Does health facility infrastructure predict performance? Disconnects between service readiness, process quality, and client experience in Ethiopia

Expanding healthcare access without guaranteeing care quality fails to improve population health. Although health systems in low- and middle-income countries frequently rely on structural readiness as a proxy for healthcare quality, whether readiness associates with actual clinical process quality and client-reported care experiences remain unclear. This study evaluated the relationships between structural readiness, observed clinical process quality, and client-reported quality ratings in Ethiopia. We analyzed nationally representative data from the 2021-22 Ethiopia Service Provision Assessment (ESPA), combining facility audits, direct clinical observations, and client exit interviews across antenatal care (ANC), family planning, and sick-child services. We measured structural readiness using WHO tracer indicators (0–1 index). We evaluated process quality by observing provider adherence to evidence-based guidelines and assessed client quality ratings through overall service ratings and user experience measures. We examined the relationship between structural readiness and process quality using correlation analysis and restricted cubic splines, and identified predictors of high client ratings using multivariable logistic regression. Statistically significant associations were declared at p < 0.05. Facilities demonstrated moderate structure readiness across sick-child care (mean:0.51; 95% CI: 0.49–0.53), ANC (mean: 0.54:95% CI: 0.53–0.56), and family planning (mean: 0.62; 95% CI: 0.58–0.65). The clinical process quality was low; providers completed a mean of only 22% of recommended clinical steps for sick-child care, 24% for family planning, and 47% for ANC. Structural readiness correlated weakly with process quality, with guideline adherence varying widely even among facilities with identical readiness scores. Although 27% to 39% of clients rated overall service quality as excellent, fewer than 40% expressed full confidence in the facility’s capacity to get quality of care if they became seriously ill by tomorrow. High client quality ratings were driven primarily by interpersonal care experiences, specifically shorter waiting times, respectful provider communication, and medicine availability, rather than structural readiness or clinical process quality. Structural readiness correlates weakly with both clinical process quality and client satisfaction. While essential, physical infrastructure alone does not guarantee evidence-based or client-centered care. Quality improvement efforts in Ethiopia must directly target provider clinical practice and interpersonal care experience alongside physical infrastructure investments.