Assessment of patients’ satisfaction with the quality and care of UNRWA primary healthcare services

30 January 2025

Executive Summary
The PSS aims to evaluate the quality of healthcare services provided to Palestine refugees by The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). The PSS’s primary objectives were to assess patient satisfaction, identify areas for improvement, and enhance the overall quality of healthcare services in five fields of operation (FO), namely Jordan, Lebanon, Syria, Gaza, and West Bank (including East Jerusalem). However, due to the start of war in October 2023, the Gaza FO is excluded from the survey. Therefore, this report covers the remaining four FOs. The Patient Satisfaction Survey is designed to gather feedback from patients regarding their experiences with healthcare services provided in the HCs of four FOs. The intended audience of the PSS includes healthcare providers, policymakers, and stakeholders within UNRWA.
The sampling strategy involved selecting HCs using the Probability Proportional to Size (PPS) method, ensuring that HCs with higher consultation volumes, in 2022, had a greater chance of being included. In total, the survey was conducted in 72 HCs out of 118 HCs in four FOs. Below table shows the patient selection from HCs and household (HH) inside and outside camps in four FOs.

Data collection for surveys, observations and PFAs was conducted by local teams of experienced data collectors using KOBO (an online and offline data collection application) on smartphones and laptops. The KIIs were audio recorded, if the interviewees allowed, otherwise, notes were taken and uploaded on KOBO.
Quantitative data analysis included descriptive statistical analysis, and cross-frequency tabulations, while qualitative data analysis employed inductive and deductive techniques. The findings were compiled into a detailed report with segregated results for each FO and agency-wide, including challenges and recommendations. The results were presented at a dissemination workshop in Amman, Jordan, for health senior management on November 11, 2024.

The Patient Satisfaction Survey was conducted from 25 July 2023 to 30 September 2024.
2.1. Summary of Findings
2.1.1. Accessibility of Healthcare Services
The assessment of accessibility of healthcare services within UNRWA HCs across Jordan, Lebanon, Syria, and the West Bank (including East Jerusalem) reveals notable disparities. Geographic accessibility is generally high, with an average of 90% positive responses, but physical accessibility options like elevators and ramps show significant shortcomings, particularly in Lebanon (23%) and Syria (15%). Elevator functionality is a critical issue, with internal environment assessments highlight
low availability of elevators, particularly in Lebanon (8%) and in Syria where no functioning elevators were reported. However, accessible toilets for persons with disabilities are insufficient, especially in Syria (18%) compared to the West Bank (including East Jerusalem) (89%).
Social accessibility is strong, with 98% of respondents across all FOs reporting no social barriers to accessing healthcare. Operational hours are largely considered convenient by 98% of respondents, and Saturday is the preferred day for visiting HCs across most FOs. However, there is a noticeable preference for in-person consultations (40%) over telemedicine (5%), largely due to the comfort and security it provides. While 55% of respondents stated that they have no preference indicating
they are comfortable with both in-person and telemedicine consultation modes.
Observational data was collected using semi-structured checklists designed to capture key behaviors, interactions, and environmental factors relevant to the study objectives. The observers discreetly recorded their findings without influencing the observed activities, maintaining a non-intrusive presence to ensure natural behavior. The findings indicate challenges in parking facilities for disabled persons, with only 24% adequacy across all FOs, and significant issues in Lebanon and Syria regarding ramp availability and slippery surfaces.

2.1.2. Interpersonal Skills of Healthcare Providers
The assessment of interpersonal skills at UNRWA HCs across Jordan, Lebanon, Syria, and the West Bank (including East Jerusalem) evaluates communication clarity, staff listening abilities, patient expression time, and privacy maintenance. High satisfaction levels were reported, with 100% positive feedback in Lebanon and the West Bank (including East Jerusalem) for staff communication and 99% in Jordan and Syria. Language comprehension satisfaction was similarly high across all FOs. Patient expression time showed a slight drop, with 96% overall satisfaction, notably lower in Syria at 90%. Privacy during physical examinations received consistent positive responses (97%), but chaperone availability was a significant concern, particularly in Syria (38%) and Jordan (53%).
Observational data confirmed high levels of confidentiality and patient privacy, with consistent 100% scores across all FOs. Patient privacy protection also scored impressively, with Jordan at 94% and other FOs at 100%. Treatment plan explanation and addressing patient concerns averaged 98% each, with only West Bank showing a slight drop in treatment plan explanation at 91%. However, challenges such as cultural differences, the impact of trauma, overcrowding, and understaffing were noted, especially in Syria. Staff emphasized the importance of empathy, respect, and clear communication, supported by patient feedback indicating high satisfaction with staff language use. Areas needing improvement include chaperone availability, patient expression time, and privacy measures in Syria. Addressing these issues will enhance patient trust and healthcare quality.

