University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA THE IMPACT OF INTERNALLY GENERATED FUNDS ON QUALITY HEALTHCARE DELIVERY IN GHANA. A CASE STUDY OF PANTANG HOSPITAL BY REBECCA CYNTHIA AGBEKO (10700538) A LONG ESSAY SUBMITTED TO THE UNIVERSITY OF GHANA BUSINESS SCHOOL, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTER OF SCIENCE IN ACCOUNTING AND FINANCE AUGUST 2019 University of Ghana http://ugspace.ug.edu.gh 2 University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that this dissertation is the result of my original research and that no part of it has been presented for another degree in the University of Ghana Business School or elsewhere. ……………………………………… …………………… REBECCA CYNTHIA AGBEKO DATE (10700538) i University of Ghana http://ugspace.ug.edu.gh CERTIFICATION I hereby certify that the preparation and presentation of this dissertation were supervised in accordance with the guidelines on supervision of dissertations laid down by the University of Ghana Business School. ……………………………………… …………………… FRANCIS ABOAGYE-OTCHERE PHD DATE (SUPERVISOR) ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS I give all thanks, praises and honour to the Almighty God for sustaining me throughout the academic years successfully. It is by His grace that this thesis report has come into reality. I thank the University of Ghana Business School and lecturers for their guidance throughout the study. I wish to acknowledge with gratitude, my supervisor Francis Aboagye-Otchere PhD for deepening my understanding in the rudiments of academic research. I would like to appreciate staff and colleagues of Pantang Hospital for their contribution in producing this thesis. Special gratitude goes to Mr Alex Kissi the Administrator for his contribution to the field work. Last but not least, profound thanks go to Mr. Davies Anane-Timpong for his support in the preparation of the document. iii University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to my husband Mr. David Hatsu and sister Victoria Agbeko-Dillard whose efforts, pieces of advice, inspiration and encouragement has brought me this far. May the Almighty God continue to bless you both iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ................................................................................................................... i CERTIFICATION ................................................................................................................ ii ACKNOWLEDGEMENTS.................................................................................................. iii DEDICATION ..................................................................................................................... iv TABLE OF CONTENTS ...................................................................................................... v LIST OF TABLES ............................................................................................................... ix LIST OF FIGURES .............................................................................................................. x LIST OF ABBREVIATIONS /ACRONYMS ....................................................................... xi ABSTRACT ....................................................................................................................... 11 CHAPTER ONE ................................................................................................................... 1 INTRODUCTION ................................................................................................................ 1 1.1 Background to the Study .............................................................................................. 1 1.2 Problem Statement ....................................................................................................... 3 1.3 Objectives of the Study ................................................................................................ 5 1.4 Research Question ....................................................................................................... 5 1.5 Scope and Limitations.................................................................................................. 5 1.7 Organization of the Study ............................................................................................ 6 CHAPTER TWO .................................................................................................................. 8 LITERATURE REVIEW ...................................................................................................... 8 2.1 Introduction ................................................................................................................. 8 2.2 Healthcare Financing Trends........................................................................................ 8 v University of Ghana http://ugspace.ug.edu.gh 2.2.1 Background of Internally Generated Funds (IGF) or User Fees in the .................. 10 Health sector of Ghana ................................................................................................. 10 2.2.2 Non-Drug IGF (User Fees) .................................................................................. 12 2.2.3 Government Subvention and Allocations ............................................................. 13 2.2.4 Donor Funds........................................................................................................ 14 2.2.5 Health Insurance Claims and other Strategic purchasing ...................................... 14 2.2.6 Debt Relief Health Financing .............................................................................. 15 2.3 The Concept of Quality .............................................................................................. 16 2.4 Service Quality Dimension ........................................................................................ 16 2.4.1 Employees’ Capacity ........................................................................................... 17 2.4.2 Technology ......................................................................................................... 18 2.4.3 Communication Channels .................................................................................... 19 2.4.4 Financial Resources ............................................................................................ 19 2.5 Quality Service Delivery ............................................................................................ 20 2.5.2 Service Quality and Client (Patients’) Perception and Expectation ....................... 21 2.6 Quality Healthcare Service Delivery challenges from a Patient’s (Client) Perspective 22 2.7 The Perspective of Healthcare Providers on Quality Health Service Delivery Problems ........................................................................................................................................ 24 2.8 The Challenges of Quality Healthcare Delivery ......................................................... 25 CHAPTER THREE ............................................................................................................. 31 METHODOLOGY.............................................................................................................. 31 3.1 Introduction ............................................................................................................... 31 3.2 Profile of Pantang Hospital ........................................................................................ 31 3.3 Research Design ........................................................................................................ 32 3.4 Population ................................................................................................................. 34 vi University of Ghana http://ugspace.ug.edu.gh 3.5 Sample and Sampling Technique ............................................................................... 34 3.6 Data Collection .......................................................................................................... 35 3.6.1 Source of Data Collection .................................................................................... 35 3.6.2 Instrument of Data Collection .............................................................................. 35 3.6.3 Procedure of Data Collection ............................................................................... 36 3.7 Methods of Data Analysis .......................................................................................... 36 CHAPTER FOUR ............................................................................................................... 38 RESULT AND DISCUSSION ............................................................................................ 38 4.0 Introduction ............................................................................................................... 38 4.1 Demography .............................................................................................................. 38 4.1.1Gender ................................................................................................................. 39 4.1.2 Age group ........................................................................................................... 40 figure 4.2 age group of respondent ............................................................................... 40 4.1.4 Levels of Education ............................................................................................. 42 4.1.5 Departments and Positions of Respondents .......................................................... 43 4.1.6 Number of Years served ...................................................................................... 44 4.2 The various sources of funds available to Pantang hospital ........................................ 45 4.4 The impact of IGF on quality healthcare delivery ....................................................... 50 4.5 The level of healthcare delivery in Pantang hospital ................................................... 50 4.6 Challenges in Healthcare Delivery ............................................................................. 53 4.6.1 The Challenges that Pantang hospital faces in healthcare delivery ....................... 53 4.7 Discussions ................................................................................................................ 56 CHAPTER FIVE ................................................................................................................ 60 SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS ................... 60 vii University of Ghana http://ugspace.ug.edu.gh 5.0 Introduction ............................................................................................................... 60 5.1 Summary of Findings ................................................................................................. 60 5.2 Conclusion ................................................................................................................. 62 5.3 Recommendations...................................................................................................... 63 5.4 Suggestion for Future Studies .................................................................................... 63 REFERENCES ................................................................................................................... 65 APPENDIX A ..................................................................................................................... 73 APPENDIX B ..................................................................................................................... 76 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 4.1:Sources of Funds Received by Pantang Hospital .................................................. 45 Table 4.2: The Relationship between IGF and Quality Healthcare Delivery......................... 47 Table 4.3: Impact of IGF on Quality Healthcare Delivery.................................................... 50 Table 4.4: Level of Healthcare delivery in Pantang Hospital................................................ 51 Table 4.5: The Correlation between the factors the affect Quality Healthcare delivery ......... 51 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 2.1 Conceptual Framework ...................................................................................... 30 figure 4.2 age group of respondent ...................................................................................... 40 figure 4.3 Marital Status of respondent ................................................................................ 41 Figure 4.4 Levels of Education of respondent ...................................................................... 42 figure 4.5 Departments and Positions of Respondents.......................................................... 43 Figure 4.6 position of respondent ........................................................................................ 43 Figure 4.7: Number of Years served by Respondents (Staff)................................................ 44 Figure 4.8 how long clients have been receiving treatment at pantang ................................. 44 Figure 4.9 trend of fund received between 2013 and 2018 ................................................... 46 Figure 4.10 total funds received between 2013 and 2018 ..................................................... 46 Figure 4.12 Challenges Faced in Health Delivery ................................................................ 53 Fig 4.13: Challenges faced by Clients in accessing quality Healthcare at Pantang ................ 54 Figure 4.14 Areas That Need Improvement ......................................................................... 55 figure 4.15 areas that need improvement ............................................................................. 55 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS /ACRONYMS Internally Generated Funds (IGF) Non-Governmental Organizations (NGOs xi University of Ghana http://ugspace.ug.edu.gh ABSTRACT Quality Healthcare is one of the paramount goals of every government all over the world. As a result, all governments throughout the world (both past and present) have strived to formulate and implement several healthcare policies that seek to ensure quality healthcare delivery to their populist. Pantang hospital is a government health facilities situated in Pantang and it seeks to provide affordable high quality and client friendly mental and general health services. In order for the hospital to deliver on its mandate there should be adequate funds which is sourced from various angles including funds generated internally. However, the major challenges faced by state institutions is funding of which Pantang hospital is not an exception. The study employed mostly qualitative and a bit of quantitative approach, the population comprised all heads of the various units in the Pantang hospital with much focus on the finance section as well as the clients. The sample was purposively chosen and the sample selected comprised 23 staff of Pantang hospital and 500 clients (patients). Interviews and questionnaires were used as data collection instruments. The data was analyzed using correlation and a multiple regression model to measure the relationship and the impact between internally generated funds and quality healthcare delivery in Pantang hospital. The study concluded that the main sources of funds for Pantang hospital are donations, support from NGOs, government support (i.e. Goods & Service and Compensation) and IGF. Pantang hospital has been doing well in mobilizing funds internally to support it operations. However, they depend heavily on IGF which is the second highest source of fund for its operational activities. IGF can impact quality healthcare delivery in Pantang hospital up to (0.488 or 48.8%) and quality healthcare delivery in Pantang hospital cannot be explained or determined by the amount of money available only at a point in time but other factors. The two major financial challenges are ( unavailable government support and delayed claim payment) which is preventing Pantang hospital from delivering quality healthcare. Whiles delay in receiving treatment and bad attitude of some health workers forms the greatest challenge. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background to the Study Quality Healthcare is one of the paramount goals of every government all over the world. A healthy population is said to be a wealthy economy. As a result all governments throughout the world (both past and present) have strived to formulate and implement several healthcare policies that seek to ensure quality healthcare delivery to their populist. According to the UN (2000) every human being deserve to enjoy the highest attainable standard of health conducive to living a life in dignity. The Universal Declaration of Human Rights (UDHR) which indicates that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, medical care and the right to security in the event of sickness, disability” (Constitution of Ghana, 1992; UN, (1948) and therefore, the right to good health care is not only essential, but also a major responsibility of the government. Ayensu (2015); Loewenson and Whiteside (1997) contends that, healthcare in developing countries is a complex and multi-faceted issue. Most developing countries including Ghana, is doing all it can to offer a complete healthcare scheme to the citizenry. The United Nation’s Millennium Development Goals (MDGs) has captured quality healthcare in goals (4, 5, & 6) that must be achieved by all member states. Nevertheless, there is not equitable healthcare delivery in all member states globally. Some countries in South America, part of Asia and Sub-Sahara Africa are faced with numerous challenges which makes a global attainment of these healthcare goals very difficult. 1 University of Ghana http://ugspace.ug.edu.gh A lot of countries in the Sub-Saharan Africa are faced with challenges of providing adequate quality healthcare and coverage to the entire population as a result of economic recession and limited resources (Agyepong, 1999; Janovsky, 1996). In response to these challenges, different governments are in the process of implementing, or of considering implementing, health sector reforms (Cassels 1995; Cassels and Janovsky 1996) which ultimately aim to improve quality and coverage of health services as well as efficiency. Among these challenges is healthcare financing which has had a toll on government budget as well as household income and has affected the quality of healthcare service delivery in a country such as Ghana. A report by WHO in 2005 indicates that the Government of Ghana spent about 6.2% of GDP on healthcare, or US $30 per capita which constitutes approximately 34% of government expenditure. According to Agyepong (1999) Sources of health financing for district, health services in Ghana include internally generated funds (IGF) (or user fees), central government allocations, funding from NGOs and other donors, and community contributions in cash or in kind for specific projects. IGF as a source of healthcare finance have been fairly successful in terms of revenue generation, cost recovery and establishment of a revolving drug fund. However, revenue generation and cost recovery have tended to be seen as ends in themselves rather than as means to improving utilization and quality healthcare. Agyepong (1999; (Creese, 1991) asserted that IGF have not had as much impact on quality and utilization as they could have. Similar observations have been made elsewhere. Although financing for drug purchasing is no longer a problem, there continue to be localized shortages of drugs in some institutions, even when the drug in question is available on the market. Minimum stock levels are not observed and drugs are not ordered on time, resulting in artificial shortages 2 University of Ghana http://ugspace.ug.edu.gh while healthcare providers complacently congratulate themselves on having been so successful with cost recovery that, they have surpluses in the institutional account. Whether the situation is the same in all part of the country or not; there are few studies that has been conducted to try affirm or disprove this assertion; thus the aim of this study to assess the impact of internally generated funds on quality healthcare delivery in the Pantang hospital is therefore necessary. 1.2 Problem Statement Pantang hospital is a government health facilities situated at Pantang and it seeks to provide affordable high quality and client friendly mental and general health services. In order for the hospital to deliver on their mandate there should be adequate funds which is sourced from various angles including funds generated internally. However, the major challenges faced by state institutions is funding of which Pantang hospital is not an exception. This may affect the attainment of their goal since more than half of their clients are battling with mental illness with family members and other stakeholders showing little commitment towards their treatment. Healthcare financing which includes IGF plays a crucial role in offering quality healthcare service to the population of an economy. Good health is important for human happiness and comfort. It also makes a significant impact to economic advancement, as healthy people live longer, produce more and make more savings. According to Ann and Miloud (2011; Ayensu, 2015), the private sector owns over 50 percent of health facilities in Ghana. This notwithstanding the government still have challenges financing the 50 percent state owned healthcare facilities. 3 University of Ghana http://ugspace.ug.edu.gh Several studies have been conducted to evaluate the effect of IGF on healthcare delivery in some parts of Ghana before the introduction of the National Health Insurance Scheme (NHIS), however the impact of IGF after the introduction of the NHIS is yet to be assessed. Ghana has conducted several reforms in the health sector, popularly known in the country as the Medium Term Health Strategy which were aimed at improving access to basic services, quality of care and efficiency, as well as strengthening links with other sectors such as agriculture, education etc. which also impact on the health of people (Agyepong, 1999; Government of Ghana 1995;1996;1997). The introduction of IGF as a means to solve part of the financial challenges of healthcare providers has degenerated into the cash and carry system that existed before the introduction of NHIS which sought to cushion healthcare financing a bit in Ghana from the year 2005 downwards. In 2005, the Government of Ghana spent about 6.2% of GDP on health care, or US $30 per capita. Of that, approximately 34% was government expenditure (Matey, 2014; WHO, 2008 Although the NHIS is seen or perceived as a measure to help improved access to healthcare delivery in Ghana, non-payment and delay in payment of claims by the National Health Insurance Authority (NHIA) coupled with government decision to wane public institutions from subversion has place huge financial burden on many health service providers. This has warrant them to revert to cash and carry system or over reliance on IGF for the provision of healthcare service to Ghanaians, with majority fallen within the poverty range. However, as most healthcare facilities are relying heavily on IGF as a major source of funds to healthcare providers, it impact on quality healthcare delivery is yet to be assessed therefore the aim of this study. 4 University of Ghana http://ugspace.ug.edu.gh 1.3 Objectives of the Study The main objective of this study is to assess the impact of internally generated funds on quality healthcare delivery in Ghana with Pantang hospital as a case study. This objective is broken down as follows; i. To identify the various sources of funds available to Pantang hospital. ii. To assess the relationship between IGF and quality healthcare delivery in Pantang hospital. iii. To assess the impact of IGF on quality healthcare delivery. iv. To find out the financial challenges that Pantang hospital faces in healthcare delivery. 1.4 Research Question i. What amount of Pantang hospitals funding comes from IGF? ii. What is the impact of IGF on equitable access to healthcare delivery? iii. Does Pantang hospital have the needed facilities to deliver quality healthcare to its clients? iv. Do they have the needed staff strength to deliver quality healthcare to its clients? v. What are the financial challenges of Pantang hospital that affect healthcare delivery? 1.5 Scope and Limitations This research was limited to the clients and staff of Pantang hospital with concentration on the impact of IGF on quality healthcare delivery. Also the willingness of clients and staff (respondents) of Pantang hospital to give out information and collaborating with the researcher was another limitation . Only a few allowed for an in-depth study to be conducted as they were hesitant to give out certain vital 5 University of Ghana http://ugspace.ug.edu.gh information such as finance and this may affect the findings of the study. Again apathy and tediousness in answering questionnaires may influence respondents to pick or thick any answer on the questionnaire and this may also affect the outcome of the study compared with the real situation on the ground. 1.6 Significance of the Study To health managers and stakeholders like physicians, nurses, pharmacists, laboratory technicians, orderlies, etc., the study would provide invaluable information that would allow them to provide useful suggestions for the improvement in management practices of managers. The findings of this study would enrich the existing information on the subject. This study will serve as a scholarly material for future studies. It would thus be used as a material of reference by other researchers who will be conducting a study into a similar topic in the future. 1.7 Organization of the Study This study has been structured into five (5) main chapters, namely the introduction, literature review, methodology, analysis and conclusion. Chapter one (1) of the study presents the introduction and background of the study, statement of the problem, research objectives, research questions, scope and limitations of the study as well as the organization of the study. Chapter two (2) focuses on the review of related literature. Literature that is relevant to the topic was reviewed together with the conceptual framework, theoretical framework as well as the empirical framework. Then chapter three (3) also focused on the methodology adopted for the study. It incorporated the profile of Pantang hospital, research design, population, sample and sampling techniques, 6 University of Ghana http://ugspace.ug.edu.gh data collection procedure, data source, data collection instrument as well as data analysis methods. Chapter four (4) focused on the profile of the sampled organizations, analysis of the data gathered and also the discussion of findings. Chapter five (5) focused on the summary, conclusion and recommendations and also gave suggestion for further studies. 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter captures the review of literature on, definitions and Healthcare financing, Internally generated funds, Challenges, Perspective of healthcare providers on quality healthcare delivery challenges, Client (patients’) perception and expectations, Quality delivery and Service quality in the health sector. 2.2 Healthcare Financing Trends Healthcare financing refers to the collection of funds from various sources (e.g; government, households, businesses, and donors etc.) pooling them to share financial risk across larger population groups and using them to pay for services from public and private healthcare providers. The objectives of health financing are to make funding available, ensure appropriate choice and purchase of cost-effective interventions, give appropriate financial incentives to providers and ensure that all individuals have access to effective health services. Sources of healthcare financing in Ghana for hospitals and other health facilities includes internally generated funds (IGF) or user fees, central government allocations (GoG), funding from NGOs and other donors, and community contributions in cash or in kind for specific projects Agyepong (1999;2010). Agyepong (2010) established that the funds sourced from IGF (Drugs) IGF(Others); Government subvention (Salaries) and Government budget allocation (Capital expenditure), Government budget allocation (Recurrent expenditure), Claims from National Health 8 University of Ghana http://ugspace.ug.edu.gh Insurance Authority (NHIA), Outreach fees from Mother and Child Health (MCH), Programme funds, donations from NGOs etc, are all used in the delivery of Health care. A study conducted by Soyibo et al, (2005) established that the major sources of finance for the health sector in Nigeria are the three tiers of government (Federal State and Local Government), public general revenue accumulated through various forms of taxation, the health insurance institutions (private and public), the private sector (firm and households), donors and mutual health organizations. The sources of healthcare funds in Nigeria as postulated by Soyibo et al, (2005) is not different from the Ghanaian situation although there exist some differences in demography. The provision of quality healthcare is hindered by financing challenges despite the huge government spending, coupled with bilateral and multilateral assistance in the health sector. The trend of healthcare delivery in Ghana is not seen as the best compared to other countries in Sub-Saharan African. There are various sources of funds channelled into the health sector however, due to inconsistency or unreliability of these sources makes planning a huge problem and therefore affects service delivery. According to Obansa & Orimisan (2013), Healthcare financing is worse hit especially in the poor continent where healthcare faces serious problem of acceptability with out-of-pocket (cash-and-carry) expenditure accounting for over 70% of the total private health expenditure and is enough to dent the little progress the health system has made. Hence, the increasing out-of-pocket expenditure due to high disease burden on most poverty-stricken households has kept them in the vicious cycle of the poverty trap (HERFON, 2006; Obansa & Orimisan, 2013). In assessing the expenditure incurred by households against the funds which is directed to the health sector, Soyibo et al (2005) found that private and household expenditure on health 9 University of Ghana http://ugspace.ug.edu.gh between 1998-2002 was the highest with an average of 69.1% and 64.3%, while government expenditure in the same period was a paltry 20.6%. Donor’s average expenditure in the period was 10.3%, while firms input were 4.9% respectively (Soyibo et al, 2005). This gives the indication that there is a financing gab that should be filled by other sources of funds which includes IGF mobilization. The health sector of Ghana is faced with a lot of setbacks regardless of the various reforms that the sector has undergone from independence till now. This phenomenon is not different in other parts of Africa, for instance Obansa and Orimisan (2013) enumerated some challenges facing the Nigerian health system which includes few hospitals with few drugs, inadequate and substandard technology and a lack of infrastructural support, including electricity, water and diagnostic laboratories resulting in misdiagnosis. 