ISSUES IN HEALTH PLANNING
& MANAGEMENT IN NIGERIA
VOL-1
ISBN 978-34330-1-6
© 1998
A publication of
NATIONAL COLLABORATING CENTRE
FOR EDUCATION AND TRAINING IN HEALTH PLANNING
AND MANAGEMENT
University of llorin, llorin, Nigeria.
Printed Offset and Produced by: NATHADEX PRINTING A PUBLISHING ENT.
Opp. Doctor's Quarters, Odo-Okun, Sawmill, llorin,
ii
FOREWORD
It is an opportunity to be invited to write a foreword to a Book of Readings in
Health Planning and Management. The book written by a group of researchers and
practitioners mainly at the University of llorin, llorin, Nigeria, and edited by somebody
who is not only involved in research in Health Planning and Management, but has been
involved in training health practitioners at all levels of practices in the West African Subregion, will certainly add to the emerging literature in Nigeria on such a vital subject -HEALTH.
Good health is basic to human life. Good health is a vital instrument for socioeconomic development. The issue of planning for and providing good health for the
citizen of the world has been demonstrated by WHO to be something beyond the confines
of any one profession. Thus a multi-disciplinary approach as demonstrated by the
authors, and titles of articles in this book could only be an added effort to providing the
people of the world better health even at this turn of the century.
Focusing on a wide area that emphasizes investment in health and economic
development, the book highlights information support for provision of primary health
care, the need for population data in health planning in Nigeria, understanding factors of
health and illness in health planning, enhancing patients satisfaction through adequate
medical care, and evolving a control structure for health technology management in
Nigeria. Certainly, the need for healthy living as a basis for planning and management for
efficiency and effectiveness in the health sector deserves attention as has been given, and
this adds to the robustness of this book.
This unique addition to existing literature in health planning and management in
Nigeria will provide useful guide to health professionals and non-professionals. It is
expected to open the window for more discussions on the various issues addressed. I
hereby commend the book to all those who desire good health for themselves and others.
Professor I. I. Ihimodu,
Dean, Faculty of Business & Soc. Sciences,
University of Ilorin, Ilorin, Nigeria.
January, 1998.
iv
DEDICATION
This book of Readings in Health Planning and Management is our modest
contribution in honour of Professor Eyitayo Lambo (Fellow of Operation Research), a
pioneer Head of Department of Business Administration, University of Ilorin, Ilorin,
Nigeria. As one of the pioneer researchers and teachers in Health Economics, Planning
and Management in Nigeria, Professor Eyitayo Lambo's contribution to emerging
literature in these areas is well acknowledged. After retirement from University teaching
in 1992, Professor Eyitayo Lambo continues to contribute to better health for the people
of the world by sending as Health Economist with the African Regional Office, World
Health Organization. We wish him a healthy life in retirement.
Editor,
Amos O. PETU, Ph.D.
v
TABLE OF CONTENTS
Foreword........................................................................................................
Dedication......................................................................................................
Table of Contents...........................................................................................
iii
v
vi
Economic Development and Health Policy in Nigeria
Dr. K. T. Okorosobo and C. F. Okorosobo (Mrs.) ........................................
1
Sustainable Development, Public Health and the
Imperative of Paradigm Shift
Remi Medupin................................................................................................
23
The Spectrum of Modern Health Care System in Nigeria
A. O.Petu.......................................................................................................
43
Enhancing patient Satisfaction through Adequate Medical Care
J. O, Olujide and A. L. Badmus ....................................................................
64
Information Support for Primary Health Care
T. M. Akande .................................................................................................
85
The Effect of Stress on Entrepreneurial Work
S. L. Adeyemi (Mrs.) ......................................................................................
98
Healthy Living and Increased Labour Productivity in Nigeria
Ilesanmi Oladele Ayodeji ..............................................................................
119
vi
Social Life Events and Personal Homeostasis as
Factor of Health and Illness
J. O. Fayeye...................................................................................................
133
Exercise Therapy a Neglected Aspect of Health Care
Management in Nigeria
Talabi, A. E. ..................................................................................................
145
Planning for Health and Socio-Economic: What Benefits from Water and
Environmental Sanitation Programmes
J. A. Bamiduro...............................................................................................
156
The Need for Population Data in Health Care Planning in Nigeria
J. Funso Olorunfemi......................................................................................
169
vii
ENHANCING PATIENT SATISFACTION THROUGH
ADEQUATE MEDICAL CARE
BY
DR.J.O.OLUJIDE
Department of Business Administration,
University of Ilorin,
Ilorin.