2.1.3. Quality of Healthcare and Compliance
The Quality of Healthcare assessment highlights significant variations across FOs. Administrative quality is best in Lebanon for updating personal information (60%) and Syria and Jordan for timely appointments (90%). Syria shows the lowest scores, with only 39% for updating personal information and 65% for overall waiting times. The average percentage of positive responses for administrative procedures ranged from 66%, lowest, in Syria to 75%, highest, in Jordan. Basic medical care is notably high in following clinical guidelines during procedures, with Syria leading at 99%, but clinical examinations in Jordan are less satisfactory at 51%. Referral mechanisms are
strongest in the West Bank (including East Jerusalem) at 97%, with Syria reporting the highest referral rate to non-UNRWA services at 23%. The Family Health Team (FHT) approach has an overall positive response of 88%, with the lowest in Jordan at 51%. Inclusivity and sensitivity show a positive response average of 72%, though awareness of GBV services is only 12%. Other medical services like pharmacy and laboratory score highly, with pharmacy satisfaction at 94% in Lebanon and laboratory at 97%. Patient rights and engagement vary, with Lebanon having the highest awareness of patient rights at 88% and Syria the lowest at 73%. Overall, improvements are needed in administrative processes, clinical care, referral efficiency, and patient engagement to enhance healthcare quality and accessibility.

2.1.4. Compliance with Standards and Best Practices
The compliance assessment of UNRWA healthcare facilities reveals varied adherence to standards across different FOs. Jordan shows the lowest average compliance at 68%, with specific deficiencies in radiology services and outdated equipment. Lebanon follows with 72%, facing issues in physiotherapy and radiology.
Syria performs slightly better at 77% but struggles with similar challenges in radiology and physiotherapy. The West Bank (including East Jerusalem) leads with an average compliance of 82%, yet still requires improvements, particularly in available radiology services in HCs.
In specialized care, awareness of the e-Mother and Child Health (MCH) application is highest in Lebanon at 88%, but actual download rates are low. Compliance in obstetric documentation and follow-up is high, averaging 95%, while preconception care and oral health screening are notably poor at 16% and 44%, respectively. Child healthcare compliance is strong in initial appraisals and history taking, with Syria and Jordan leading at 97% and 94%. However, family planning counselling and follow-up care show variability, with lower scores in the West Bank (including East Jerusalem) and Jordan. For Non-Communicable Diseases (NCDs), Lebanon achieves the highest compliance at 88%, while Syria scores lowest at 80%. Despite good performance in hypertension and diabetes management, challenges include inconsistent risk scoring and medication stock-outs in Syria. Oral health compliance is highest in Syria for services and equipment (100%) but lower in Jordan, particularly in preventive services (65%). Efforts to address challenges include enhanced training and telemedicine initiatives, although issues like staff shortages and resource limitations persist.
The areas needing improvement related to compliance in specialized care, include low awareness and usage of e-health applications in Syria and West Bank, inadequate compliance with preconception care and oral health screening for pregnant women across all FOs, and challenges with family planning services in West Bank and Jordan. For NCDs, there are inconsistent risk scoring practices across all FOs, with patients in Syria facing additional challenges like medication stock-outs and lower overall compliance. In Jordan, patients experience issues with oral health services, including lower compliance for preventive services and equipment challenges. Across all FOs, there are general concerns such as the need for enhanced training programmes, staff shortages, and resource limitations affecting service delivery.
2.1.5. Facility Management
The survey and observations of administrative efficiency reveal that Jordan and Lebanon show high standards, with Jordan at 89% and Lebanon at 93% in overall positive responses. Syria has the lowest average at 79%, with specific deficiencies in facility maintenance (66%), cleanliness of toilets (68%), and emergency preparedness (8%). The West Bank (including East Jerusalem) performs well with an average of 92% but has areas needing improvement, particularly in patient feedback (17%). Jordan and the West Bank (including East Jerusalem), while generally performing well, need to address specific issues such as toilets cleanliness and patient feedback mechanisms. Lebanon maintains high standards but should continue to monitor emerging concerns. The overall positive response averages 89%, highlighting generally good standards but pointing to targeted areas for improvement, especially in Syria. Syria’s HCs face critical issues, including inadequate facility maintenance, insufficient waste disposal bins, and poor emergency preparedness.
2.1.6. Patient Flow Analysis
There are significant disparities in waiting times across different services and FOs, with Jordan consistently showing longer waits in several categories, with average waiting time of 147 minutes, followed by Lebanon at 96 minutes, West Bank (including East Jerusalem) at 87 minutes, and Syria with the lowest at 81 minutes.
Across UNRWA healthcare facilities, significant challenges include prolonged waiting times and scheduling issues, particularly at registration, reception, and specialist services. In Jordan, issues include long waits and challenges with scheduling appointments, especially in dental and laboratory services. Lebanon faces similar problems with long wait times and overcrowding, notably in pharmacies and dental clinics. Syria reports long waits and logistical challenges due to facility layout and poor internet connectivity, while the West Bank (including East Jerusalem) struggles with overcrowding leading to longer wait times for appointments and treatments, medication unavailability, and accessibility issues delay necessary patient care and create bottle necks for patient flow, particularly in dental and maternal services. Physiotherapy services were not covered in Jordan and Syria through patient flow analysis (PFA) as do such patient was available during the PFA, and there were no specific issues reported for patient flow to avail specialist services in Syria.