2.2.1 Background of Internally Generated Funds (IGF) or User Fees in the Health sector of Ghana Internally generated funds are those funds that are realized through the efforts or operations of the entity itself (i.e. the funds were not borrowed or realized through other external means). It is funds not constituting the proceeds of any loan, debt issuance, equity issuance, asset sale, insurance recovery or indebtedness (www.investopidea.com). Several studies conducted on internally generated funds (IGF) is done on district assemblies for instance Owusu (2015) was on Kumasi Metropolitan Assembly and found that IGF is a major source of funds without which it will be difficult for the assembly to function effectively , Ogechi (2013) study area was on Lagos state, Umar (2015) was on Kaduna state. According to Agyepong (1999; 2010) user fees or IGF in Ghana started in 1971 with the hospital fee act. The 1971 fees were very low and aimed to reduce unnecessary use of services rather than to generate revenue. In July 1983 the fees were slightly raised, and in 10 University of Ghana http://ugspace.ug.edu.gh July 1985 a new hospital lee act was passed and the fees were substantially raised, the aim of the Ministry of Health being to recover at least 15% of its total recurrent expenditure. Initially, health centres and clinics were allowed to retain only 25% of their revenue, and hospitals 50%, while the rest was sent to the central Ministry of health and the National Treasury (Waddington and Enyimayew 1989, 1990). In 1990 the law was amended and insti- tutions were allowed to retain 100% of the fees; and a revolving fund for drugs known as Cash and Carry was initiated. Under Cash and Carry, institutions were to recover 100% of the cost of drugs, keep the revenue for drugs separate and use it only to purchase more drugs. The ‘Cash and Carry’ revolving drug fund currently operates at all facility levels from community clinics to teaching hospitals and successfully recovers 100% of the cost of drugs plus a small overhead (average 110-15% of drug costs in theory but in practice sometimes much more). Apart from fees for drugs, fees have been gradually introduced for other consumables such as OPD cards, gloves, gauze, needles and syringes. In addition there are informal user fees of various shades of legality, such as the ‘mother's voluntary contributions' collected by MCH staff to help with transport for outreach which are usually documented and accounted for; and ‘under the table fees’ which are not documented anywhere and go into the pockets of the staff who collect them (Agyepong, 1999;2010). This background as stipulated by (Agyepong, 1999) did not take into account the changes that the National Health Insurance Scheme (NHIS) has brought to the health sector which has affect most of the user fees are now covered by the NHIS. As emphasized by (Agyepong,2010) IGF have been fairly successful in terms of revenue generation, cost recovery and establishment of a revolving drug fund. However, revenue generation and cost recovery have tended to be seen as ends in themselves rather than as means to improving utilization and quality, and user fees have not had as much impact on quality and utilization as they could have. Similar observations have been made elsewhere 11 University of Ghana http://ugspace.ug.edu.gh (Creese 1991). Although financing for drug purchasing is no longer a problem, there continue to be localized shortages of drugs in some institutions, even when the drug in question is available on the market. Minimum stock levels are not observed and drugs are not ordered on time, resulting in artificial shortages while care providers complacently congratulate themselves on having been so successful with cost recovery that, they have surpluses in the institutional account. There are problems in the area of equity with IGF charges. The clause providing exemption for the poor and treatment of emergencies, whether they are in a position to immediately pay or not, is hardly used and people are sometimes denied the care they need. In part, the non- use of the clause exempting the poor is because the costs of exemption are to be borne by the facility out of the surplus it generates. People are reluctant to watch their surpluses being eroded in a way which brings no obvious benefit to the facility or the workers. There is also extra ‘social work' involved in verifying that a person is indeed unable to pay since if just a statement of inability to pay is used, everyone will become ‘too poor to pay’. 2.2.2 Non-Drug IGF (User Fees) User fees healthcare expenditure is another source of health financing. They are payments for health services at the time of illness (that is, out-of-pocket expenditures), often levied on essential interventions. Experience has taught repeatedly that user fee end up excluding the poor from essential health services, while at the same time recovering only a tiny fraction of cost. User fees can represent a large and sometimes catastrophic burden on a household. An overall trend on user fee is that consultations and medications are the most costly to individuals relative to other health related expenses. However for the non-poor, hospitalization is on average more costly than medications (Ogunbekun et al, 1999). The progressive increase in non-drug IGF is related to the increasing inclusion of non-drug medical supplies such as gloves, gauze, syringes and needles in the cash and carry system. 12 University of Ghana http://ugspace.ug.edu.gh It is difficult to keep track of donor and NGO funds since some are allocated vertically and others are used to implement projects directly at the community level: the District, health administration is sometimes not aware of the existence of some of these sources or how much is involved (Agyepong, 1999; 2010) 2.2.3 Government Subvention and Allocations Central government provides money to districts for recurrent and capital expenditure. Amounts available from central government and internally generated revenue from 1991- 2012 shows that government budgetary allocations to the district as well as IGF have been rising over time. Agyepong (2010) indicated that initially, central government provisions for capital expenditure passed through the health ministries, and its allocation and use was centralized. However, from 1995 onwards, as another step towards decentralization, it has been passed through district assemblies as a block fund for all sectors, known as the district assemblies common fund (Kpabitey 1996). The proportion of this fund used on health-related capital projects in each district depends on the priorities of the district assembly and the lobbying power of the district health directorate. However some funding may be sent from the centre with specific instructions to be used for a particular capital project, e.g. World Bank funds for building offices for District Health Management teams. Soyibo et al, (2005) asserted that public health facilities in Nigeria are financed primarily by the public through tax revenue. The federally collected revenue consist of crude oil and gas export proceeds, petroleum profit tax, royalties and the related proceeds of domestic crude oil sales/other oil revenues, companies’ income tax, customs and exercise duties, value-added tax (VAT), tax on petroleum products, education tax, and other items of independent 13 University of Ghana http://ugspace.ug.edu.gh revenues to the federal government. Although similar to the Ghanaian situation, the sources of funds pooled by the government is slightly different. 2.2.4 Donor Funds Donor health funding is a source of healthcare financing which is required to fill the domestic health sector savings-investment gap. Even if poor countries allocate more domestic resources to health, this would still not resolve the basic problem, because poor countries lack the needed financial resources to meet the most basic health needs of their populations (Nuamah, 2013). Donor money for a particular year may pass through the district health administration, and thus the amounts will be known before it is included. This amount cannot be assumed to represent all the donor money which comes to the district or facilities in cash or in kind that year and all health facilities in the district who are to benefit from the donor funds will be considered. At $30 to $40 per capita for essential interventions, basic health costs would represent more than 10% of GNP of the least developed countries, far above what can be mobilized out of domestic resources (GHS report,2010). Aids assistance to Ghana has been through investment projects with technical cooperation component, free standing technical cooperation (FTC), and concessional loans and grants. Investment project assistance remains the major source of external assistance to Ghana and most part of Africa (Nuamah, 2010). Government macroeconomic reforms also attract some support under programme budget assistance. 2.2.5 Health Insurance Claims and other Strategic purchasing Health Insurance Scheme as instituted in Ghana by the Kuffour administration sought to help provide equitable healthcare to all and also help health facilities to cushion their financing. Since its inception the scheme has chalked some successes as well as challenges. Prompt 14 University of Ghana http://ugspace.ug.edu.gh payment of claims by the NHIA helps health facilities to meet their debt obligations on time. Strategic purchasing requires that the insurance agency or agency managing insurance fund must make various arrangements for purchasing services from health care providers on behalf of insured consumers. Healthcare providers from national public or private healthcare systems should ensure that the healthcare packages which they provide have to be responsive and financially fair. This can be achieved through strategic purchasing. The successes in strategic purchasing depend not only on what types or mixes of healthcare interventions to buy, but also from whom to buy and how to buy them. Good purchasing contributes to achieving health sector policy goals by ensuring that funds are allocated and used effectively. Strategic purchasing of an appropriate set of interventions requires a continuous search for the best interventions to purchase, the best providers to purchase from and also the establishment of the best payment mechanisms and contracting arrangements. The provision of competition, either between providers or, more rarely, between financiers of healthcare, is already being used as a strategy to finance health reform programmes in Ghana and other parts of Africa. There are evidences across the country of the effective implementation of public-private- partnership in financing and provision of health services. 2.2.6 Debt Relief Health Financing Debt relief is another source of healthcare financing in low-income countries through deeper debt relief with the savings allocated to the health sector. The heavily indebted poor countries (HIPC) initiative helped reduce debt servicing by around 2% of GNP for some 30 heavily indebted poor countries, and perhaps around one-fourth of that will be allocated directly to the health sector. Given the outstanding results of the first phase, in terms of channeling debt savings into social expenditure, there seem to be additional initiatives worth taking, although it would entail further bilateral financial support for strengthening the HIPC initiative (HERFON, 2006; Nuamah, 2010). 15 University of Ghana http://ugspace.ug.edu.gh 2.3 The Concept of Quality Quality‟ as defined by International Organization for Standardization is a relative concept and if the inherent characteristic of a service meets the requirements of the customer, it can be rated as high quality (Reinartz, 2004). In a service industry, like healthcare, experience of the patient plays a crucial role in rating and assessment of quality of services. Quality in healthcare may comprise of newer technology, newer and effective medication, and higher staff to patient ratios, affordability, efficiency and effectiveness of service delivery (Tam, 2005; Wanjau et al.,2012). The health sector comprises the public system with major players including the Ministry of Health and parastatals organizations, and the private sector, which includes private for-profit, Non Governmental Organizations, and Faith Based Organizations facilities (RoK, 2010). In healthcare industry service quality has become an imperative (Ennis and Harrington, 2001) in providing patient satisfaction because delivering quality service directly affects the customer satisfaction, loyalty and financial profitability of service businesses. In healthcare, service quality can be broken down into two quality dimensions: technical quality and functional quality (Dean and Lang, 2008). While technical quality in the health care sector is defined primarily on the basis of the technical accuracy of the medical diagnoses and procedures or the conformance to professional specifications, functional quality refers to the manner in which the health care service is delivered to the patients. The public health sector consists of the following levels of health facilities: national referral hospitals, provincial general hospitals, district hospitals, health centres, and dispensaries. Health services are integrated as one goes down the hierarchy of health structure from the national level to the provincial and district levels (Wanjau et al.,2012; RoK, 2011). 2.4 Service Quality Dimension There are two main models of service quality, which include: Service Quality Model of Glied, (2000) which indicates that the expectations of the customer depend on the five 16 University of Ghana http://ugspace.ug.edu.gh determinants market communication, image, word of mouth, customer needs and customer learning. Experiences depend on the technical quality (what/ outcome) and the functional quality (how/process), which is filtered through the image (who). Both expectations and experiences can create a perception gap. While the Gap Model propounded by Parasuraman, Zeithaml and Berry (1990) was a slight modification of Gonzalez Padin and Romon. (2005) model which says that the expected service is influenced by the word-of-mouth, the personal needs, past experience and also by the external communication to customers. A perception gap can appear between the expected service and the perceived service (Coulthard, 2004). Petrick, (2009) identified ten determinants of service quality that may relate to any service: Competence, Courtesy, Credibility; Security; Access; Communication, Understanding knowing the customer; Tangibles; Reliability; Responsiveness. Later they were reduced to five to include Tangibles; Reliability; Responsiveness; Assurance: competence, courtesy, trustworthiness, security and Empathy (Wanjau et al.,2012). 2.4.1 Employees’ Capacity Highly skilled physicians, nurses, administrators, and ancillary staff are critical to producing high-quality outcomes and effective quality improvement hence hospital growth (Argote, 2000). There is need for selective hiring of qualified staff. Successful recruitment and retention of staff is tied to empowerment of staff that must be treated as full partners in the hospital operation and given opportunities for advancement (Brown and Duguid, 2003). The hospitals need to place great emphasis on recruiting and retaining top-level physicians and nurses, accompanied by an effort to encourage these professionals to form working teams, including case managers, pharmacists, social workers, and others, to promote quality (Brown and Duguid, 2003). To facilitate service quality and growth, hospitals must implement effective human resource strategies involving selective hiring, and retention of physicians and nurses (Cohen and Levinthal, 2001); monitoring of doctors on staff (or with privileges) and 17 University of Ghana http://ugspace.ug.edu.gh ensuring that they must continue to meet certain performance and practice standards to retain credentials (Crewson, 2004). To improve efficiency in service delivery, public sector hospitals must build the capacity to attract and employ an adequate number of high-quality nurses (Argote and Ingram, 2000) suggests that the key to service delivery is to adapt to circumstances that are constantly changing and that the long-term winners are the best adapters, but are not necessarily the winners of today‟s race for market share. Hospitals quality of service often fails because of the sum total of seemingly inconsequential events arising from employees lack of capacity as in itself service delivery requires specific skill levels and experience which must be continuously learned (Wanjau et al.,2012; Cohen and Levinthal, 2001). 