AND
MR. A. L. BADMUS
Department of Business Administration
University of Ilorin,
Ilorin.
INTRODUCTION
The concept of consumer satisfaction occupies a key position in marketing
thought and practice. Satisfaction represents the major plank of marketing activity and
invariably serves to connect decision process culminating in actual purchase and
consumption with post-purchase and brand loyalty. The centrality of the concept is
reflected by its inclusion in the marketing concept- that profits are generated through the
satisfaction of consumer needs and wants (Churchill and Supprenant, 1982).
J. O. Olujide Mr. A. L. Badmus
65
The idea of satisfaction is fundamental to the delivery of the service. The goal of
business is to serve the customer in some way and to fill some need, which is precisely
the prescription of the marketing concept. Liechty and Churchill (1979) assert that the
marketing concept as a measure of consumer satisfaction appears particularly appropriate
in terms of satisfying the existence of the service business. Unfortunately, majority of
government-owned service institutions sidetrack the centrality of marketing concept and
are neither customer focused nor market-driven. Consumer opinion is yet to locate its
rightful place in the formulation of health care and social policies.
Linder-Pelz (1982) defines patient satisfaction as positive evaluation of distinct
dimensions of the health care. The care being evaluated might be a single clinic unit,
treatment throughout an illness episode, a particular health care setting or the health care
system in general. Satisfaction with medical care is a relevant factor determining whether
a person seeks medical services, complies with treatment and maintains a continuing
relationship with a physician (Larson and Rootman, 1976).
OBIECTIVES OF THE STUDY
The adequacy of health provision represents the most important concern of any
government the world over since the development and growth of any economy hinges on
the healthiness of its citizenry. Enhancing patient satisfaction through adequate medical
care is a sine qua non for achieving this developmental objectives.
Consequently, patient satisfaction represents a relevant parameter in the
utilization of health care services in any nation. And considering the global strategic plans
-of "health for all by the year 2000", it becomes imperative to actually ascertain whether
or not the people feel adequately served by our public and private health institutions.
Therefore, the objectives are as follows:
66
Patient Satisfaction and Medical Care
a)
To find out patients' assessment of the medical care provided in the government
owned health institutions in Ilorin;
To identify the basic elements of the service which patients complain about, are
satisfied or dissatisfied with or which otherwise affect their utilization of or
response to health care and;
to recommend some ideas to providers of care-health planners, administrators
and policy makers on how to modify their provision of care in order to make
their patients relatively more satisfied.
b)
c)
METHODOLOGICAL ISSUES IN SOCIOLOGICAL STUDIES OF
CONSUMER SATISFACTION WITH MEDICAL CARE
The concept of satisfaction with medical care up till now is marooned in
ambivalence and mired in controversies with some researchers considering satisfaction as
antecedents to utilization. Korsch (1954) treats satisfaction as an outcome measure and
inherent in this view is an interest in the interactions of provider and patient stressing
instrumental and expressive aspect - a clear distinction by identifying a provider and by
stressing cost convenience and perceived competence.
Alternative conceptualization of satisfaction views it as an important input
variable. Scuhmall (1964) and Anderson (1966, 1973) perceive satisfaction with trust and
confidence in 'doctor' as a predisposing variable. Similarly, the prevailing
conceptualization of utilization of preventive care measures. Afferata (1978) notes that
the two conceptualizations are not necessarily incongruent with each other but
complement each other. He further contends that low relationships between health beliefs
and utilization may be the result of cancellation effect if no control for provider is
introduced and that relationship between demographic variables and utilization may be
due to the different experiences of clinic populations and private practice users.
The unending shift in the burden of disease from acute to chronic
J. O. Olujide Mr. A. L. Badmus
67
conditions and changes in the age structure of population of patients and individuals
requiring long-term medical treatment and social care, underscores the growing
importance of the studies of quality of medical care as a component of health care
research. It has been realized that satisfaction with care is a relevant variable in deciding
whether or not a person seeking medical advice complies with treatment and maintaining
a continuing relationship with a practitioner. Also, the attitudes of the patients are of
paramount importance with respect to long-term care, the quality of care can become
synonymous with the quality of life and satisfactions with care collapses to an important
component of life satisfaction. Care assess to be of high quality on the basis of clinical,
economic or other provider defined criteria will be far from ideal if as a result of the care,
the patient is dissatisfied. There is then a sound rationale for making the organization and
delivery of health care more responsive to the patient needs.
