RA412. B17 bite C .l 381569 University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA BUSINESS SCHOOL SUBSCRIBER PERCEPTION OF QUALITY OF HEALTH CARE SERVICES UNDER THE NEW JUABENG AND KETU DISTRICT MUTUAL HEALTH INSURANCE SCHEMES IN GHANA. * y ' BY ANITA ASIWOME BAKU (10067969) A THESIS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF A MASTER OF PHILOSOPHY DEGREE IN BUSINESS ADMINISTRATION (HEALTH SERVICES MANAGEMENT) JULY, 2007 University of Ghana http://ugspace.ug.edu.gh DECLARATION I declare that except for references to other people’s works which have been duly acknowledged, this work is the result o f my own research undertaken under supervision and has not been presented in part or in whole for the award o f any degree anywhere. i kii"A K i f Anita A. A. Baku (Student) Q < Dr. Kwabena Adu Poku (Supervisor) ^~\ Mr. Alfred Obuobi (Supervisor) University of Ghana http://ugspace.ug.edu.gh DEDICATION This thesis is dedicated to my family and friends with love and gratitude for the immeasurable support I received from them in coming this far. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT This work owes its form and content to the diverse contributions o f several people. I would therefore like to extend to these people in a special way, an unquantifiable big word o f gratitude. The first, my supervisors, Dr. Kwabena Adu Poku and Mr. Alfred Obuobi, for the willing and painstaking manner they read and offered sound advice, helpful suggestions and constructive criticisms which gave meaning to the work. The second, Dr. E. K. Sakyi, for his invaluable contribution which only paralleled that o f my supervisors and Mr. Nkrumah for providing me with some insightful articles and his willingness help at every stage o f the work. The third, Messrs Adafula and Ampem-Darkwa; the former for his critical insights as he read through my work, and the latter for being instrumental in the choice o f the two districts used for the study. Last but not least, Mr. Jacob Hanson for his constant encouragement and attention, and my parents especially my father, Dr. Kofi Baku for being my first teacher and supporting me throughout my studies. University of Ghana http://ugspace.ug.edu.gh ABSTRACT The perception that an individual forms about a thing affects that individual’s behaviour and attitude towards that thing. The District Mutual Health Insurance Schemes in Ghana are a new way o f financing health care in the country. The need to sustain these newly introduced schemes by improving and sustaining quality o f health care services under them is extremely important. However, there is a dearth o f knowledge on subscribers’ perception o f the quality o f health care services under these schemes. Bridging this knowledge gap is a necessary first step in determining the improvement and subsequent sustainability o f the quality o f health services provided under the schemes. A convenient sample o f 400 respondents each from the New Juabeng and Ketu District Mutual Health Insurance schemes participated in the study. The empirical research was conducted using questionnaire and interviews to assess subscribers’ perception o f service quality under the two schemes. Respondents’ perception o f service quality was measured along the following quality dimensions the level o f communication, the demeanour o f staff and availability o f essential drugs using a likert scale. The scale was anchored 1 and 5 with one being “very good” and 5, “very poor” . The findings o f the study indicate that subscribers in New Juabeng rated the overall level o f communication and the attitude o f staff as good on the likert scale, whilst those in Ketu rated the same quality dimensions as fair. On the issue of availability o f essential drugs, 63% o f the respondents in New Juabeng said University of Ghana http://ugspace.ug.edu.gh prescribed drugs were available at the health care facilities and tyfZo o f the respondents in Ketu said prescribed drugs were available at health care facilities in the locality. Respondents on the two schemes appeared to agree that an explanation on medical tests to be taken by them was important in determining the level o f communication, while the courtesy o f the nursing staff was a major determinant o f the attitude o f staffs in the health care facilities. Respondents recommended that nursing staffs o f the various health facilities be courteous and helpful, National Health Insurance Drugs should be in constant supply at the health care facilities and health care facilities be expanded to accommodate the increases in hospital attendance following the introduction o f the health insurance scheme. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Declaration...............................................................................................................................I Dedication............................................................................................................................... II Acknowledgement............................................................................................................... Ill A b s tr a c t ........................................................................................................................................ IV Table o f Contents................................................................................................................VI List o f Tables........................................................................................................................XI Figure.....................................................................................................................................XII List o f Acronyms and Abbreviations.........................................................................XIII Chapter One..................................................................................... 1 Introduction............................................................................................1 1.0 Background........................................................................................................................ 1 1.1 Problem Statement............................................................................................................6 1.2 Objectives o f the Study...................................................................................................7 1.3 The Research Questions..................................................................................................8 1.4 Significance and Justification for The Study............................................................. 9 1.5 Structure o f the Study....................................................................................................10 1.6 Conclusion....................................................................................................................... 