMBER.................................... 8 IF YES, PROBE: Would you say this was all the NOT APPLICABL .................................................................. 9 time, most of the time, or a few times? IF CLIENT SAYS THEY DID NOT HAVE ANY PRIVATE EXAMS, CIRCLE 9 AN NO. QUESTIONS CODING CLASSIFICATION SKIP 10 Did the doctors, nurses, or other health care YES, ALL OF THE TIME ...................................................... 1 providers involve you in decisions about your YES, MOST OF THE TIME.................................................. 2 care? YES, A FEW TIMES ............................................................. 3 NO, NEVER ........................................................................... 4 IF YES, PROBE: Would you say this was all the DON'T KNOW/CAN'T REMEMBER.................................... 8 time, most of the time, or a few times? NOT APPLICABL .................................................................. 9 IF CLIENT SAYS THEY DID NOT MAKE ANY DECISIONS, CIRCLE 9 11 Would you say you were treated differently YES, ALL OF THE TIME ...................................................... 1 because of any personal attribute, like your age, YES, MOST OF THE TIME.................................................. 2 marital status, number of children, your YES, A FEW TIMES ............................................................. 3 education, wealth, or something like that? NO, NEVER ........................................................................... 4 DON'T KNOW/CAN'T REMEMBER.................................... 8 IF YES, PROBE: Would you say this was all the time, most of the time, or a few times? 12 Did you feel like you were treated roughly, for YES, ALL OF THE TIME ...................................................... 1 instance were you pushed, beaten, slapped, YES, MOST OF THE TIME.................................................. 2 pinched, physically restrained or gagged, or YES, A FEW TIMES ............................................................. 3 physically mistreated in any other way? NO, NEVER ........................................................................... 4 DON'T KNOW/CAN'T REMEMBER.................................... 8 IF YES, PROBE: Would you say this was all the time, most of the time, or a few times? 13 Did you feel the doctors, nurses or other YES, ALL OF THE TIME ...................................................... 1 healthcare providers shouted at you, scolded YES, MOST OF THE TIME.................................................. 2 you, insulted, threatened, talked to you rudely, YES, A FEW TIMES ............................................................. 3 or verbally mistreated you in any other way? NO, NEVER ........................................................................... 4 DON'T KNOW/CAN'T REMEMBER.................................... 8 IF YES, PROBE: Would you say this was all the time, most of the time, or a few times? A202 GO TO SECTION 3 - 300 (FN1) Revise the name and required dosage of the COVID-19 vaccine according to the local health guidelines. AN 3. ACCESS TO CARE NO. QUESTIONS CODING CLASSIFICATION SKIP 300 CHECK COVER FOR TYPE OF EXIT INTERVIEW: EPC ESC, EAC, EFP INS4 INS3 Thank you for answering my questions about your delivery experience. Now I am going to ask you a few questions about when you first reached the health facility to give birth to your child. 301 What time did you arrive at the facility to give HOURS . . . . . . . . . . . . . . . . . . . . . . . . . birth to your child? USE 24-HOUR FORMAT MINUTE . . . . . . . . . . . . . . . . . . . . . . . . . IF THEY DON'T KNOW THE EXACT TIME, ASK THEM TO APPROXIMATE. IF THEY DON'T KNOW HOURS AND MINUTES ........................... 98 CAN'T GIVE AN APPROXIMATE TIME, SELECT THE CODE ‘98’ FOR 'DON’T KNOW HOURS AND MINUTES' 302 What time were you first seen by a provider? HOURS . . . . . . . . . . . . . . . . . . . . . . . . . USE 24-HOUR FORMAT MINUTES . . . . . . . . . . . . . . . . . . . . . . . IF THEY DON'T KNOW THE EXACT TIME, ASK THEM TO APPROXIMATE. IF THEY CAN'T GIVE AN APPROXIMATE TIME, DON'T KNOW HOURS AND MINUTES ........................... 98 SELECT THE CODE ‘98’ FOR 'DON’T KNOW HOURS AND MINUTES' 303 What time did you get a bed in the facility? HOURS . . . . . . . . . . . . . . . . . . . . . . . . . USE 24-HOUR FORMAT MINUTE . . . . . . . . . . . . . . . . . . . . . . . . . IF THEY DON'T KNOW THE EXACT TIME, ASK THEM TO APPROXIMATE. IF THEY CAN'T GIVE AN APPROXIMATE TIME, DON'T KNOW HOUR AND MINUTES.............................. 98 SELECT THE CODE ‘98’ FOR 'DON’T KNOW HOURS AND MINUTES'. IF THEY DID NOT NO BED ................................................................................ 95 HAVE A BED AT THE FACILITY, USE THE CODE '95' FOR"NO BED". INS4 Now I am going to ask you a few questions about some common problems clients have at health facilities. As I mention each one, please tell me whether any of these were problems for you when you arrived at the facility, and if so, whether they were major or minor problems for you. 304 Was the time you waited to see a provider a YES, MAJOR PROBLEM ....................................................1 problem? YES, MINOR PROBLE .........................................................2 NO, NOT A PROBLEM .........................................................3 IF YES, PROBE: Would you say this was a DON'T KNOW ........................................................................8 major problem or a minor problem? 305 Were the hours of service at this facility, that is YES, MAJOR PROBLEM ....................................................1 when the facility opens and closes, a problem? YES, MINOR PROBLE .........................................................2 NO, NOT A PROBLEM .........................................................3 IF YES, PROBE: Would you say this was a DON'T KNOW ........................................................................8 major problem or a minor problem? 