Tester and Mechanic (1975) compared consumer satisfaction with prepaid group
practice and fee for service and Hulka et al (1971) developed a sophisticated method of
measuring attitudes towards electors based on the Thurtine equal appearing interval
techniques modified to a Likert format. Korsch et al (1976) employed relatively complex
techniques to study parental evaluations of pediatric care. Their hypothesis was that a
causal relationship existed between the nature of the verbal communication between
doctor and patient and the outcome in terms of patient satisfaction.
Studies of hospital care have been reported by McGhee (1966) and Cartwright
(1967). McGhee found that the greatest single defect in hospital care was the barrier to
easy exchange of information. In Cartwright study (1967), patients were asked to identify
what struck them most about their experience in hospital? 40% were entirely enthusiastic
in their replies, the staff being the most frequent subject for praise. The food, the physical
surrounding and the medical treatment also received favourable comments. Just under 20
percent were mainly critical; the
68
Patient Satisfaction and Medical Care
staff, the food, the physical conditions and the hospital routines being the most frequent
sources of unfavourable comments. When asked directly, 61% of the patients reported
some difficulty in getting information, 21% being unable to find out what they wanted to
know about their conditions and treatment; 40% indicating a variety of other difficulties
regarding information. Cartwright saw this as part of a general failure to recognize the
social and psychological requirements of patients.
Scott and Gilmore (1966) interviewed a sample of patients attending outpatient
clinics. 20 percent complained about the lack of primacy but other than this, there was
little evidence of dissatisfaction. In general, majority of patients stated that they were
very satisfied with their care when asked to give an overall assessment, though the
communication of information about illness and treatment appeared to be the most source
of dissatisfaction.
There are many other methodological issues which need to be considered. One
is the way in which patient satisfaction with a service or care environment may be rated.
Where comparisons are to be made between two service units, it is necessary to devise
some measure of customer satisfaction so that relevant comparison can be drawn. There
are three approaches that can be employed to get a scale of satisfaction. Firstly, there is
global evaluation which is inadequate measure of consumer opinion since the majority
studies indicate that the level of satisfaction expressed varies with different aspects of
medical care.
Results of Henley and Davis studies (1967) support a multidimensional
conceptualization of patient satisfaction. They also indicate that the level of satisfaction
expressed varies with different aspects of medical care. Global evaluations which ask
respondents how satisfied they are in general tend to mask these differentials and for the
fact that they do not take cognizance of such specific instances of dissatisfaction, global
evaluations tend to be biased toward the satisfaction end of the scale.
The two alternatives to global evaluations are variations of the
J. O. Olujide Mr. A. L. Badmus
69
same approach. Both distinguish separate facets of a service, one treating them as discrete
items while the other composting individual items to arrive at an overall score of
satisfaction. Each of them has its merits and demerits bit both can provide sensitive
measures of consumer opinion and can give indications of how a care situation would
have to be changed in order to enhance patient satisfaction.
Within the three types of approaches mentioned, studies can be differentiated
according to whether they only measure the extent of satisfaction - dissatisfaction or
whether they measure the range as well. The former makes use of respondents who are
satisfied or dissatisfied while the latter makes use of a multidimensional scale and gives
an indication of the relative intensity of satisfaction and dissatisfaction and is the most
sensitive measure of consumer opinion.
Locker and Dunt (1978) contends that any measure of consumer satisfaction
needs to take account of differential satisfaction with individual aspects of services, to
employ a multidimensional scale for rating the consumers response and to base responses
on actual experiences of care. A further issue is the extent to which respondents' reports
reflect their time feelings about the service they received. This can be tackled if questions
are used which differentiate between a service and the individual providing it.
Another important issue is the nature of consumer assessment of care. Also, one
needs to know the basis of expressions of satisfaction and dissatisfaction. Stimson and
Webb (1975) have suggested that satisfaction is related to perception of the outcome of
care and the extent to which it meets patient's expectations. This is supported by Larsen
and Rootman (1976) who demonstrated that a relationship between satisfaction and
expectation is not necessarily direct but contend that, it then seems reasonable to suggest
that expression of satisfaction are the end-product of a process of evaluation in which
expectations figure to some extent (Locker and Dunt, 1978).
