Individual and district scale determinants of users' satisfaction with primary health care in developing countries.

The paper has two aims: to explore possible determinants of user satisfaction based on a broad conception of the health care system involving both individual and district scale variables, and to add to the limited knowledge and empirical study about such determinants in developing countries. The study was carried out in one of Brazil's poorest states, Ceará, in the northeast of the country. Brazil has a policy of an increased role for the population in management together with decentralised management to the local administrative (municipio) scale. For user views on health care to be useful in management, understanding their determinants needs to explore not only individual scale factors but also influences from the local health system and wider society, here termed district scale factors. The study design took different angles on users' satisfaction to build three measures: the particular health event (termed perceived quality); a generalised perception (termed satisfaction); and, satisfaction with the Community Health Worker (termed CHW satisfaction). Potential determinants explored at the individual scale (17 variables) are grouped into: socio-demographic and economic characteristics; health outcome; health care provision; and, awareness of space for local voice in planning. Potential determinants explored at the district scale (50 variables) are grouped into: formal organisation and management (health system inputs, management capacity, outputs and outcomes); informal organisation (population awareness of health system activities, staff characteristics, district management style); and, local political culture (geographic and socio-economic population profile, commitment to the district of local leaders, norms and values of staff regarding practice). Three determinants were key for all three user evaluation measures: getting an appointment, getting better, and the type of district (rural-urban). Our primary conclusion from this study is that there are limitations to the extent that user satisfaction can fulfill the claims made for it. On a more positive note, with these limitations noted, user satisfaction can prove a useful management tool more modestly at a local, context-specific scale.