2.4.2 Technology Technology for harnessing of Information and data play a critical role in the quality service delivery in hospitals (Allen, 2001). Investments in Technology that facilitate service assessment and improvement process is essential (Dutton and Starbuck, 2002). The hospital must show four main commitments: a willingness to invest in Information Technology; investments in Information Technology and in Quality Insurance departments with qualified staff that abstract medical records, analyze data, and facilitate the Quality Insurance process (Cibulskis and Hiawalyer, 2002). According to the Government of Kenya (2001) report , successful Technology strategy that needs to be employed by hospitals must involve four main commitments: a willingness to invest in Information Technology, Working with physicians and others to customize an information system to meet specific needs and culture of the institution; nurturing and encouraging buy-in so new systems will be utilized and their benefits will be realized and devising information technology systems that provide real-time feedback to providers as they are caring for patients (Wanjau et al.,2012; GOK, 2001). 18 University of Ghana http://ugspace.ug.edu.gh 2.4.3 Communication Channels Communication is the most important aspect of the Service delivery as Communication with patients is vital to delivering service satisfaction because when hospital staff takes the time to answer questions of concern to patients, it can alleviate many feelings of uncertainty (EFP, 2006). In addition, when the medical tests and the nature of the treatment are clearly explained, it can alleviate their sense of vulnerability (Friedman and Kelman, 2006). This component of service is valued highly as reflected in the in-depth interviews and influences patient satisfaction levels significantly (Pickton and Broderick, 2001). Research (Payne,2006) indicates that communication challenges have a negative impact on: access to treatment, participation in preventive measures, ability to obtain consent, ability for health professionals to meet their ethical obligations, quality of care, including, hospital admissions, diagnostic testing, medical errors, patient follow-up, quality of mental health care and patient safety. According to the Institute of Medicine of the National Academies (U.S.), communication challenges contribute to reduced quality, adverse health outcomes, and health disparities (Wanjau et al.,2012; 2004). 2.4.4 Financial Resources Financial management, in service organizations, has been a constraint and an obstacle to other functions that contribute to service delivery (Adams and Colebourne, 1999). They suggest an „enlightened‟ approach to finance in service organizations. This consists of more participative and positive approach were far from being an obstacle, it contributes to strategic planning, costing systems, personnel motivation, quality control, continued solvency, and keeping outsiders‟ confidence in management (Arhin-Tenkorang, 2000). In particular, there is a need to distinguish „good costs‟ that improves organizational capabilities and quality service delivery from „bad costs‟ that increase bureaucracy hence becoming obstacles to service delivery (Sun and Shibo, 2005). Allocated resources for health flow through various 19 University of Ghana http://ugspace.ug.edu.gh layers of national and local government‟s institutions on their way to the health facilities (Blas and Limbambala, 2001). Financial accountability using monitoring, auditing and accounting mechanisms defined by the country legal and institutional framework is a prerequisite to ensure that allocated funds are used for the intended purposes (Oliveira-Cruz, Hanson, and Mills. 2001). In many developing countries, governments do not have the financial and technical capacity to effectively exercise such oversight and control functions, track and report on allocation, disbursement and use of financial resources (Smee, 2002). Political and bureaucratic leakage, fraud, abuse and corrupt practices are likely to occur at every stage of the process as a result of poorly managed expenditure systems, lack of effective auditing and supervision, organisational deficiencies and lax fiscal controls over the flow of public funds (Peters, Elmendorf, Kandola and Chellaraj, 2000). Falsification of financial statements is more of a problem in proprietary (private) hospitals. Executives will sometimes exaggerate revenue and misstate expenses in order to meet expectations of industry analysts and shareholders (Maureen, 2005). Public hospitals in Kenya are in dire need of funding to rehabilitate, redesign, equip and staff them to ensure effective and efficient service delivery to Kenyans (RoK, 2001). Low funding for Community Health Workers programme in the country has adversely affected the delivery of health services especially at the grass-roots (Maureen, 2005). Most of the public hospitals in Kenya especially rural areas are in a sad state that has incapacitated them from offering efficient services to patients and to alleviate the deplorable condition proper measures must be taken into consideration (Wanjau et al.,2012; Maureen, 2005). 2.5 Quality Service Delivery Quality Service delivery has significant relationship with customer satisfaction (Swanson and Davis, 2003), customer retention (Yavas, Benkenstein and Stuhldreier, 2004), loyalty (Boshoff and Gray, 2004), costs (Wilson 2008), profitability (Irving and Dickson, 2004), 20 University of Ghana http://ugspace.ug.edu.gh service guarantees (Kandampully and Butler, 2001) and growth of organization (Sohail, 2003). However, the poor quality of healthcare delivery in some public health facilities has resulted in high turnover and weak morale among staff, making it difficult to guarantee 24- hour coverage resulting in, problems with patients care, increased cost of operations due to inefficiencies (Owino and Korir, 1997) leading some patients to look for an alternative provider and to spread negative word of mouth which affects potential clients hence growth of the hospital (Tam, 2005). The quality of healthcare delivery in the cities according to Obansa & Orimisan (2013) is not meeting expectation left a lot in the rural areas and their assertion is not different from the Ghanaian situation. 2.5.2 Service Quality and Client (Patients’) Perception and Expectation Clients (patients) before receiving healthcare service may have or develop some expectation which will either be met or not. Clients whose expectations are met always come satisfied and vice versa. There have been several cases of unmet health expectation by patients in most part of Africa. According to (Boshoff and Gray, 2004; Alglanan hizmet and Connor , 2003) patients or customers perception of functional issues which they perceive and interact with during the course of seeking treatment such as physical facilities, internal process; interactions with doctors, nurses and other support staff as poor and unresponsive is further worse. Whereas there has been an attempt to improve the situation (RoK, 2010) it seems not much has been achieved in raising the quality of healthcare delivery in most public health facilities and this is compounded by limited information on the factors that affects quality service delivery in most public health facilities in Ghana. Also studies that assesses quality service delivery are mostly done in the service sectors like the financial sector as well as the utility sectors. Nonetheless, studies that evaluates the 21 University of Ghana http://ugspace.ug.edu.gh impact of IGF as a source of funds on quality service delivery is rare in a country such as Ghana. 2.6 Quality Healthcare Service Delivery challenges from a Patient’s (Client) Perspective Qualitatively, there is a lot of expressed client dissatisfaction. Factors identified as influencing client perceptions of quality of care in Ghana (Dovlo et al. 1992; Haran et al. 1993; Kumekpor and Richardson 1992; Odoi-Agyarko et al. 1992) are similar to those described from other countries (Maime et al. 1992; Thaddeus and Maime 1994; (Jaffre and Prual 1994). They include accessibility, distance, ease of getting there, convenience, costs, humanness, technical competence, and information provision to clients, bureaucratic arrangements and efficiency, physical facilities, continuity of care, outcome of care and availability of drugs, supplies and essential equipment. Some specific issues leading to client dissatisfaction in the Ghanaian context include the equity problem under cash and carry which creates ‘unavailability’ for the poor. There is also the continued problem, previously discussed, of clients being asked to buy some of their drugs outside the institution. This causes inconvenience and a financial strain on people since it may entail travel outside the community. Some patients even suspect that the public sector workers may be in league with the private drug sellers, making sure patients buy drugs pri- vately so the public workers can get a percentage of the profits - otherwise why should you run short of a drug that is readily available on the market? Another client problem is the perceived competence of the provider. People want to see a ‘doctor’ not necessarily in terms of a degree per se. but in terms of competence to make a diagnosis, give appropriate therapy and achieve prompt recovery without complications. There is some mistrust of the skills of lower level workers, and conflicts may arise between patient perceptions of quality and providers’ technical knowledge, as the village health 22 University of Ghana http://ugspace.ug.edu.gh worker programme showed. Village health workers were trained by the District Health Management team for four to six weeks, supplied with drugs and supervised by the sub- district health team. They were limited to the use of 10-12 over-the-counter drugs and not trained or allowed to give injections. Remuneration was to be from their user fees as well as community contributions. To date, most community clinics staffed by village health workers are struggling to stay financially viable or have collapsed. Partly because of the low utilization rates and revenue. An internal evaluation in 1992 (Agyepong and Marfo) showed that community members were not using the clinics because they felt the quality of care was not up to the standard they wanted and the training of the village health worker was inadequate since they could not perform functions that nurses can and which they valued, such as giving injections. Clinics which are still doing well financially, and have relatively high attendance rates, are those in an area where the supervising sub-district staff have observed and lodged a complaint that the village health workers are 'undertaking additional "curative care" activities for which they have not been trained’. Clients also want to see an upgrading of the diagnostic competence of sub-district level facilities, commonly expressed as wanting laboratories. X-rays etc. Personal characteristics of the provider are important, as shown by the earlier example of a fall in utilization at one centre following the transfer of a popular medical assistant and replacement with one whose conduct was unacceptable. This is similar to the findings from a study in Zaire (Hadad and Fournier 1995) where it was observed that ‘A drop in utilization follows the appointment of a nurse who is competent, but whose conduct is highly offensive’ and 'The appointment of a relatively competent nurse whose strength lies in interpersonal relationships has a positive influence on the activity of a centre’Agyepong(1999;2010-). 23 University of Ghana http://ugspace.ug.edu.gh 2.7 The Perspective of Healthcare Providers on Quality Health Service Delivery Problems From the provider perspective, the current pattern of a few large health centres with many staff is not the appropriate service provision strategy for a population that lives in scattered small villages with poor road access and no proper public transport system. It is true that proximity to health services does not necessarily guarantee use (Malison et al. 1987), however it does influence utilization to an extent, as our slight rise in OPD utilization in recent years shows Nurse: population ratios can influence coverage. However, the relation- ship between staff numbers and coverage is not simple since the pattern of staff distribution and availability of resources for service provision also affects the effectiveness of service delivery. There are difficulties in transferring staff to rural areas as many do not want to live in isolated areas. Staffing problems are not just to do with numbers of staff and distribution, but also skills, competence and orientation. Many staff still have stronger allegiance to vertical divisions and their targets rather than integrated service delivery to a given population. Some of these attitudes are reinforced by the old command structure in the Ministry of Health, remnants of which still linger on despite decentralization, where each unit directly controls its staff members right down to the lowest level of the health system. Currently in-service training is the main strategy used to deal with problems of staff technical competence. The form it is taking is centralized, short-term, predominantly ‘classroom’ training organized from regional or national level. The decision as to what kind of training to organize and who to train may be driven by availability of funds from different programmes. e.g. Malaria, EPI, TB etc., to run particular training. Some staff in the district who need training may be left out because the funds are not enough to cover "everybody’. Frag- mentation of training for different areas, as well as leaving out some staff who need the new skills and information, does not help to create good integration at the district level. The train- 24 University of Ghana http://ugspace.ug.edu.gh ing often may not have much impact on service delivery in the district since provision is not made for supervision, reinforcement and implementation. Moreover, training usually intro- duces new or improved approaches that may require more resources, and they are usually not forthcoming. There is also the whole neglected area of the motivation and morale of health workers. It is unlikely that adequate quality and cove rage of health services can be achieved without well- motivated staff with a high morale. Al Hussein et al. (1992) describe the nurses’ perspective on factors leading to poor nursing care in government institutions in the Central region of Ghana. Issues raised by the nurses include being required to perform tasks below their level of training, e.g. professional nurses cleaning wards; or conversely, being required to perform tasks above their level of training, e.g. auxiliary nurses doing suturing and setting up intravenous infusions. These problems were related to staff shortages. Other concerns raised were working environment factors such as inadequate equipment and supplies, lack of effective supervision, lack of co-operation from other health team members, poor service conditions such as lack of continuing education, promotion. and grossly inadequate allowances, as well as conflict in nurse to nurse inter relationships arising from differences in education and status of nurses (Agyepong, 1999;2010) 2.8 The Challenges of Quality Healthcare Delivery The poor health status of a large percentage of people in sub-Sahara Africa is widely known for years. Over the past decade, however, Africa’s healthcare crisis has received renewed attention because of the greater awareness of the militating factors and a greater understanding of the link between health and economic development (Lowel et al, 2010). The major factors that affect the overall contribution of the health system to economic growth and development of Nigeria as stated by Asamoah and Atintole (2009) includes lack of consumer awareness and participation; inadequate laboratory facilities; lack of basic 25 University of Ghana http://ugspace.ug.edu.gh infrastructure and equipment; poor human resource management; poor remuneration and motivation; lack of fair and sustainable health care financing; Unequal and unjust economic and political relations between Ghana and advanced countries; the neo-liberal economic policies of the Ghana; Pervasive Corruption; Very low government spending on health; High out-of-pocket expenditure on health; Absence of integrated system for disease prevention; surveillance and treatment. All these challenges enumerated by Asamoah and Atintole (2009) are not alien to the Ghana’s health sector although its severity may vary which will make its impact on quality healthcare delivery be felt in a different way.  