With respect to the various services provided by the government-
70
Patient Satisfaction and Medical Care
owned institutions, many people hold what Friedson (1972) calls practical expectations anticipated outcomes which derive from an individual's own experience, the reported
experience of others or a knowledge from other sources or what has been described as the
minimum tolerable or the least acceptable level. This offering might not be the only
alternative but it is better than nothing. Friedson defines the ideal expectation as preferred
outcomes deriving from a patient's evaluation of his problem and goals in seeking
medical care. The practical and ideal expectations may not coincide thereby giving rise to
a situation in which the patients are satisfied because their practical expectations have
been met although the care they receive does not meet their goals.
Other supports for patient's expectation can also be found in the data provided
by Cartwright (1967) and in the association found by Mechanic and Tessler (1975)
between expressed satisfaction, skepticism towards medical care, faith in doctors and
readiness to seek health care. Korsch et al (1968) found that satisfaction was lower when
patients' expectations that physicians would be communicative and friendly were not met.
ACCESS DEFINITIONS AND RELATIONSHIP TO CONSUMER
The definition of access in medical care has generated a lot of controversy with
different scholars giving their own view of what the concept means. Some authors
likened access with entry or use of the system while others use it to mean such terms as
accessible. Though access a times is used to characterize factors which influence entry or
use, there is still differing opinions concerning the range of factors included within access
and whether it characterises the range of factors include within access and whether it
characterises the resource or client.
A second dissatisfying factor is the extent of patient care which include coping
with patients who have self-destructive diseases, dealing with angry or disrespectful
patients and making decision beyond competence.
J. O. Olujide Mr. A. L. Badmus
71
IMPACT OF DOCTOR-PATIENT COMMUNICATION ON SATISFACTION
AND OUTCOME
Given that the basic technical care has been made and the appropriate treatment
prescribed in any given health care system, one would expect that the positive application
of certain psychosocial variables would usually lead to a positive outcome and this
outcome in turn, would lead to a satisfied patient.
The psychosocial variables embrace the patient and his expectations, the
physician communication with his patients and the patient's motivation and ability to
carry out the physician instructions. This leads us to view effective primary-care delivery
as being a product of a long and complex causal chain whose links include the
psychosocial components.
Owing to the difficulty of testing the entire long chain as a total visit, several
variables were employed. Francis (1969) and Korsch (1968) demonstrated relationship
between patient expectation and compliance and between compliance and satisfaction.
Other studies too have shown the link between compliance and outcome (Wilson 1973,
Feintein, 1959).
Berdict and Williamson (1973) studies focus on two variables -satisfaction with
the health care process, satisfaction with care process and satisfaction with care response
to the process of medical intervention while the latter focuses on the results of the
intervention. Result from the studies point to the fact that d-p communications do appear
to affect patient's expectations and outcome does seem to affect patient satisfaction.
However, it was noted that communication did not appear to influence compliance and
neither communication nor compliance affect outcome.
METHODOLOGY
The survey population consisted of a random sample of one hundred and eighty
people who attended any of the public hospitals/clinics in Ilorin. These hospitals and
clinics are primary health
72
Patient Satisfaction and Medical Care
care centres.
The sample was restricted to those who have made at least one out-patient clinic
visit in 1995 to ensure that they qualify as consumers of health care and that the
information given relates to current experience.
PROCEDURE FOR DATA COLLECTION
The data used for the study was gathered from a survey conducted in 1995 in
Ilorin town. The data was collected by means of a 32-item questionnaire in which
respondents were asked specific questions relating to various aspects of medical care
received from the public hospitals. Respondents were also asked to list and comment on
those aspects that mostly caused satisfaction or dissatisfaction with the services received.
The questionnaire was administered to assess the respondents' attitude towards the
physicians, the nurses, the pharmacy services, the empathy, courtesy and professional
interest of the contact staff, adequacy of information given and received, access
mechanisms and convenience of the facilities of the public hospitals and clinics. Only the
pharmacy service was investigated among auxiliary and support services because it, is the
only one that was common to al the health centres considered and with which majority of
the people had contact with. Out of the 180 questionnaires administered, 175 were highly
completed and returned unable giving a satisfactory response rate of 97.2%.
