Enhancing Patient Satisfaction Through Adequate Medical

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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


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FOREWORD

It is an opportunity to be invited to write a foreword to a Book of Readings inHealth Planning and Management. The book written by a group of researchers and

practitioners mainly at the University of llorin, llorin, Nigeria, and edited by somebodywho 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 Sub-

region, 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 socio-

economic 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 confinesof 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 healthcare, the need for population data in health planning in Nigeria, understanding factors of

health and illness in health planning, enhancing patients satisfaction through adequatemedical 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 forefficiency and effectiveness in the health sector deserves attention as has been given, and

this adds to the robustness of this book.


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This unique addition to existing literature in health planning and management in

Nigeria will provide useful guide to health professionals and non-professionals. It isexpected 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.


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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), apioneer Head of Department of Business Administration, University of Ilorin, Ilorin,

Nigeria. As one of the pioneer researchers and teachers in Health Economics, Planningand Management in Nigeria, Professor Eyitayo Lambo's contribution to emerging

literature in these areas is well acknowledged. After retirement from University teachingin 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, WorldHealth Organization. We wish him a healthy life in retirement.

Editor,

Amos O. PETU, Ph.D.


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v

TABLE OF CONTENTS

Foreword........................................................................................................ iiiDedication...................................................................................................... v

Table of Contents........................................................................................... 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 ShiftRemi Medupin................................................................................................ 23

The Spectrum of Modern Health Care System in Nigeria

A. O.Petu....................................................................................................... 43

Enhancing patient Satisfaction through Adequate Medical CareJ. O, Olujide and A. L. Badmus .................................................................... 64

Information Support for Primary Health Care

T. M. Akande ................................................................................................. 85

The Effect of Stress on Entrepreneurial WorkS. L. Adeyemi (Mrs.) ...................................................................................... 98

Healthy Living and Increased Labour Productivity in Nigeria

Ilesanmi Oladele Ayodeji .............................................................................. 119


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vi

Social Life Events and Personal Homeostasis asFactor of Health and Illness

J. O. Fayeye................................................................................................... 133

Exercise Therapy a Neglected Aspect of Health CareManagement in Nigeria

Talabi, A. E. .................................................................................................. 145

Planning for Health and Socio-Economic: What Benefits from Water andEnvironmental Sanitation Programmes

J. A. Bamiduro............................................................................................... 156

The Need for Population Data in Health Care Planning in NigeriaJ. Funso Olorunfemi...................................................................................... 169


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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 AdministrationUniversity of Ilorin,

Ilorin.

INTRODUCTION

The concept of consumer satisfaction occupies a key position in marketingthought 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 thesatisfaction of consumer needs and wants (Churchill and Supprenant, 1982).


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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 preciselythe prescription of the marketing concept. Liechty and Churchill (1979) assert that the

marketing concept as a measure of consumer satisfaction appears particularly appropriatein terms of satisfying the existence of the service business. Unfortunately, majority of

government-owned service institutions sidetrack the centrality of marketing concept andare 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 distinctdimensions 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 whethera person seeks medical services, complies with treatment and maintains a continuing

relationship with a physician (Larson and Rootman, 1976).

OBIECTIVES OF THE STUDYThe 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 medicalcare 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 strategicplans -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 healthinstitutions.

Therefore, the objectives are as follows:


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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;b) To identify the basic elements of the service which patients complain about, are

satisfied or dissatisfied with or which otherwise affect their utilization of orresponse to health care and;

c) 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 maketheir patients relatively more satisfied.

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 asantecedents 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 bystressing 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 andconfidence in 'doctor' as a predisposing variable. Similarly, the prevailing

conceptualization of utilization of preventive care measures. Afferata (1978) notes thatthe two conceptualizations are not necessarily incongruent with each other but

complement each other. He further contends that low relationships between health beliefsand 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


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conditions and changes in the age structure of population of patients and individuals

requiring long-term medical treatment and social care, underscores the growingimportance 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 decidingwhether 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 becomesynonymous 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 ofmeasuring 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 acausal relationship existed between the nature of the verbal communication betweendoctor 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 identifywhat 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 physicalsurrounding and the medical treatment also received favourable comments. Just under 20

percent were mainly critical; the


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staff, the food, the physical conditions and the hospital routines being the most frequentsources 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 toknow 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 werevery 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 sourceof dissatisfaction.

There are many other methodological issues which need to be considered. Oneis 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. Thereare three approaches that can be employed to get a scale of satisfaction. Firstly, there isglobal evaluation which is inadequate measure of consumer opinion since the majority

studies indicate that the level of satisfaction expressed varies with different aspects ofmedical care.

Results of Henley and Davis studies (1967) support a multidimensionalconceptualization of patient satisfaction. They also indicate that the level of satisfaction

expressed varies with different aspects of medical care. Global evaluations which askrespondents 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


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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 ofsatisfaction. 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 wouldhave 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 orwhether 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 mostsensitive measure of consumer opinion.

Locker and Dunt (1978) contends that any measure of consumer satisfactionneeds to take account of differential satisfaction with individual aspects of services, to

employ a multidimensional scale for rating the consumers response and to base responseson 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 ofcare 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 andexpectation 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 whichexpectations figure to some extent (Locker and Dunt, 1978).

With respect to the various services provided by the government-


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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 theminimum 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 seekingmedical 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 whenpatients' 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 authorslikened 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 oruse, 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 itcharacterises 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 disrespectfulpatients and making decision beyond competence.