Lack of consumer awareness and participation: The majority of consumers are ignorant or unaware of available services and their rights regarding health service delivery mainly because of the absence of a bill of rights for consumers (claim holders) and providers (duty bearers). The role of the family in preventing and managing illness is also underestimated or inadequately supported by government programmes. It is now well known that interventions should be implemented through the health system as well as at the household level. The capacity of families and communities should be developed to increase awareness for meaningful participation in their health care and that of their children.  Inadequate laboratory facilities: In most public hospitals in Africa, most of the laboratories in the primary and secondary healthcare centers require some infrastructural upgrading to provide a safe, secure and appropriate working environment. Some basic health centre laboratories are better equipped than those in comprehensive health centers and some secondary level hospitals, but equipment was often minimal. Most laboratory staff in secondary facilities were qualified as medical laboratory scientist or technicians, whereas most of those in primary health care facilities were qualified as science laboratory technicians. There is minimal quality 26 University of Ghana http://ugspace.ug.edu.gh control of laboratory test in secondary facilities and none in primary facilities because they lack appropriate professional supervision.  Lack of basic infrastructure and equipment: Basic life-saving commodities are in short supply in most low income health systems. This is, in part, a result of resource shortages, but, there are still problems even when substantial increase in funding are available, as in the case of Global Fund to fight AIDS, Tuberculosis and Malaria. Building effective and accountable national procurement and drug management systems is an increasing prominent component of the health system action agenda. The provision of quality healthcare delivery relies on the availability of regular supplies of drugs and equipment, as well as appropriate infrastructure at the facility level. Facilities without safe water and electricity, with nonfunctioning equipments, and inadequate deliveries of drugs, diagnostic and other supplies are all too common in many countries in Africa (HERFON, 2006, FMoH, 2004, Travis et al, 2004).  Poor human resources and management: Although human resources are no panacea for the poor health situation in any country, no health intervention can be successful without an effective workforce. Every country should, therefore, have a national workforce plan to build sustainable health systems to address national health needs. These plans should aim to provide access to every family to a motivated, skilled, and supported health worker. To optimize health system performance, workers should be recruited from, accountable to, and supported for work in their community where feasible. The 2003 and 2004 World Health Reports proposed improving rewards to health workers to improve productivity, along with deploying community health workers and engaging community in their health care. The 2004 report advocated using such approaches as contracting local government financing, 27 University of Ghana http://ugspace.ug.edu.gh empowering community, using vouchers, etc., to subsidize key health services for the poor.  Poor remuneration and motivation: Over the years, poor remuneration of health workers have had an adverse effect on their morale such that about two-thirds of doctors and other health professionals prefer and are practicing abroad (Ghana Medical Association report, 2015) while there is an acute shortage of physicians in Ghana and most part of Africa which reflect in the doctor-to-patient ratio. Health workers are paid meager salaries (about 75% lower than that of a doctor even in Eastern Europe) and they work in insecure areas and have heavy workloads, but lack the most basic resources, and have little chance of career advancement. Doctors complain of ‘brain waste’ and seek better opportunities for professional development in countries with better medical infrastructure (Lambo,2006).  Lack of fair and sustainable health care financing: Beyond the level of spending, the key questions concern how the health system is financed and what proportion of contributions comes from users themselves, either through out-of-pocket expenditure or through insurance payments. The WHO is promoting the principle that whatever system of financing a country adopts should not deter people from seeking and using services. In most cases, this will mean that payment at the point of service will need to be eliminated, or at least be related to ability to pay. The financing system should also, as a minimum measure, protect people from catastrophic expenditure when they become ill, promote treatment according to need, and encourage providers to offer an effective mix of curative and preventive services. 28 University of Ghana http://ugspace.ug.edu.gh  Pervasive Corruption: Corruption has often manifested in the health sectors of most countries in Africa through the supply of fake drugs, substandard equipments, willful misdiagnosis of diseases, sharing of unallocated budget funds, inflation of contracts, diversion of drugs, favoritism in treatment and appointments based on political patronage. According to Akintole (2012) some examples abound: a consignment of vitamin A supplement by the Canadian government through its bilateral assistance to Nigeria was diverted in 2008 and it is was found in most itinerant chemist shops across the country (UNICEF, 2007). A formal minister of health, Adenike Grange was sacked in 2008 for her complacency in the sharing of N300 million unallocated health sector fund. Corruption deprives the economy in general and the health sector in particular of vitally needed funds (Thisday, 2008).  Very low governments spending on health: Government expenditure on health in most countries in the sub-Sahara Africa is significantly low considering the health needs of the people. Thisday(2008) acknowledged that less than one-tenth of government expenditure is channeled into the health sector of most countries in Africa. According to Central Bank of Nigeria reports, federal government health spending increased from the equivalent of US$141 million in 1998 to the equivalent of US$228 million in 2003. Health spending as a proportion of total federal spending decline between 1998 and 2000, but increased in subsequent years, reaching 3.2% in 2003. Most federal health spending goes to teaching and specialized hospitals and federal medical centres. State spending on health is currently around 6.3% of total spending, estimated for 2003 at about US$420 million or US$3.50 per capita. Like federal spending, state health spending is concentrated on the main area of state responsibility, secondary hospitals, and is also most likely on personnel. For 2003, the data available showed that spending on health was equivalent to US$300 million or 29 University of Ghana http://ugspace.ug.edu.gh US$2.45 per capita. Like other levels of government, most health spending by local governments is on personnel (World Bank CRS, Nigeria, 2005).  High out-of-pocket expenditure on health: This has further worsened the pauperization of the adverse economic condition of the poor. It is estimated that out- of-pocket spending on health services accounts for 8.7% of total household expenditure. This health spending includes expenditure on outpatient care, transportation to health care facilities and medication. This is one of the largest share of health expenditure out of total household expenditure in developing countries (This day, 2008). Figure 2.1 Conceptual Framework IGF (Cash and Carry & Insurance Claims) Availability of Health facilities Government budgetary Commitment of Allocation and Health Personnel Subvention Client (patient) Contributions from Sources of Funds to expectation Donor Agencies the Health Facilities Time spent in Contribution of the healthcare community to treatment health projects Donations from NGOs Quality Healthcare Delivery 30 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Introduction This chapter captures the profile of Pantang hospital, research type, the target population, sample and sampling techniques, data collection procedure and the method that was used to analyse the data. It shows how the researcher conducted the research or the strategies employed by the research to achieve the objective of the study. 3.2 Profile of Pantang Hospital The Pantang hospital is the second psychiatric hospital established in Accra and the third in the country after Accra Psychiatric and Ankaful Hospitals, and was opened by General I.K. Acheampong in 1975 and was headed by Dr.Sika-Nartey, a Psychiatrist. The hospital was originally planned to be a Pan-African Mental Health Village. The hospital is situated near a village called Pantang, about 1.6 kilometres off the Accra- Aburi road and 25 kilometres from Accra Central. The vision of the hospital is to become a medical centre of excellence, offering high quality integrated health care services. Its mission is to provide affordable high quality and client friendly mental and general health services by a highly motivated staff. The goal of the hospital is to provide quality mental healthcare services for children and young people from birth to their eighteenth birthday, who have mental health problems and disorders to acquire a well-integrated, high quality multidisciplinary mental health service and support, to meet their health needs, and their families. As a result the Pantang hospital provides 24/7 mental health services to everyone with various form of mental illness. 31 University of Ghana http://ugspace.ug.edu.gh The hospital provides healthcare services such as Child Mental Health Clinic, Eye Clinic, Radiology Services, Drug Treatment and Rehabilitation Center, Clinical Psychology, `Occupational Therapy Services, Medical Laboratory services, Maternity, R.C.H (Reproductive and Child Health) Services and Out Patient Department (OPD) Services. They have 9 wards for inpatient admissions of persons with mental disorder who need to be admitted. The Out Patients Departments (O.P.Ds.) is the Patients first point of contact which provides free psychiatric service to the patients nationwide, as well as Primary Health Care and R.C.H services to over 15 villages in its catchments area of about 10km radius. The researcher chose Pantang Hospital as the focus of her study because of the vision of its forbearers to be a Pan-African Mental Health Village in the Sub Region and also because of its strategic location off the Accra-Aburi road which make it conducive for the mental healthcare delivery. The Pantang hospital is faced with huge financial challenges due to the kind of services they provide as well as their stakeholders’ commitment level. 3.3 Research Design In a number of past studies, researchers have collected data on service quality from individual respondents in a cross-section of firms in various industries (Appiah-Adu and Singh, 1999; Boxx et al., 1991; Lok and Crawford, 1999). However, the study used and exploratory survey procedure with focus only on Pantang hospital. The use of funds as well as its generation is a major concern in public administration. Many state institutions rely heavily on government subvention to fund their operational activities. 32 University of Ghana http://ugspace.ug.edu.gh Other sources of funds sometimes are sourced to boost the activities of the governmental institutions. Due to the nature of this study, both qualitative and quantitative approaches was employed. According to De Vos (2002) the two main research design used are the qualitative and the quantitative methods. Qualitative and quantitative methods are complementary approaches to the study and assessment of organizational performance and attributes (Nuamah, 2011). The qualitative research method as stated by Neuman (1995) focuses on developing truth and occasions it employs little issues and themes for analyses. On the other side, quantitative research methods employ facts and figures and statistics for analyses. The advantages of qualitative methods include the use of the focal unit’s own terms to describe itself, the intensive and in-depth information that can be obtained about a unit, and the amenability of the method for exploratory research on issues and processes about which little information exists. Alternatively, the advantages of quantitative methods include the ease of cross-sectional assessments and comparisons (across individuals, organizations, or sub-units), the replicability of the assessment in different units and by other researchers or organizational development professionals, and a common, articulated frame of reference for interpreting the collated information. Although both methods share the potential for producing cumulative bodies of information for assessment and theory testing, quantitative approaches may be more practical for purposes of knowledge-based approaches for organizational development generally (Trice, 1993; Cooke and Rousseau, 1988). The study employed a descriptive method with an exploratory survey as the design for this study. However, since the data collected included both qualitative and quantitative data, the mixed method was adopted for the study. 33 University of Ghana http://ugspace.ug.edu.gh 3.4 Population According to Fraenkel and Wallen (1993), a population is the group to which the result of the study is intended to apply. The population is a large group of people who exhibit characteristics that stimulate research work. Brenda (2009) stated that the target population of a study comprise of the entire set of entities for which the outcome of the study can be deducted upon. In defining the target population the geographical and other characteristics must be critically considered. The target population comprised all heads of the various units in the Pantang hospital with much focus on the finance section as well as the clients. 3.5 Sample and Sampling Technique Sampling techniques provide a range of methods that help a researcher to reduce the amount of data needed to collect by considering only data from a sub-group rather than all possible cases. The time frame within which the research ought to be conducted makes sampling of the respondents more prudent (Cohen, Manion and Morrison, 2003). Lind et al., (2008) elucidates sampling as a feasible study of the entire population. According to Agyedu et al., (1999), the process of sampling makes it possible to limit a study to a relatively small portion of the population. A sample is thus a subset of the population and consists of representative group of individuals, objects or events that form the population of the study. The data for this study was obtained by self-administered questionnaire distributed to 23 employees who were selected from the various units and departments in Pantang hospital and 500 clients (patients) . The sample was chosen on a purposive sampling basis from the directory. To limit the study to Pantang hospital, Accra all heads of department and units were consulted. 34 University of Ghana http://ugspace.ug.edu.gh Purposive sampling helps the researcher to pay attention to issues that meet the needs of the study whiles convenient sampling is appropriate when the characteristics of the population is uniform (Saunders et al., 2007). The sample selected for the study comprised 23 (ie.10 heads of units and their finance officers) and three administrators of Pantang hospital and 500 clients (patients). 3.6 Data Collection The researcher presented a letter of introduction to seek for permission from the management of Pantang hospital before the data collection process began. 3.6.1 Source of Data Collection Using interviews or questionnaires as data collection instruments as Kumar (2011) put it, it is important to consider the benefits as well as the cost of these instruments. The type of data collection instrument used can affect the findings. Kumar (2011), stipulated that selecting either to use questionnaire or interview, the type of population needs to be considered. The sources of data were primary and secondary data which were collected from the selected departments who were willing to participate in the research exercise as well as clients (patients).The summary financial records showed the various funds received by the hospital were also considered. 