SCALE OF MEASUREMENT
The survey scale of instrument was a comprehensive patient satisfaction
questionnaire including items that assess attitudes towards all aspects of care relevant to
the study. A multi-item measure of each dimension as well as an overall index that
aggregate across dimensions was developed because levels of satisfaction may differ
depending on the dimension of care under consideration. This was done by considering
some of the ideas on patient satisfaction questionnaire suggested by Mangelsdorff (1979).
J. O. Olujide Mr. A. L Badmus
73
These ideas together with those gathered through informal discussions with
people who are in the public hospitals as their sources of medical care led to the
identification of. four aspects of care on which satisfaction items were formulated. The
aspects of patient satisfaction considered include:
(a)
Physician interaction aspect which was made up of seven items relating to the
conduct humanness of the doctors.
(b)
Nurse interaction aspect which was made up of four items that relates to the
empathy and courtesy of the nurses as well as the adequacy of the information
given by the nurses.
(c)
Pharmacy services which was composed of four items relating to information,
financial aspects and drug availability.
(d)
There was also a global evaluation item that asked for the overall assessment of
the medical care received from the public hospitals and clinics.
All these gave a total of 25 scored satisfaction items. The response format
employed a five-point Likert scale as follows:
Point 1
completely satisfied
Point 2
satisfied
Point 3
no opinion
Point 4
dissatisfied
Point 5
completely dissatisfied
The Likert scale format allowed for greater discrimination of the intensity of a
respondent's belief regarding an issue.
Besides they were four questions that tried to investigate the personal
experiences of respondents at the public hospitals/clinics. Three of these items were
scored on a nominal scale (Yes and No) while the fourth item was open-ended and
solicited opinions or attitudes but reports of actual experience. There were also three
other open-ended questions and two of these asked the respondents to list and comment
on the aspects of medical care that they were most satisfied/dissatisfied with while the
last item requested respondents to give suggestions as to how improve the
74
Patient Satisfaction and Medical Care
medical care in the public hospitals/clinics.
The result was a 32 item satisfaction questionnaire and demographic information
regarding sex, age and educational background were also asked for.
TECHNIQUE OF DATA ANALYSIS
To analyze the data collected, statistical analysis was employed. The statistical
techniques employed include:
(1)
Frequency distribution analysis (FDA):
The FDA was used to determine the proportion of satisfied to dissatisfied
respondents with the various aspects of care considered. This will in turn help to identify
those aspects of care which patients complain about, are satisfied or dissatisfied with and
which will otherwise affect their utilization of health services.
(2)
Cross Tabulation Analysis (Chi-squared-test of Significance):
This was used to determine whether the observed variations in the respondents
degree of satisfaction were due to difference in sex,, age, educational background or
whether they were due to other factors different from the ones considered in the study.
J. O. Olujide Mr. A L Badmus
75
Table 1: Summary of the distribution of responses to the satisfaction items relating to the
conduct/humanness of the doctors:
Frequency distribution
Item
Item content
%
%
%
No
Satisfied
No Opinion
Dissatisfied
5
Spends enough time
in treatment
73.7
6.3
20.0
6
Show interest/
concern
72.0
10.9
17.1
7
Willing to listen
84.0
4.6
11.4
8
Allows one to ask
questions
66.9
6.3
26.8
9
Adequacy of information
given by doctor
60.5
11.4
28.1
10
Careful daring
treatment
77.7
9.1
13.2
11
Outcome/efficacy
of care
81.7
6.3
12.0
Table 1 above shows the frequency distribution of the response to the various
aspects of medical care answered and because of the low frequencies of completely
satisfied and completely dissatisfied, these were collapsed to form the satisfied and
dissatisfied columns respectively.
The above results show that majority of the respondents are satisfied with the
conduct/humanness in the public hospitals/clinics in Ilorin Town with as high as 84%
being satisfied with the doctors willingness to listen to patient's complaints. Although all
of these assessments (with respect to the physician interaction aspect) are predominantly
favourable, they do indicate that about 10 to 30% of the respondents arc dissatisfied with
the various items relating to the
76
Patient Satisfaction and Medical Care
conduct/humanness of the doctors.
When these responses were subjected to further analysis (cross tabulation and
significant test), the results indicate that the observed variations in all the responses with
respect to sex and educational background were however not statistically significant. In
other words, the observed variations in the respondents' degree of satisfaction with the
conduct/humanness of the doctors were not due to differences in sex or educational
background. This was also found to be true for the responses to five of the items with
respect to age. the exceptions were the two items relating to information; the extent to
which you can ask the doctor questions about your health and the amount of information
given to you by the doctor concerning your medical problems. The observed variations to
these two items with respect to age were found to be statistically significant at P = 0.05.