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IMPACT OF DOCTOR-PATIENT COMMUNICATION ON SATISFACTION

AND OUTCOMEGiven 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 thisoutcome 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 tocarry 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 thepsychosocial components.

Owing to the difficulty of testing the entire long chain as a total visit, severalvariables 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 responseto 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 appearto affect patient's expectations and outcome does seem to affect patient satisfaction.

However, it was noted that communication did not appear to influence compliance andneither 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


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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 theinformation 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 carereceived 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 professionalinterest 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 theonly one that was common to al the health centres considered and with which majority ofthe 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 tothe 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 consideringsome of the ideas on patient satisfaction questionnaire suggested by Mangelsdorff (1979).


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J. O. Olujide Mr. A. L Badmus 73

These ideas together with those gathered through informal discussions withpeople 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. Theaspects 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 satisfiedPoint 2 - satisfiedPoint 3 - no opinion

Point 4 - dissatisfiedPoint 5 - completely dissatisfied

The Likert scale format allowed for greater discrimination of the intensity of arespondent's belief regarding an issue.

Besides they were four questions that tried to investigate the personalexperiences 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 threeother 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


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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 statisticaltechniques 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 identifythose 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 respondentsdegree of satisfaction were due to difference in sex,, age, educational background orwhether they were due to other factors different from the ones considered in the study.


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J. O. Olujide Mr. A L Badmus 75

Table 1: Summary of the distribution of responses to the satisfaction items relating to theconduct/humanness of the doctors:

Frequency distributionItem Item content % % %

No Satisfied No Opinion Dissatisfied

5 Spends enough timein treatment 73.7 6.3 20.0

6 Show interest/

concern 72.0 10.9 17.17 Willing to listen 84.0 4.6 11.4

8 Allows one to ask questions 66.9 6.3 26.8

9 Adequacy of informationgiven by doctor 60.5 11.4 28.1

10 Careful daring

treatment 77.7 9.1 13.211 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 completelysatisfied 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 allof 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


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conduct/humanness of the doctors.

When these responses were subjected to further analysis (cross tabulation andsignificant test), the results indicate that the observed variations in all the responses with

respect to sex and educational background were however not statistically significant. Inother 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 withrespect 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 tothese 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 respondentsare 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. Thedata 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 theywere most dissatisfied with. Many of the respondents complained about rudeness and/oruncaring attitude of the nurses.

Further analysis (cross tabulation and significance test) of the responses showedthat 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 variablesnot considered in the study.


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J. O. Olujide Mr. A. L. Badmgs 77

Table 2

SUMMARY OF THE DISTRIBUTION OF RESPONSES TO THE

ITEMS RELATING TO COURTESY, EMPATHY AND ADEQUACYOF INFORMATION GIVEN BY THE NURSES

Item Frequency Distribution (%)No Item content satisfied No Opinion Dissatisfied

13. Amount of courtesy

shown by the nurses 21.7 8.0 70.34. Length of waiting time

for doctor 15.4 4.0 80.612. Continuity of care 21.1 13.7 65.2

21. Length of waitingtime for drugs 31.4 7.4 61.2

22. Comfort of the

waiting rooms 30.9 11.4 57.723. Other patients seen

at the hospital/clinic

general cleanness ofhospital/clinics 51.4 8.6 40.0

Source: Questionnaire

As can be seen from the table, an overwhelming 80% of the respondentsexpressed 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 ofwaiting 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


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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 ofthe 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 lattergroup, 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 themfelt 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 consistentconsidering the highly unfavourable assessment of the nurses.

A good majority i.e. 76% of the respondents felt that they would rather beattending 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 themost of the public hospitals, the range of equipment/facilities available that

makes for better quality of


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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. Itdoes 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 specificsatisfaction items could be found in the comments made by the respondents in the open-

ended 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 andthe operating hours of the hospitals/clinics.

The nurses attracted the most unfavourable comments. Respondents describedthe 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 includegeneral laxity of all health workers to emergencies causing unnecessary delays thatsometimes 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 uncleanenvironment of the places of care especially lack of good toilet facilities.

DISCUSSION

The findings contrast strongly with those of the satisfaction studies carried out indeveloped countries where the majority of consumers are usually satisfied with the

quality of health cae and probably because of the number of dissatisfaction elements are

minimal. They also contrast


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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 patientbelieves 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 tothe 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 staffcould 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 wouldlike 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 onlythe 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 comfortof 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


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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 companionfor 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 customer-focused.

The number of dissatisfied respondents to emergency care is a strong indication

that emergencies are not given the prompt attention they deserve. Some of therespondents' comments in this regard offer some insight into the reasons for the delays.

'Emergency cases, I strongly believe that anything emergency should be treated withquick 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 patientsare 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 accidentvictims.

- the social factor. The social status plays an important role in patients gettingthe 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 thehospital workers and administration.


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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 theinteraction between the health workers, the environment of service and the consumers of

medical care.

Results indicate that inspite of poor funding, inadequate infrastructureand 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 continuedto 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 andnon-professional attitude of the nurses.

Other areas of concern are the length of waiting time for services, theenvironment 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 andrelated agencies to re-orientate the nurses, create a clean and conducive environment forservuction and made drugs available at affordable costs. All these will help to improve

the image of our public health institutions and patients satisfaction.


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REFERENCES

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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.

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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

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medical Care 2nd Series Oxford University Press 1986.22. Stimson, G. and Webb, B., On-going to see the Doctor, Rutledge and Kegan Paul,

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Enhancing Patient Satisfaction Through Adequate Medical