306 Were the number of days services are available YES, MAJOR PROBLEM ....................................................1 to you at this facility a problem? YES, MINOR PROBLE .........................................................2 NO, NOT A PROBLEM .........................................................3 IF YES, PROBE: Would you say this was a DON'T KNOW ........................................................................8 major problem or a minor problem? Ex NO. QUESTIONS CODING CLASSIFICATION SKIP 307 CHECK COVER FOR TYPE OF EXIT INTERVIEW: EPC ESC, EAC, EFP 309 INS5 Now I am going to ask you a question about your experience after giving birth this time. For this question, please think about the time you have spent in the facility since the birth of your baby on [DATE]. As I read the question, please tell me whether it was a problem for you, and if so, whether it was a major or a minor problem for you. 308 After the delivery of your baby and before you YES, MAJOR PROBLE . . . . . . . . . . . . . . . . . . . . . . . 1 were discharged, was the time you waited to YES, MINOR PROBLE . . . . . . . . . . . . . . . . . . . . . . . 2 see a health provider for a maternal postnatal NO, NOT A PROBLEM . . . . . . . . . . . . . . . . . . . . . . . 3 check, or any other health reason, a problem? DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 IF YES, PROBE: Would you say this was a major problem or a minor problem? INS6 For the next questions, I want to ask a few questions about this entire delivery experience at this facility. 309 Was the cost for services or treatments at this YES, MAJOR PROBLEM . . . . . . . . . . . . . . . . . . . . . 1 facility a problem? YES, MINOR PROBLE . . . . . . . . . . . . . . . . . . . . . . . 2 NO, NOT A PROBLEM . . . . . . . . . . . . . . . . . . . . . . . 3 IF YES, PROBE: Would you say this was a DON'T KNOW ............................ 8 major problem or a minor problem? 310 Is this the closest health facility to your home? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 INS7 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW ............................ 8 INS7 311 What was the main reason you did not go to the INCONVENIENT OPERATING HOURS .......................... 01 facility nearest to your home? BAD REPUTATION ............................................................. 02 DON’T LIKE PERSONNEL................................................. 03 IF CLIENT MENTIONS SEVERAL REASONS, NO MEDICINE ..................................................................... 04 PROBE FOR THE MOST IMPORTANT, OR PREFERS TO REMAIN ANONYMOUS ........................... 05 MAIN REASON. IT IS MORE EXPENSIVE ................................................... 06 WAS REFERRED................................................................ 07 SERVICE NOT OFFERED AT FACILITY NEAREST TO HOME ........................................................................ 08 OTHER 96 SPECIFY DON’T KNOW ...................................................................... 98 4. CLIENT PERSONAL CHARACTERISTICS INS7 Thank you for answering my questions about your experience at this facility. My final questions are about yourself. 401 How old were you at your last birthday? AGE IN YEARS ..................... DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 402 Have you ever attended school? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 404 403 What is the highest level of school you PRIMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (FN1) attended: primary, secondary or higher? SECONDARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 [COUNTRY SPECIFIC] HIGHER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Ex NO. QUESTIONS CODING CLASSIFICATION SKIP 404 CHECK COVER FOR TYPE OF EXIT INTERVIEW: EAC 408 EPC EFP 406 ESC 407 405 How many times have you given birth, before this delivery? 408 NUMBER OF BIRTH . . . . . . . . . . . . . . . . . . IF NONE ENTER 00. PROBE: PLEASE INCLUDE STILLBIRTHS OR ANY CHILDREN WHO WERE BORN ALIVE BUT LATER DIED. 406 How many times have you been pregnant? 408 NUMBER OF PREGNANCIES. . . . . . . . . . . IF NONE, ENTER "00" 407 What is your relationship to {CHILD NAME}? MOTHER/ STEP MOTHER ................................................ 01 FATHER/ STEP FATHER .................................................. 02 BROTHER/MALE COUSIN ................................................ 03 SISTER/FEMALE COUSIN ................................................ 04 AUNT ..................................................................................... 05 UNCLE .................................................................................. 06 GRANDMOTHER................................................................. 07 GRANDFATHER .................................................................. 08 OTHER RELATIVE FEMALE ............................................. 09 OTHER RELATIVE MALE .................................................. 10 NON RELATIVE FEMALE .................................................. 11 NON RELATIVE MALE ....................................................... 12 408 Are you currently married or living together with a YES, CURRENTLY MARRIED ........................................... 1 (man/woman) as if married? YES, LIVING WITH A MAN/WOMAN ................................ 2 NO, NOT IN UNION ............................................................. 3 409 RECORD THE TIME THE INTERVIEW ENDED HOURS . . . . . . . . . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . . . . . . . . . INS8 Thank you very much for taking the time to answer my questions. Once again, any information you have given will be kept completely confidential. Have a good day! Ex INTERVIEWER'S COMMENTS: (FN1) Revise according to the local educational system.