The data in table 2 below strongly indicate that the majority of the respondents
are dissatisfied with the behaviour of the nurses in the public hospitals/clinics with as
high as 70% expressing dissatisfaction with the courteous treatment by the nurses. The
data is also supported by the fact that this aspect of medical care attracted the most
unfavourable comments where the respondents were specifically asked to report on any
bad experience or where they were asked to list and comment on the aspect of care they
were most dissatisfied with. Many of the respondents complained about rudeness and/or
uncaring attitude of the nurses.
Further analysis (cross tabulation and significance test) of the responses showed
that the observed variations in the degree of satisfaction were not due to differences in
sex, age or educational background of the respondents but may be due to other variables
not considered in the study.
J. O. Olujide Mr. A. L. Badmgs
77
Table 2
SUMMARY OF THE DISTRIBUTION OF RESPONSES TO THE
ITEMS RELATING TO COURTESY, EMPATHY AND ADEQUACY
OF INFORMATION GIVEN BY THE NURSES
Item
No
13.
4.
12.
21.
22.
23.
Item content
Amount of courtesy
shown by the nurses
Length of waiting time
for doctor
Continuity of care
Length of waiting
time for drugs
Comfort of the
waiting rooms
Other patients seen
at the hospital/clinic
general cleanness of
hospital/clinics
Frequency Distribution (%)
satisfied
No Opinion
Dissatisfied
21.7
8.0
70.3
15.4
21.1
4.0
13.7
80.6
65.2
31.4
7.4
61.2
30.9
11.4
57.7
51.4
8.6
40.0
Source: Questionnaire
As can be seen from the table, an overwhelming 80% of the respondents
expressed dissatisfaction with the length of waiting time for doctor. Other items where
majority of the respondents expressed dissatisfaction include continuity of care i.e. the
fact that one has to see a completely different doctor with each visit (65.2%), length of
waiting time I for drugs (57.7%) and ability to get medical care in emergency (55.4%).
Even with the other items, the proportion of dissatisfaction range from 23% for
convenience of operating hours to 40% for cleanliness of care
78
Patient Satisfaction and Medical Care
environment and other people seen at the hospital/clinic.
Further analysis of the responses showed that the observed variations in the
degree of satisfaction were not die to differences in age, sex or educational background of
the respondents. An exception was with the item on comfort of the waiting rooms where
the observed variations in the responses with respect to sex was found to be statistically
significant at P = 0.05.
The frequency distribution analysis of the responses to the overall appraisal of
medical care showed that 30.3% of the respondents were satisfied, 8.6% had no opinion
while 61.1% of them were dissatisfied with the totality of the services. Of the latter
group, 9.7% of them claimed to be completely dissatisfied. This result is consistent with
the other findings relating to specific aspects of care.
No significant difference could be found in the responses with respect to sex,
age or educational background.
Analysis of the result of the items that prove the respondents personal
experiences at the public hospital/clinics revealed that 61.7% of the respondents felt that
it was not easier to go to the drug store than to bother with a doctor while 38.3% of them
felt that it was. This result is consistent with the earlier favourable assessment of doctors.
56% of the respondents felt that the doctors or the other people working, in the hospital
did not care about them while 44% felt otherwise. This result is still consistent
considering the highly unfavourable assessment of the nurses.
A good majority i.e. 76% of the respondents felt that they would rather be
attending private hospital/clinics if they had the money to pay the bills. It is interesting to
note that:
(1)
Despite the amount of medical care in the public hospitals/clinics, as many as
24% still prefer their services. Reasons given by the respondents for this
preference include the wider range of specialty and expertise possesses by the
most of the public hospitals, the range of equipment/facilities available that
makes for better quality of
J. O. Olujide Mr. A. L Badmus
79
care especially in situations calling for specialised diagnosis treatment and
follow-up and the fact that medical care is relatively care;
(2)
Of the 30% of the respondents who are satisfied with the overall services, only
24% of them would like to continue with their service if they had money. It
does imply that the economic factor plays a very important role in the amount of
patronage the public medical institution have at present.