3.6.2 Instrument of Data Collection The researcher used both primary and secondary sources of data in conducting the research and instruments such as questionnaire, interviews guide, records books and ledger were used. Ary et al., (2002) iterated that, questionnaires and interviews are the basic ways in which data are collected in surveys. He stated that “the use of multiple data collection instruments ensure validity and reliability of data generated through triangulation”. 35 University of Ghana http://ugspace.ug.edu.gh Abayie (2011) also hold the view that a questionnaire is mostly designed and utilized primary data collection. The merits of using questionnaire in primary data collection was outlined in (Bancroft et al.,2000) that, it is cost effectively good to be used especially in situations where the targeted population widely despaired. Bancroft et al., (2000) viewed secondary data source as the name given to data used for purposes other than those for which it was collected. Due to the research design employed, the questionnaire contained both open and close-ended questions of which respondents were required to respond to them by either ticking or providing short answers to the questions. The closed-ended items were measured with the use of a 5 point Likert scale developed where 1 = Strongly Disagree, 2 = Disagree, 3 = Not Sure, 4 = Agree and 5 = Strongly Agree. 3.6.3 Procedure of Data Collection Questionnaires were self-administered and a period of one week was given to the respondents (staff of Pantang hospital) to respond to the questionnaire. This took undue pressure of the respondents and gave them ample time to respond effectively to the items in the questionnaire. During the administration of the questionnaire, interviews were also conducted to seek clients’(patients) view on quality healthcare delivery at Pantang hospital. This instrument was to help in getting prompt feedback however it was difficult as respondents (clients or patients) were reluctant to respond to some of the questions. Also a participatory observation was used. 3.7 Methods of Data Analysis The data collected from respondents was numbered and coded to aid in the data entry process. Statistical techniques were used to analyze, summarize and interpret the data 36 University of Ghana http://ugspace.ug.edu.gh accordingly. Due to the mixed method of research design used, tables and figures were used to analyze the qualitative data whiles Statistical Package for Social Scientists (SPSS) was used to analyze the quantitative data. The correlation and a multiple regression model was used to measure the relationship between IGF and quality healthcare delivery in Pantang hospital. A factor analysis was performed to determine the impact of the various sources of funds as well as IGF on quality healthcare delivery in Pantang hospital. 37 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULT AND DISCUSSION 4.0 Introduction This chapter presents a detailed discussion and analysis of results of the study with particular reference to the impact of IGF on Quality Healthcare Delivery in Pantang Hospital. These are presented according to the research questions raised to guide the study. It presents both quantitative and qualitative discussion on the impact of IGF on quality healthcare delivery in Ghana. 4.1 Demography As part of the research analysis, the demography of the respondents for the study is presented to give insight and also help to understand better their response and how they affected the outcome and generalization of the study. Pantang hospital is generally noted for the psychiatry services (treatment) but also offer general healthcare service, however due to the condition of the psychiatry patients, the researcher could not interact with them. This limited the study respondents (clients) to those receiving general healthcare service from the hospital. In all, 500 clients were interviewed and 23 questionnaires were given out to staff of Pantang hospital. Out of the 500 clients came a response rate of 77% (i.e. 385 patients) gave a favorable responses that was used for the study. 38 University of Ghana http://ugspace.ug.edu.gh 4.1.1Gender The gender of the respondents is presented in figure 1. figure 4.1 gender of respondent 350 300 250 200 150 100 50 0 Males Females Staff 17 6 Clients(Patients) 79 306 Fig 4.1: Gender of Respondents The data in Figure 4.1 shows that 23 staff were interacted with and 74% (17) were males whiles 26% (6) were females. This gives an indication that majority of the heads of the various units were males with few females in a female dominated sector (profession) such as the health sector. Also the results show that 79.5% (306) of the client of Pantang hospital were females while 20.5% (75) were males. This is not surprising since the population is dominated by females in Ghana. Again, due to child bearing and it associated issues, females turn to visit the hospitals more than their male counterpart (Knape et al.,2014). 39 number of respondents University of Ghana http://ugspace.ug.edu.gh 4.1.2 Age group figure 4.2 age group of respondent Staff Clients 195 126 36 18 13 10 0 0 <20 years 21-30 years 31-45 years 46 -60 years The age groups of the respondents were also considered and the results revealed that a little below two-thirds (65%) of the staff of Pantang were between the ages of 31 and 45 years while about a third (35%) were between 46 and 60 years. This shows that majority of the staff of Pantang hospital were young and can impact positively on it growth and development in providing quality healthcare service to their clients. Again, the results revealed that about half (50.6%) of the clients were between 31 and 45 years, almost a third (32.7%) were between the ages of 21 and 30 years, a little below a tenth (9.3%) were between ages 40 and 60 years whiles 7.4% were 20 years and below. This gives the indication that majority (83%) of the clients of Pantang hospital are between 21 and 45 years. This support the data in fi gure 1 which suggest that most clients go to Pantang with child bearing related issues. 40 University of Ghana http://ugspace.ug.edu.gh 4.1.3 Marital Status figure 4.3 Marital Status of respondent Staff Clients 207 132 36 18 5 0 Married Single Divorced The marital status of the staff of Pantang revealed that close to four-fifth (78.3%) were married while one-fifth (21.7%) were singles with no divorced staff. Also the clients marital status revealed that more than half (53.8%) were married, about a third (34.3%) were singles while 12% were divorced. This give the indication that majority of the respondents are in marital relationships. 41 University of Ghana http://ugspace.ug.edu.gh 4.1.4 Levels of Education The levels of education of respondents were sought for and the result is presented in figure 5. Figure 4.4 Levels of Education of respondent PhD Masters Degree Diploma SHS JHS Not educated 0 50 100 150 200 Not educated JHS SHS Diploma Degree Masters PhD Clients 0 7 54 90 162 72 0 Staff 0 0 0 0 17 4 2 The result revealed that a little below one-fourth (74%) of the staff of Pantang hospital were degree holders, 17.4% were maters degree holders while 8.6% were PhD holders. This shows that the staff of Pantang are highly trained. Also, the result on the clients revealed that more than a third (42%) were degree holders, a little above one-fifth (23.4%) were diploma holders, 14% were SHS graduates while 1.8% were JHS graduates. This gives the indication that majority of the clients of Pantang hospital have had tertiary education and therefore may not compromise on quality. 42 University of Ghana http://ugspace.ug.edu.gh 4.1.5 Departments and Positions of Respondents figure 4.5 Departments and Positions of Respondents Administration Radiology 9% 9% Eye Clinic Clinical 9% Psychology 4% Accounts Medical 31% Laboretary 4% Out Patients Child Mental Department Clinic 17% 4% Reproduction Drug Teatment and Child Health and 9% Rehabilitation 4% Figure 4.6 position of respondent Lab Technician Phamacist 4% 4%Clinical Psychologist 9%Optometrist Accountant 4% Midwive 35% 4% General Nurse 18% Health Administrator Radiologist 13% 9% The study results on the various departments and units and positions of the respondents is presented in figure 5 and 6. The result revealed that a little below a third (31%) were from the accounts department, about one-sixth (17%) were from the Out Patients Department (OPD), a little below a tenth each were from the Administration, Reproduction and Child Health (RCH) unit, Eye clinic and Radiology respectively while 4% each were from the Child mental clinic, Medical Laboratory and Clinical psychology respectively. This shows that 43 University of Ghana http://ugspace.ug.edu.gh almost half (48%) of the respondents were from the accounts and the OPD since they are the first point of contact (i.e. where treatment begins) and the last place to go before one exit the hospital premises. Through these departments, expectations and level of satisfaction with respect to quality of healthcare delivery could be ascertained. 4.1.6 Number of Years served Figure 4.7: Number of Years served by Respondents (Staff) <5 years 6-10 years 11-20 years >21 years 15 15 10 5 5 3 0 0 <5 years 6-10 years 11-20 years >21 years Figure 4.8 how long clients have been receiving treatment at pantang < 5 years 6- 10 years 11-20 years >21 years 0% 0% 26% 74% The number of years that respondents (staff) have served in Pantang hospital was sought for and the results revealed that almost two-thirds (65.2%) has served from between 6 to 10 years, a little above one-fifth (21.7%) have served for 5 years or less whiles 13% have served from 11 to 20 years in Pantang hospital. 44 University of Ghana http://ugspace.ug.edu.gh Also the results of the number of years that patients have been attending Pantang hospital revealed that a little below three-quarter (74%) of the patients have been attending Pantang hospital for 5 years or less while about one-fourth (26%) have been attending Pantang hospital between 6 and 10 years. It is surprising that none of the patients have been receiving medical treatment from Pantang hospital for not more than 10 years. This is because Pantang hospital has been in existence for more than 4 decades. It is gives an indication of the level of satisfaction, loyalty and retention of patients. It may also be as a result in the shift of focus from the provision of Psychiatry services to general healthcare provision. 4.2 The various sources of funds available to Pantang hospital Table 4.1:Sources of Funds Received by Pantang Hospital Sources Donations Government Government Support IGF Total Funds Year (Goods & (Compensation) from NGOs Received Service) 2013 Data N/A 2,544,915.00 Data N/A Data N/A Data N/A 2,544,915.00 % 0.00 100.00 0.00 0.00 0.00 100.00 2014 4,435.00 374,216.38 Data N/A 607,000.00 1,312,953 2,298,604.38 % 0.193 16.28 26.41 57.12 100.00 2015 10,639.80 0.00 Data N/A 509,280.00 2,004,114.99 2,524,034.79 % 0.422 0.00 0.00 20.12 79.40 100.00 2016 116,776.80 0.00 10,003,579.48 1,116,131.80 2,892,586.13 14,129,074.21 % 0.83 0.00 70.80 7. 90 20.47 100.00 2017 55,764.03 2,102,953.50 15,930,511.25 30,000.00 3,046,402.47 21,165,631.25 % 0.26 9.94 75.27 0.14 14.39 100.00 2018 29,201.00 690,912.47 15,999,544.93 30,000.00 4,634,460.37 21,384,118.77 % 0.14 3.23 74.82 0.14 21.67 100.00 Total 216,816.63 5,712,997.35 41,933,635.66 2,292,411.80 13,890,516.96 64,046,378.40 The various sources of funds received by Pantang hospital between 2013 and 2018 is presented in Table 1. The data shows that Pantang hospital the main sources of funds are donations, support from NGOs, government support (i.e. Goods & Service and 45 University of Ghana http://ugspace.ug.edu.gh Compensation) and IGF. Although there are some lapses with respect to the accuracy of the funds reported from 2013 to 2015, but it has been resolved from 2016 onwards. The data shows a lot of inconsistencies in the various sources of fund received annually. Also there is deviation from the source of funds available and what is actually received annually. Figure 4.9 trend of fund received between 2013 and 2018 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Year 2013 2014 2015 2016 2017 2018 IGF 0 1,312,953 2,004,114.9 2,892,586.1 3,046,402.4 4,634,460.3 Support from NGOs 0 607,000.00 509,280.00 1,116,131.8 30,000.00 30,000.00 Government (Compensation) 0 0 0 10,003,579. 15,930,511. 15,999,544. Government (Goods & Service) 2,544,915.0 374,216.38 0 0 2,102,953.5 690,912.47 Donations 0 4,435.00 10,639.80 116,776.80 55,764.03 29,201.00 Fig 4.9: Trend of Funds Received between 2013 and 2018 Figure 4.10 total funds received between 2013 and 2018 Donations Government 0% (Goods & IGF Service) Support from 22% 9% NGOs 4% Government (Compensation) 65% The trend and the proportion of the various sources of funds received from 2013 to 2018 as presented in Figure 10 and 11 shows that Government (compensation) constitute a little below two-thirds (65%), IGF constitute a little above one-five (22%), government (Goods 46 Amount GHS University of Ghana http://ugspace.ug.edu.gh and Service) forms a little below a tenth (9%) whiles NGOs support was just 4% of the total funds received by Pantang hospital from 2013 to 2018. Government support (goods & service) was higher than the other sources of funds in 2013. However, IGF continue to increase from 2013 to 2018, coming second to government support (Compensation) with government support (goods& service) continuously dwindling. Government support (compensation) is given to take care of the Psychiatry OPD and not the entire facility. Therefore taking that away, gives an indication that Pantang hospital depend heavily on IGF which is the second highest source of fund for its operational activities. The data also shows that Pantang hospital has been doing well in mobilizing funds internally to support it operations whiles government continue to wane itself from state owned institution in order for them to be self-reliant. However, it is expected that 15% of government budget allocation annually goes in to support the health sector of the economy. Considering the number of government health facilities in Ghana, the support (i.e. Government Compensation and Goods & Service) to a special health facility like Pantang hospital together with the inconsistencies in other sources of funds is what this study seeks to find its effects on quality of healthcare delivery The relationship between IGF and quality healthcare delivery in Pantang hospital The research objective two sought to identify the relationship (Correlation) between IGF and Quality Healthcare delivery between 2013 and 2018 and the data is presented in Table 2. The quality of products or service has strong positive impact on customer satisfaction. Some defined quality of product or services in terms of performance, conformance, reliability, durability, serviceability, aesthetic, and customer perceived quality (Yuen and Chan, 2010). These are variables used to measure quality in the production and distribution sector and not the service sector such as the health facilities. In assessing the correlation as well as the 47 University of Ghana http://ugspace.ug.edu.gh impact of IGF and quality healthcare delivery, the study took into consideration factors such as (commitment of personnel, availability of equipment and facilities, staff strength of health facility, time spent in delivering and receiving healthcare, clients expectation and funds which includes IGF) that may affect the provision of quality healthcare. It is expected that if these variables are available, quality healthcare will be delivered to patients (clients). The satisfaction of the customers will definitely pave way for clients’ loyalty. Table 2: The Relationship between IGF and Quality Healthcare Delivery Correlations Quality Healthcare Internally Generated Delivery Funds Quality Healthcare Pearson 1 .488 Delivery Correlation Sig. (2-tailed) .326 N 6 6 Internally Generated Pearson .488 1 Funds Correlation Sig. (2-tailed) .326 N 6 6 The data in Table 2 shows a positively low correlation (0.488 or 48.8%) between IGF and quality healthcare delivery in Pantang hospital. This shows that although there is a positive relationship between IGF and Quality healthcare delivery in Pantang hospital, their rate of growth or increment are not the same. It is argued that high level of healthcare delivery would reflect in the population size of patients that receive healthcare in a particular health facility (Keller et al., 2013; Llanwarne et al., 2013). Therefore it is expected that a proportionate increase or growth in IGF should reflect in the quality of healthcare delivery in similar manner. This is because IGF constitute the second highest source of fund. 48 University of Ghana http://ugspace.ug.edu.gh 50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 2013 2014 2015 2016 2017 2018 Patients Population 41010 39610 39128 37265 39822 47213 Fig4. 