BMJ open · 2026
Importance-performance gap analysis of health service quality in conflict-affected Yemen: a cross-sectional facility-based survey of patients' and healthcare providers' perspectives.
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Hyzam Dalia, Dureab Fekri, Dhaiban Mustafa, Boah Michael, Al-Mahbashi Taha, Hadi Aiman, Al Sakkaf Khaled, Feldmann Gaby, Ulrichs Timo
Аннотация
OBJECTIVE: To examine perceived gaps between required healthcare service quality and current service performance as reported by patients and healthcare providers in public health facilities in conflict-affected Yemen.
DESIGN: Cross-sectional facility-based survey using an importance-performance framework.
SETTING: 20 public health facilities in five Yemeni governorates: Abyan, Lahj, Aden, Taiz and Hadramout.
PARTICIPANTS: 400 patients and 396 healthcare providers from rural and urban public health facilities.
PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the perceived quality gap, calculated as mean current performance minus mean required importance. Service quality was assessed across five domains: process, object, interaction, infrastructure and atmosphere. Secondary measures included rural–urban differences and responses to a structured multiple-response item on perceived barriers to quality improvement.
RESULTS: Across all five domains, importance ratings were high and performance scores lower, producing negative gap scores. The largest domain-level gap concerned quality of process (patients: –0.939; providers: –0.582), driven by telephone accessibility, care without prior appointment and service availability beyond standard working hours. Quality of object also showed notable gaps, particularly for modern medical equipment. Quality of atmosphere showed the smallest gaps. Patients generally reported larger perceived gaps than providers, and urban respondents reported wider gaps across several domains. Frequently reported barriers included financial constraints, low remuneration, staff demotivation, limited management capacity and insufficient quality-improvement skills.
CONCLUSION: Public facilities in conflict-affected Yemen showed consistent perceived gaps between required and current healthcare service quality. The findings suggest that access-related processes, service capacity, equipment availability and workforce motivation may warrant consideration in quality-improvement planning. Importance-performance analysis can support context-sensitive priority-setting in fragile and conflict-affected health systems.
DESIGN: Cross-sectional facility-based survey using an importance-performance framework.
SETTING: 20 public health facilities in five Yemeni governorates: Abyan, Lahj, Aden, Taiz and Hadramout.
PARTICIPANTS: 400 patients and 396 healthcare providers from rural and urban public health facilities.
PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the perceived quality gap, calculated as mean current performance minus mean required importance. Service quality was assessed across five domains: process, object, interaction, infrastructure and atmosphere. Secondary measures included rural–urban differences and responses to a structured multiple-response item on perceived barriers to quality improvement.
RESULTS: Across all five domains, importance ratings were high and performance scores lower, producing negative gap scores. The largest domain-level gap concerned quality of process (patients: –0.939; providers: –0.582), driven by telephone accessibility, care without prior appointment and service availability beyond standard working hours. Quality of object also showed notable gaps, particularly for modern medical equipment. Quality of atmosphere showed the smallest gaps. Patients generally reported larger perceived gaps than providers, and urban respondents reported wider gaps across several domains. Frequently reported barriers included financial constraints, low remuneration, staff demotivation, limited management capacity and insufficient quality-improvement skills.
CONCLUSION: Public facilities in conflict-affected Yemen showed consistent perceived gaps between required and current healthcare service quality. The findings suggest that access-related processes, service capacity, equipment availability and workforce motivation may warrant consideration in quality-improvement planning. Importance-performance analysis can support context-sensitive priority-setting in fragile and conflict-affected health systems.