Some more support for the attitudes expressed in relation to the specific
satisfaction items could be found in the comments made by the respondents in the openended section of the questionnaire. The doctors were constantly mentioned as one of the
aspects of satisfaction and comments included their willingness to listen to patients,
proper attention to patients, encouraging attitude of the doctors. . Other aspects of
satisfaction mentioned by the respondents include the affordability of medical care and
the operating hours of the hospitals/clinics.
The nurses attracted the most unfavourable comments. Respondents described
the general attitude of the nurses to patients as 'rude' unfriendly', uncaring, 'not kind' and
use of abusive language on patients.
Other items of dissatisfaction frequently mentioned by the respondents include
general laxity of all health workers to emergencies causing unnecessary delays that
sometimes result in loss of life; unavailability of drugs at the hospital pharmacy; too
many patients to a doctor; length of waiting time for all the services and unclean
environment of the places of care especially lack of good toilet facilities.
DISCUSSION
The findings contrast strongly with those of the satisfaction studies carried out in
developed countries where the majority of consumers are usually satisfied with the
quality of health ca»e and probably because of the number of dissatisfaction elements are
minimal. They also contrast
80
Patient Satisfaction and Medical Care
with studies which have suggested that other factors may not be as important as the why a
patient feels about his doctor and the assertion that the degree to which a patient believes
the doctor cares about him may well be the most important elements in determining
compliance and satisfaction/Harper 1976). The findings are not however, surprising
considering the deplorable state of health care delivery system in Kwara State in
particular and Nigeria in general.
Most of the areas causing dissatisfaction are in one way or the other related to
the inadequacies of the health system. The length of waiting time for services for
instance, is. directly related to the disproportionate number of patients, pharmacists and
other health workers and the dissatisfaction with communication with the pharmacy staff
could be related to the fact that the staff are forced to give less than adequate attention to
each patient because by the great number of patients they have to attend to. We would
like to quote some of the respondents to support these:
"patients' time care being wasted at all the stages of treatment, hospital
staff are not enough particularly the professionals'. There are not
enough doctors to attend to patients. Many patients 'wait for long time
before seeing a doctor. The dissatisfaction would be minimised if only
the government can increase the number of staff especially the doctors
in various department because of the number of some people'.
Other inadequacies like the non-availability and prices of drugs and the comfort
of the writing rooms also reflect the inadequate allocation of funds to the health care
sector.
The animosity against the behaviour of the nurses is so strong and we quote
some of the respondents in this regard.
It is no easy thing seeing the doctor but once he comes he gives you full
attention, however the reception that one receives from the nurses and
other para-medical staff are
J. O. Olujide Mr. A. L. Badmus
81
always terrible. The attitude of the nurses towards the patients are not
encouraging because sympathy counts most with patients'...
The attitude of the nurses are inexplicable and against their professional ethics
especially considering the fact that the profession is known for empathy and companion
for the sick. This non-professional attitude together with the uncaring attitude of all the
health workers impacts significantly on patients' satisfaction and supports our earlier
assertion that many of the government owned service institutions are not customerfocused.
The number of dissatisfied respondents to emergency care is a strong indication
that emergencies are not given the prompt attention they deserve. Some of the
respondents' comments in this regard offer some insight into the reasons for the delays.
'Emergency cases, I strongly believe that anything emergency should be treated with
quick and urgent action. In most cases, the doctors and nurses are too far to attend to all
the cases'.
.......in the case of emergency, they will ask you and as a result life may
be lost' in case of emergency treatment like accident-victims, it is
somehow delayed till the dying point of the patients unless the patients
are part of the important or sick people in the state'.
From the comments quoted above it can be deduced that the reasons why
emergencies are not promptly attended to include:
inadequate number of health personnel to attend to patients
hospital/government policies regarding settlement of bills and accident
victims.
the social factor. The social status plays an important role in patients getting
the prompt services they deserve.
With regard to the cleanness of the care environment, respondents specifically
reported lack of good toilet facilities for the patients. This reflects laxity on the part of the
hospital workers and administration.
82
Patient Satisfaction and Medical Care
CONCLUSION
This research work has given us an insight into the operations of our public
health institutions particularly those areas affecting utilization of health services, and the
interaction between the health workers, the environment of service and the consumers of
medical care.
Results indicate that inspite of poor funding, inadequate infrastructure
and overwork, the performance of the doctors in the public hospitals/clinics was
satisfactory and confidence the consumers had in them was equally satisfactory.