2.2. Summary of Recommendations
The following recommendations are based on identified areas needing improvement, as highlighted in the detailed findings section. Implementing these targeted recommendations will enhance patient satisfaction and ensure sustainable healthcare improvements.
2.2.1. Operational and Administrative Recommendations

1. Improve infrastructure for accessibility, including ramps, grab rails, elevators, and accessible toilets in Syria, Lebanon, and Jordan.
   2. Implement a robust referral system and optimize appointment scheduling to manage patient load and reduce overcrowding in Syria, Lebanon, Jordan, and West Bank (including East Jerusalem).
   3. Standardize and streamline referral processes, particularly in Lebanon, and conduct a comprehensive study on referral mechanisms.
   4. Enhance telemedicine services for all patients across FOs, especially in Syria, to offer remote consultations and reduce overcrowding and patient waiting times.
   5. Upgrade IT systems to streamline patient information updates and reduce waiting times in Syria and Jordan.
   6. Increase patient awareness of HC operating hours and introduce an online appointment scheduling system in Lebanon.
   7. Train healthcare providers to explain treatment plans clearly and enhance clinical examination procedures in Jordan.
   8. Conduct awareness campaigns and training sessions on the Family Health Team (FHT) approach and specialized services in Jordan and Syria.
   9. Improve medication counselling by pharmacists in Jordan and provide confidential counselling spaces in Syria.
   10. Ensure gender-appropriate chaperones are available during examinations and encourage patients to bring an accompanying person if needed.
   11. Enhance privacy measures during physical examinations and reinforce patient confidentiality guidelines in Syria and Jordan.
   12. Implement rigorous cleaning protocols and regular audits in Lebanon and Syria to ensure high hygiene standards.
   13. Educate cleaning staff about the Infection Control Committee, use of appropriate protective gear, and improve oversight in Syria and West Bank (including East Jerusalem).
   14. Upgrade signage and lighting in West Bank (including East Jerusalem) and Jordan for better visibility and guide patients more effectively.
   15. Develop and display clear emergency information, evacuation routes, and warning systems in Syria.
   16. Establish designated areas for patient feedback in West Bank (including East Jerusalem) and increase community participation in Syria.
   17. Address the lack of skilled physiotherapy staff and assistive devices across all FOs.

2.2.2. Strategic Recommendations
1. Roll out and enhance telemedicine services across all FOs, with a focus on Syria, and educate the community on using telemedicine through various programmes.
2. Implement cross-training programmes and comprehensive, role-specific training to address skill gaps in radiology, physiotherapy, and pharmacy.
3. Offer flexible training options to accommodate staff schedules and enhance their skills.
4. Extend operational hours based on patient preferences and introduce mobile clinics for underserved and remote areas to alleviate central HC burden.
5. Establish effective monitoring and accountability mechanisms, including regular audits, standardized reporting formats, and performance reviews to maintain high standards of patient safety and infection control.