11: Trend of Patient Population As shown in Figure 4.11, IGF continues to growth which was even expected to reflect in the trend of patients (Clients) population of Pantang hospital. Nonetheless, it is visible from Figure 13 that patient population started to decline from 2014 up to 2016 but rose again in 2017 upwards. The amount of high and low satisfaction depends upon the level of customer expectation or fall above/below to that level (Gerpott, Rams & Schindler, 2001). The satisfaction of the customers will definitely pave way for consumer loyalty. Customer loyalty is a vital element for the continued existence and operation of firms business (Chen & Hu, 2010). Loyalty can be measure by the intention of repurchase, recommending the product/services to other and patience towards price (Kim & Yoon, 2004).Patient population helps to predict the level of quality that is received by clients in a services providing facility (Keller et al., 2013; Llanwarne et al., 2013). Satisfied clients will not always attend to the health facility but also refer others to the health facility for healthcare. This will increase the patient population size of the health facility. Therefore a fall in the patient population with a continual growth in IGF gives an indication that quality healthcare delivery is not based on funds alone but other factors. Although, quality of life received and enjoyed by the citizens may affect the frequency in receiving healthcare treatment. . 49 Amount GHS University of Ghana http://ugspace.ug.edu.gh 4.4 The impact of IGF on quality healthcare delivery The third objective of the study sought to establish the impact of IGF on quality healthcare delivery and the data is presented in Table 3. Table 4.3: Impact of IGF on Quality Healthcare Delivery Model Summary Std. Error of the Model R R Square Adjusted R Square Estimate 1 .488a .239 .048 3344.02189 a. Predictors: (Constant), Internally Generated Funds Coefficients Sum of Model SquarUenss tandardized dCof efficientsM eanS tSanqduaradirzeed CoefficieFn ts Sig. 1M odel Regression 14010881.72B6 Std1. E rro1r4 010881.72B6e ta 1.253 t .32Si6g.b 1 R(Ceonssitdanut)a l 44729929.603782 43.840 245 65.11117 182482.402 1 4.909 .000 TIntoertnaall ly Generated F5u8nd7s4 0811.333 .001 5 .001 .488 1.119 .326 aa.. DDeeppeennddeenntt VVaarriiaabbllee:: QQuuaalliittyy HHeeaalltthhccaarree DDeelliivveerryy b. Predictors: (Constant), Internally Generated Funds The data in Table 3 gives the indication that IGF can impact quality healthcare delivery in Pantang hospital up to (0.488 or 48.8%) when the R is considered. Considering the predictability or how IGF only can explain the behavior of Quality healthcare delivery in Pantang hospital, it is seen that IGF can only predict or explain the level of healthcare delivery of Pantang hospital up to 0.239 or 23.9%. A marginal change in IGF will result in a marginal change in quality healthcare delivery of Pantang hospital up to 0.048 or 4.8%. This gives an indication that Quality healthcare delivery in Pantang hospital cannot be explained or determined by the amount of money available only at a point in time but other factors. 4.5 The level of healthcare delivery in Pantang hospital This research also sought to establish the level of healthcare delivery in Pantang hospital. This was done by considering the clients expectation together with other factors that can 50 University of Ghana http://ugspace.ug.edu.gh affect the quality of healthcare delivery in Pantang hospital and the results is presented in Table 4 and 5. Table 4.4: Level of Healthcare delivery in Pantang Hospital Coefficients Standardized Unstandardized Coefficients Coefficients Model B Std. Error Beta T Sig. 1 (Constant) 45932.667 9135.377 5.028 .007 Clients Expectation -.088 .150 -.280 -.584 .591 a. Dependent Variable: Quality Healthcare Delivery Correlations Quality Healthcare Delivery Clients Expectation Pearson Correlation Quality Healthcare Delivery 1.000 -.280 Clients Expectation -.280 1.000 Sig. (1-tailed) Quality Healthcare Delivery . .295 Clients Expectation .295 . N Quality Healthcare Delivery 385 385 Clients Expectation 385 385 Table 4.5: The Correlation between the factors the affect Quality Healthcare delivery Correlations Total Sources of Availability Attitude Funds of Time Availability of Quality received by Facilities Medical spent in of Health Healthcare Pantang and Staff Clients receiving Emergenc person Delivery hospital Equipment Strength Expectation treatment y facility nel Pearson Quality Healthcare 1.000 .424 .063 .328 -.022 -.388 -.218 -.238 Correlation Delivery Total Sources of Funds received by .424 1.000 -.378 .559 -.084 -.962 .372 -.553 Pantang hospital Availability of Facilities and .063 -.378 1.000 -.918 .159 .490 -.457 .928 Equipment Medical Staff .328 .559 -.918 1.000 -.220 -.633 .379 -.980 Strength 51 University of Ghana http://ugspace.ug.edu.gh Clients Expectation -.022 -.084 .159 -.220 1.000 -.132 .131 .349 Time spent in -.388 -.962 .490 -.633 -.132 1.000 -.468 .594 receiving treatment Availability of -.218 .372 -.457 .379 .131 -.468 1.000 -.300 Emergency facility Attitude of Health -.238 -.553 .928 -.980 .349 .594 -.300 1.000 personnel Sig. (1-tailed) Quality Healthcare . .201 .453 .263 .484 .223 .339 .325 Delivery Total Sources of Funds received by .201 . .230 .124 .437 .001 .234 .127 Pantang hospital Availability of Facilities and .453 .230 . .005 .382 .162 .181 .004 Equipment Medical Staff .263 .124 .005 . .338 .088 .229 .000 Strength Clients Expectation .484 .437 .382 .338 . .401 .403 .249 Time spent in .223 .001 .162 .088 .401 . .175 .107 receiving treatment Availability of .339 .234 .181 .229 .403 .175 . .281 Emergency facility Attitude of Health .325 .127 .004 .000 .249 .107 .281 . personnel N Quality Healthcare 385 385 385 385 385 385 385 385 Delivery Total Sources of Funds received by 385 385 385 385 385 385 385 385 Pantang hospital Availability of Facilities and 385 385 385 385 385 385 385 385 Equipment Medical Staff 385 385 385 385 385 385 385 385 Strength Clients Expectation 385 385 385 385 385 385 385 385 Time spent in 385 385 385 385 385 385 385 385 receiving treatment Availability of 385 385 385 385 385 385 385 385 Emergency facility Attitude of Health 385 385 385 385 385 385 385 385 personnel 52 University of Ghana http://ugspace.ug.edu.gh The data in Table 4 and 5 shows that clients expectation are not met in Pantang hospital with a beta of (-0.280). In considering the correlation of other factors that helps in determining the level of quality of healthcare delivery in Pantang, the results revealed that Total Sources of Funds received by Pantang hospital, Availability of Facilities and Equipment, Medical Staff Strength contribute positively to the level of quality healthcare with correlations 0.424, 0.063 and 0.328 respectively while Clients Expectation, Time spent in receiving treatment, Availability of Emergency facility and Attitude of Health personnel are contributing negatively to the level of quality healthcare with correlation of -0.022,-0.388,-0.218 and - 0.238 respectively. 4.6 Challenges in Healthcare Delivery In addressing research question four respondents view (i.e. staff and clients) were sought on the challenges they face in delivering and receiving quality healthcare in Pantang hospital and the results are presented in Figure 14 and 15. 4.6.1 The Challenges that Pantang hospital faces in healthcare delivery Figure 4.12 Challenges Faced in Health Delivery 9 6 4 3 1 Low Delay in Lack of stafff Inadequate Inadequate Government payment of Motivation Equipment Critical Staff support NHIS claims and Logistics 53 University of Ghana http://ugspace.ug.edu.gh Fig 4.13: Challenges faced by Clients in accessing quality Healthcare at Pantang 150 103 100 88 42 50 12 35 30 0 22 10 4 15 10 8 6 According to Figure 4.13, among the challenges faced by respondents (staff) in delivering quality healthcare includes Low government support, Delay in payment of NHIS claims, Lack of staff motivation, Inadequate equipment and logistics and Inadequate critical medical staff with frequencies of (9, 6, 3, 4, 1) respectively. This shows that the two major challenges are financials (government support and delayed claim payment) which is preventing Pantang hospital from delivering quality healthcare. This gives an indication that with regular financial support together with the IGF, Pantang hospital can deliver quality healthcare to its clients considering the kind of services they render. Also among the challenges faced by clients in accessing healthcare includes Delay in receiving treatment, poor hospital environment, bad attitude of some health workers, NHIS not extensive enough, long time to locate folder, inadequate specialist, poor communication among health workers, high cost of treatment, inadequate emergency facilities, lack of basic drugs, delay in getting lab results with frequencies of (103, 12, 42, 88, 35, 30, 22, and 10, 4, 15, 10, 8, 6 respectively. The data shows that delay in receiving treatment and bad attitude of 54 Delay in receiving treatment Hospital environment no… Long queues Bad Attitude of health… NHIS not externsive Long time to locate folder Inadequate specialized… Poor communication… High cost of treatment Inadequate emergency… Lack of basic drugs Continual changes in… Delay in getting lab test University of Ghana http://ugspace.ug.edu.gh some health workers forms the greatest challenge and that if addressed, clients expectations on quality healthcare will be met. 4.6.2 Areas to improve Healthcare Delivery suggested by Staff Figure 4.14 Areas That Need Improvement Sonography Unit 4% Accounts Units 22%Medical doctors 31% Procurement units 13% Stores Catering unit 13% 9% I.T. Unit 4% Radiology Unit 4% 4.6.3 Areas suggested by client that need improvement figure 4.15 areas that need improvement 75 43 38 37 37 36 36 28 28 18 9 The data presented in Figure 16 and 17 are the responses of staff and clients of Pantang hospital about areas that need improvement in order to help deliver and receive quality 55 University of Ghana http://ugspace.ug.edu.gh healthcare. According to figure 16, the areas includes medical doctors, account units, stores, procurement unit, catering unit, sonography, radiology unit and I.T unit with percentages (31%, 22%, 13%, 13%, 9%, 4%, 4% and 4% ) respectively. This gives the indication that if more medical doctors and psychiatrist are send to Pantang together with improving the accounts unit, greater percentage of the problems of Pantang hospital will be solved. Also, figure 16 present the views of clients and they suggested that OPD facilities must be improved, improve road network to the hospital, refurbish hospital’s infrastructure, train health worker to act professionally, increase in-patient (wards) facilities, reduce time spent before getting lab result, stock the pharmacy with requisite drugs, improve filing system, setup a standard emergency facility, increase staff strength and improve client relationship with frequencies (75, 37, 37, 36, 28, 18,36, 28, 9, 38, and 43). 4.7 Discussions According to Agyepong (1999;2010), sources of healthcare financing in Ghana for hospitals and other health facilities includes IGF or user fees, central government allocations (GoG), funding from NGOs and other donors, and community contributions in cash or in kind for specific projects Agyepong (1999;2010). This study viewed healthcare funding from the broader perspective but every health facility whether private or government have their various sources of funds which deviate a bit from the assertion of Agyepong (1999, 2010). For instance, the data shows that Pantang hospital’s main sources of funds are donations, support from NGOs, government support (i.e. Goods & Service and Compensation) and IGF which lacks community contributions as a source of fund. The two major financial challenges are (unavailability of government support and delayed claim payment) which is preventing Pantang hospital from delivering quality healthcare. This gives an indication that with regular financial support together with the IGF, Pantang hospital can deliver quality healthcare to its clients considering the kind of services they render. 56 University of Ghana http://ugspace.ug.edu.gh Adams and Colebourne (1999) opined that financial management, in service organizations, has been a constraint and an obstacle to other functions that contribute to service delivery and this is in support of this study. According to Obansa & Orimisan (2013), Healthcare financing is worse hit especially in the poor continent where healthcare faces serious problem of acceptability with out-of-pocket (cash-and-carry) expenditure accounting for over 70% of total private health expenditure is enough to dent the little progress of the health system made. Hence, the increasing out-of- pocket expenditure due to high disease burden on most poverty-stricken households has kept them in the vicious cycle of the poverty trap. The study supports this assertion although the percentage seems to be a little lower considering the statistics in Pantang hospital. There were a lot of inconsistencies in the various sources of fund received annually. Also there was deviation from the source of funds available and what is actually received kept fluctuating annually which may affect planning and prudent financial management. According to Maureen (2005), low funding for Health facilities has adversely affected the delivery of health services especially at the grass-roots. IGF in Pantang hospital continued to increase from 2013 to 2018, coming second to government support (Compensation) with government support (goods& service) continuously dwindling. Government support (compensation) is given to take care of the Psychiatry OPD and not the entire facility. Therefore taking that away, gives an indication that Pantang hospital depend heavily on IGF which is the second highest source of fund for its operational activities. Pantang hospital has been doing well in mobilizing funds internally to support it operations whiles government continue to wane itself from state owned institution in order for them to be self-reliant. However, it is expected that 15% of government budget allocation annually goes in to support the health sector of the economy. Considering the number of government 57 University of Ghana http://ugspace.ug.edu.gh health facilities in Ghana, the support (i.e. Government Compensation and Goods & Service) to a special health facility like Pantang hospital together with the inconsistencies in other sources of funds will definitely affect the quality of healthcare delivery. In a service industry, like healthcare, experience of the patient plays a crucial role in rating and assessment of quality of services. Quality in healthcare may comprise of newer technology, newer and effective medication, and higher staff to patient ratios, affordability, efficiency and effectiveness of service delivery (Tam, 2005; Wanjau et al.,2012). Quality healthcare delivery in Pantang hospital cannot be explained or determined by the amount of money available only at a point in time but other factors. This is evident in this study and support Tam (2005) and Wanjau et al.