Underutilization of health services is a persistent problem in low resourced settings. Efforts to strengthen health systems often focus on improving quality of care at health facilities. Low quality is assumed to dissuade people from seeking services, though few studies have addressed this assumption directly. The purpose of this research is to empirically test the hypothesis that quality is associated with utilization of health services. Using data from the 2014 survey of the Access to Primary Health Care project in the Democratic Republic of Congo, this analysis explores the extent to which patients’ assessments of quality of care align with objective assessments of health facilities, examines the extent to which patients’ assessments of quality are associated with their satisfaction, and estimates the impact of patient satisfaction on utilization of health services. Methods utilized include factor analysis and the estimation of multivariate regression models. Findings indicate that patient assessments of quality are impacted by the degree to which they are exposed to an element of quality and the extent to which they understand its importance. Patients’ assessments of access to care are positively associated with their overall satisfaction, while assessments of safety are negatively correlated and assessments of patient-centeredness are not significantly associated. Among pregnant women, satisfaction is associated with utilization of prenatal care but not facility-based delivery. This research suggests that prevailing attitudes toward health care may be a more significant barrier to utilization than the quality of care at a particular health facility. Strategies to improve patients’ abilities to assess quality should emphasize transparency and patient education. Patient satisfaction may be improved through focus on access to services. Future research should explore the impact of changes in both quality and attitudes toward health care on the utilization of a range of services and across a variety of settings.