The attitude of nurses to work and the way they relate to patients have continued
to agitate the minds of the users of our public health institutions. The results of this
research have merely confirmed what people have been saying about the nonchalant and
non-professional attitude of the nurses.
Other areas of concern are the length of waiting time for services, the
environment of health care delivery, the non-availability of drugs and their prices and the
idea of seeing a completely different doctor on each visit.
The above indicate that a lot of work has to be done by the government and
related agencies to re-orientate the nurses, create a clean and conducive environment for
servuction and made drugs available at affordable costs. All these will help to improve
the image of our public health institutions and patients satisfaction.
J. O. Olujide Mr. A. L. Badmus 83
REFERENCES
1. Carstairs, V: 'Channels of Communication', Scottish Health Service Studies No. 11,
1972.
2. Cartwright, A: Human Relations and Hospital Care Rutledge and Kegan Paul, London
1964; Patients and Their Doctors, Routledge and kegan Faul, London, 1967.
3. Churchill, G.A. Jnr. and Supremant, C: An Investigation into the Determinants of
Customer Satisfaction,' Journal of Marketing Research XIX, 491,1992.
4. Darby. M.R. and Karni, E.; Tree competition and the Optional Amount of Fraud',
Journal of Law and Economics, 16, 67-86, 1973.
5. Eigher, F. and Langeard E: The Service Offering - Concepts and Decisions.
6. Friedson, E.: Patients Views of Medical Practice. The Modern Hospital, 89, 88, 1992.
7. Haynes, R.B.: A critical Review of the Determinants of Patient compliance with
Thercepeutic Regimens (Edited by Sackett, D.L. and Haynes, R.B) F. 26. The
John Hopkins, University Press Baltimore, 1976.
8. Hanley, B. and Davis, M.S., 'Satisfaction and Dissatisfaction": A study of the
chronically Ill-aged Patients', J. Hilt. Sc. behaviour, 8,165,1967.
9. Hulka, B.J. Zyzansi, S.J., Cassell, J.C. and Thompson, S.J., Scale for the measurement
of attitudes towards physicians and medical care, Med. Care 8,429,1970.
10….Satisfaction with medical Care in a low income population, Journal of Chronical
Diseases, 24,661,1971.
11. Kinley, J. Bradshaw and Ley, F. Patients and Satisfaction and reported acceptance of
advice in general practice. JOR, Coll. Gen. Practice 25,558,1975.
12. Korsch, B. Gozzi, E. and Francis. V. Gaps in doctor - Patient communication and
patient satisfaction, Pediatrics 42,855,1968.
84
Patient Satisfaction and Medical Care
13. Larsen, D.E. and Rootman 1, Physician Role Performance and Patient Satisfaction.
Soc. Sci. med. 10,29-32,1976.
14. Licchty, M.B. and Churchill G.A., Conceptual Insights into consumer satisfaction
with services AMA proceedings 509-513,1979.
15. Linder-pelz, S., Towards a theory of patient satisfaction Soc. Sci. med. 16, 587-592,
1982.
16. Locker, Dr and Dunt, D., Theoretical and Methodological Issues in Sociological
studies of consumer satisfaction with medical care. Soc. Sci., med. 12, 283292,1978.
17. Mangelsdoff, D.A.: patient Satisfaction Questionnaire. Med. Care 1, 86, 1979.
18. McGhee, A.: The patient's attitude to Nursing Care, Living-Stone, 1961.
19. Penchansky, R. and Thomas J. W.: The concept of Access - Definitions and Relations
to consumer satisfaction, med. Care 12,1981.
20. Roghman, KJ. hengst. A. and Zastowny T.R.: Satisfaction with medical care – its
measurement and relation to utilization, Med-care 17, 5, 1979.
21. Scot. R. and Gil.more, M.: The Edinburg Hospitals. In the Problems and Progress in
medical Care 2nd Series Oxford University Press 1986.
22. Stimson, G. and Webb, B., On-going to see the Doctor, Rutledge and Kegan Paul,
London 1975.
23. Tessler, R. and Mechanics, D.: Consumer Satisfaction with Prepaid group practice A comparative study, J. Hilth. Soc. Behaviour, 16, 95,1975.
24. Williamson, V.: Patients satisfaction with General Practitioner services: A survey by
a community Health Council, J.R. Coll. Gen Practice 39,452,1989.