(2012) view as they considered other factors apart from funds. Quality Service delivery has significant relationship with customer satisfaction (Swanson and Davis, 2003), customer retention (Yavas, Benkenstein and Stuhldreier, 2004), loyalty (Boshoff and Gray, 2004), costs (Wilson 2008), profitability (Irving and Dickson, 2004), service guarantees (Kandampully and Butler, 2001) and growth of organization (Sohail, 2003). IGF continued to growth which was even expected to reflect in the trend of patients (Clients) population of Pantang hospital. Nonetheless, patient population started to decline from 2014 up to 2017 but rise again in 2018. Patient population helps to predict the level of quality that is received by clients in a services providing facility. Reinartz (2004) argued that if the inherent characteristic of a service meets the requirements of the customer, it can be rated as high quality. Therefore, a fall in the patient population with a continual growth in IGF gives an indication that quality healthcare delivery has not met patient expectations. In healthcare industry service quality according to Ennis and Harrington (2001) has become an imperative in providing patient satisfaction because delivering quality service directly affects the customer satisfaction, loyalty and financial profitability of service businesses. 58 University of Ghana http://ugspace.ug.edu.gh Although there is a positive relationship between IGF and Quality healthcare delivery in Pantang hospital, their rate of growth or increment are not the same. It is expected that a proportionate increase or growth in IGF should reflect in the quality of healthcare delivery in similar manner since it is the second highest source of fund but that was not realized. Factors such as delay in receiving treatment and bad attitude of some health workers forms the greatest challenge and that if addressed could meet clients’ expectations on quality healthcare. 59 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE SUMMARY OF FINDINGS, CONCLUSION AND RECOMMENDATIONS 5.0 Introduction This chapter covers the summary of findings, conclusions and recommendations of the study on the impact of IGF on quality healthcare delivery in Ghana, A case study of Pantang Hospital. They are drawn from the results and analysis of the study from the previous chapter. 5.1 Summary of Findings The study revealed that Pantang hospital’s main sources of funds are donations, support from NGOs, government support (i.e. Goods & Service and Compensation) and IGF. Nevertheless, there are a lot of inconsistencies in the various sources of fund received annually. IGF continue to increase from 2013 to 2018, coming second to government support (Compensation) with government support (goods& service) continuously dwindling. Government support (compensation) is given to take care of the Psychiatry OPD and not the entire facility. Therefore, taking that away, gives an indication that Pantang hospital depend heavily on IGF which is the second highest source of fund for its operational activities. Pantang hospital has been doing well in mobilizing funds internally to support it operations whiles government continue to wane itself from state owned institution in order for them to be self-reliant. There is a positively low correlation (0.488 or 48.8%) between IGF and quality healthcare delivery in Pantang hospital. The continuous growth in IGF was even expected to reflect in the trend of patients (Clients) population of Pantang hospital. Nonetheless, it is visible from 60 University of Ghana http://ugspace.ug.edu.gh Figure 13 that patient population started to decline from 2014 up to 2017 but rose again in 2018. The impact of IGF on quality healthcare delivery gives the indication that IGF can impact quality healthcare delivery in Pantang hospital up to (0.488 or 48.8%) when the R is considered. Considering the predictability or how IGF only can explain the behavior of Quality healthcare delivery in Pantang hospital, it is seen that IGF can only predict or explain the level of healthcare delivery of Pantang hospital up to 0.239 or 23.9%. A marginal change in IGF will result in a marginal change in quality healthcare delivery of Pantang hospital up to 0.048 or 4.8%. This gives an indication that Quality healthcare delivery in Pantang hospital cannot be explained or determined by the amount of money available only at a point in time but other factors. The level of healthcare delivery in Pantang hospital when considering the correlation of other factors that helps in determining the level of quality of healthcare delivery in Pantang, the results revealed that Total Sources of Funds received by Pantang hospital, Availability of Facilities and Equipment, Medical Staff Strength contribute positively to the level of quality healthcare while Clients Expectation, Time spent in receiving treatment, Availability of Emergency facility and Attitude of Health personnel are contributing negatively to the level of quality healthcare. The challenges they face in delivering and receiving quality healthcare in Pantang hospital includes Low government support, Delay in payment of NHIS claims, Lack of staff motivation, Inadequate equipment and logistics and Inadequate critical medical staff. Also among the challenges faced by clients in accessing healthcare includes Delay in receiving treatment, poor hospital environment, bad attitude of some health workers, NHIS not 61 University of Ghana http://ugspace.ug.edu.gh extensive enough, long time to locate folder, inadequate specialist, poor communication among health workers, high cost of treatment, inadequate emergency facilities, lack of basic drugs, delay in getting lab results. The areas that need improvement according to the staff includes medical doctors, account units, stores, procurement unit, catering unit, sonography, radiology unit and I.T unit while to the patients improvement in OPD facilities, good road network to the hospital, refurbished hospital’s infrastructure, professionalism on the part of health workers, increased wards facilities, reduced time spent before getting lab result, stocked pharmacy, improved filing system, emergency facility, increased staff strength and improve client relationship could improve the level of quality of healthcare delivery. 5.2 Conclusion Base on the findings of the study, the following conclusion were made;  The main sources of funds for Pantang hospital are donations, support from NGOs, government support (i.e. Goods & Service and Compensation) and IGF.  Pantang hospital has been doing well in mobilizing funds internally to support it operations. However, they depend heavily on IGF which is the second highest source of fund for its operational activities.  IGF can impact quality healthcare delivery in Pantang hospital up to (0.488 or 48.8%) and quality healthcare delivery in Pantang hospital cannot be explained or determined by the amount of money available only at a point in time but other factors.  The two major financial challenges are (unavailability of government support and delayed claim payment) which is preventing Pantang hospital from delivering quality healthcare. Whiles delay in receiving treatment and bad attitude of some health workers forms the greatest challenge and that if addressed, clients expectations on quality 62 University of Ghana http://ugspace.ug.edu.gh healthcare will be met. Also, if more medical doctors and psychiatrist are send to Pantang together with improvement in the accounts unit, greater percentage of the problems of Pantang hospital will be solved. 5.3 Recommendations The following recommendations were made by the study;  That there should be consistency from the various sources of funds to help Pantang hospital plan it activities well to meet its core mandate.  That more specialists and other health workers be posted to Pantang hospital to improve quality healthcare and also reduce the time spent in receiving treatment whiles reducing the long queues.  That health workers should act professionally in the discharge of their duties.  That government gives special attention to Pantang hospital due to the kind of healthcare services it renders to help deliver quality healthcare leading to the achievement of the millennium development goals which includes accessibility to quality healthcare for all.  That government reconstructs the road network to the hospital to aid accessibility.  That government refurbishes the infrastructure facilities in Pantang to give it a face- lift which will affect patronage and generation of funds internally. 5.4 Suggestion for Future Studies The study was conducted only in Pantang Hospital in the greater Accra region and was unable to cover all hospitals in the region and even across the country. This affected the generalization of the outcome of the study. Also the methodology influenced the outcome of the study considering the setup or the kind of service rendered by Pantang hospital. The study therefore wishes to suggest that future researchers should consider conducting the study to 63 University of Ghana http://ugspace.ug.edu.gh cover all hospitals in the greater Accra region and if possible extend it to cover other health institutions in the country. Again, different models and analysis could be used to affirm or negate the outcome of this study. 64 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abiola, G.A., & Ehigiamusoe, U.K. (2014). Analysis of internally generated revenue and its Implications on fiscal viability of states governments in Nigeria. Journal of Empirical Economics, 2(3), 216-228. Adams, I., Darko, D. and Accorsi, S. (2004). Malaria – A Burden Explored. 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The information that you provide will wherefore be used strictly for academic purposes and will be treated confidentially. Thank you for your cooperation. SECTION A: DEMOGRAPHY 1. Gender: Male [ ] Female [ ] 2. Age Group: 21-30yrs [ ] 31-45yrs [ ] 46-60yrs [ ] 3. Marital status Married [ ] Single [ ] Divorced [ ] 4. Level of Education: Diploma [ ] HND [ ] Degree [ ] Masters [ ] PhD [ ] Others please specify______________________________________________ 5. Please specify your Department _____________________________________ 6. Position (please specify) __________________________________________ 7. Please thick the number of years you have worked in this hospital < 5 years [ ] 6 – 10 years [ ] 11–20 years [ ] > 21 years [ ] 73 University of Ghana http://ugspace.ug.edu.gh SECTION B Please thick [√ ]appropriately how you agree/disagree to the statement below Key: Strongly Disagree = SD; Disagree = D; Not Sure = NS; Agree= A; Strongly Agree = SA Statement SD D NS A SA 1. *The hospital get government support through the [ ] [ ] [ ] [ ] [ ] ministry of health. 2. The government pays all the staff working in the hospital. [ ] [ ] [ ] [ ] [ ] 3. Donor agencies donates to the hospital occasionally [ ] [ ] [ ] [ ] [ ] 4. The hospital sometimes receive support from NGOs [ ] [ ] [ ] [ ] [ ] 5. The community and the local assembly sometimes [ ] [ ] [ ] [ ] [ ] support health projects of the hospital 6. The hospital sometimes deliver healthcare to patients [ ] [ ] [ ] [ ] [ ] who pay cash after treatment 7. Patients who pay cash after treatment forms greater [ ] [ ] [ ] [ ] [ ] percentage of the hospital’s clients 8. The hospital deliver healthcare to patients who are on [ ] [ ] [ ] [ ] [ ] NHIS 9. Funds received from NHIS claims form greater percent [ ] [ ] [ ] [ ] [ ] of IGF of the hospital 10. NHIS claims are paid promptly after claims submission [ ] [ ] [ ] [ ] [ ] 11. NHIS claims paid help cushion the hospital to deliver [ ] [ ] [ ] [ ] [ ] quality healthcare to its clients 12. **The hospital has the equipment needed to provide basic [ ] [ ] [ ] [ ] [ ] healthcare to its clients 13. The various departments in the hospital are well [ ] [ ] [ ] [ ] [ ] furnished that help it to function effectively 14. ***Health personnel in the hospital are motivated to [ ] [ ] [ ] [ ] [ ] discharge their duties. 15. Health personnel love what they do to better the lives of [ ] [ ] [ ] [ ] [ ] their clients SECTION C 1. Please state the amount the hospital received between 2013 to 2018 from the following sources; Sources 2013 2014 2015 2016 2017 2018 Donations Government support (GoG) Support from NGOs IGF Community/ Local Assembly support 74 University of Ghana http://ugspace.ug.edu.gh 2 Please state the equipment acquired and facilities built from 2013 to 2018 _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 3 Please state the number of health personnel before and the number of health specialists and staff that have been introduced to improve the staff strength of the hospital from 2013 to 2018. ____________________________________ _____________________________________________________________________ _____________________________________________________________________ ___________________________________________________ 4 Please state the number of patients (clients) that have received treatment from the hospital from 2013 to 2018 ______________________________________ _______________________________________________________________ 5 Out of that number stated above, please state the number of patients that were on NHIS_______________________________________________________ ______________________________________________________________ 6 Please state the challenges that the hospital face in healthcare delivery _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 7 Please state the departments and areas that the hospital needs to strengthen to help improve the quality of healthcare delivery ________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Thank You 75 University of Ghana http://ugspace.ug.edu.gh APPENDIX B UNIVERSITY OF GHANA, LEGON MSc. ACCOUNTING AND FINANCE TOPIC: THE IMPACT OF INTERNALLY GENERATED FUNDS ON QUALITY HEALTHCARE DELIVERY IN PANTANG HOSPITAL INTERVIEW GUIDE FOR CLIENTS (PATIENTS) OF PANTANG HOSPITAL Introduction This study tries to find out the impact of IGF on quality healthcare delivery. The information that you provide will wherefore be used strictly for academic purposes and will be treated confidentially. Please thick [√ ]appropriately the question below. Thank you for your cooperation. SECTION A: DEMOGRAPHY 1) Gender: Male [ ] Female [ ] 2) Age Group: < 20yrs 20-30yrs [ ] 31-40yrs [ ] 41-50yrs [ ] 50 yrs > [ ] 3) Marital status Married [ ] Single [ ] Divorced [ ] 4) Level of Education: JHS [ ] SHS [ ] Diploma [ ] Degree [ ] Masters [ ] PhD [ ] Others please specify____________________________________ 5) Please specify the type of disease you were diagnosed of ___________________ __________________________________________________________________ 6) Please thick when you started receiving healthcare treatment from the hospital. < 5 yrs ago [ ] 6 – 10 yrs ago [ ] 11–20 yrs ago [ ] 21> years ago [ ] 7) Please state how long you have been on treatment in the hospital __________________________________________________________________ 76 University of Ghana http://ugspace.ug.edu.gh SECTION B Please thick [√ ]appropriately how you agree/disagree to the statement below Key: Strongly Disagree = SD; Disagree = D; Not Sure = NS; Agree= A; Strongly Agree = SA Statement SD D NS A SA 1. *I trust that the hospital has the needed facilities and [ ] [ ] [ ] [ ] [ ] equipment to deliver quality healthcare. 2. The environment is conducive for health treatment. [ ] [ ] [ ] [ ] [ ] 3. I believe that thee health personnel have the right [ ] [ ] [ ] [ ] [ ] expertise to treat me. 4. I know that the health personnel will handle me well and [ ] [ ] [ ] [ ] [ ] treat me with respect. 5. I expect to be treated within a possible time without any [ ] [ ] [ ] [ ] [ ] delay. 6. I pay with cash before I receive treatment [ ] [ ] [ ] [ ] [ ] 7. **I spent a lot of time before am able to see the doctor [ ] [ ] [ ] [ ] [ ] 8. There is a long cue which delay consultation and [ ] [ ] [ ] [ ] [ ] treatment 9. The attitude of health personnel create delay which [ ] [ ] [ ] [ ] [ ] affect treatment 10. There is available first aid (emergency treatment) facility [ ] [ ] [ ] [ ] [ ] to calm patients who are waiting for treatment. SECTION C 1. Please state the challenges patients face when receiving healthcare _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 2. Please state the areas that needs improvement in the hospital’s healthcare delivery. ________________________________________________________ _______________________________________________________________ Thank You 77