11 University of Ghana http://ugspace.ug.edu.gh Chapter Two................................................................................... 12 Conceptions, Determinants and Importance of Quality in Health Care........................................................................................................ 12 2.0 Introduction.......................................................................................................................12 2.1 The Concept o f Quality................................................................................................. 12 2.2 Determinants o f Services Quality ............................................................................... 13 2.3 Quality as an Issue in Health Care.............................................................................. 18 2.3.1 D ifferent Per spect ive s In H ealth C are Qu a l it y .................................. 20 2.4 Importance o f Quality and its Measurement............................................................ 22 2.5 The Context o f Quality Assurance in Ghana............................................................23 2.6 Conclusion....................................................................................................................... 26 Chapter Three................................................................................n Measuring Health Care Quality: The Context of the Study...........n 3.0 Introduction..................................................................................................................... 27 3.1 Measuring Health Care Quality...................................................................................27 3.2 Models for Measuring Quality o f Health Care Service......................................... 31 3.3 Conceptual Framework for the Study........................................................................33 3 .3 .1 L evel O f C o m m u n ic a t io n ................................................................................................33 3 .3 .3 A va ila b il ity O f D r u g s ..................................................................................................3 6 3.4 Operational Definitions o f Term s...............................................................................41 University of Ghana http://ugspace.ug.edu.gh 3 .5 C o n c lu s io n ............................................................................................................................................ 41 Chapter Four..................................................................................... « Health Reforms and Financing Strategies........................................ 43 4 .0 In trod u c tion ............................................................................................................................................. 43 4.1 S ou rce s o f F unds for the H ea lth S ec to r in G h a n a ............................................................. 44 4 .2 H ea lth R e fo rm s and F in an c in g In G hana ................................................................................44 4 .2 .1 T he N at io n a l H ealth In su r a n c e Sch em e ............................................................4 8 4 .3 D istr ic t M u tua l H ea lth In surance S ch em e s In G h a n a .....................................................51 4 .3 .1 C a se S t u d y 1 - T he N ew Ju a b e n g M un ic ipa l H ealth In su r a n c e Sc h e m e ........................................................................................................................................................52 4 .3 .2 C a se St u d y 2 - T he K etu D istr ict M u tu a l H ealth In su r a n c e Sc h e m e ........................................................................................................................................................54 4 .4 C o n c lu s io n ............................................................................................................................................... SS Chapter F ive .......................................................................................................................................57 Methods and Techniques of Data Collection........................................................ 57 5 .0 In trod u c tio n .............................................................................................................................................57 5.1 R esearch D e s ig n ....................................................................................................................................57 5 .2 .1 D emograph ic C haracter ist ic s O f R e s po n d e n t s ............................................ 59 5 .3 S am p lin g D e s ig n and P rocedures................................................................................................. 60 5 .4 Q u est ion n a ire s and In d ica to rs .......................................................................................................62 5 .4 .1 Pre -T e st ing O f Q u e st io n n a ir e .................................................................................... 63 v iii University of Ghana http://ugspace.ug.edu.gh 5 .4 .2 A dm in ist r a t io n O f Q ue st io n n a ir e s A n d In t e r v ie w s .................................63 5 .5 D a ta P ro c e ss in g and A n a ly s i s ....................................................................................................... 64 5 .6 E th ica l C on s id era t io n s ....................................................................................................................... 65 5 .8 C o n c lu s io n ............................................................................................................................................... 65 Chapter S ix ..................................................................................... 66 Presentation of Findings......................................................................66 6 .0 In trod u c tio n ............................................................................................................................................. 66 6.1 D em og rap h ic C haracteristic o f R e sp ond en ts ........................................................................66 6 .2 A v era g e P ercep tua l Ju d gm en ts .....................................................................................................70 6 .2 .1 Level O f C om m u n ic a t io n ................................................................................................70 6 .2 .2 A tt itude O f St a f f s ............................................................................................................... 71 6 .2 .3 A v a ila b il ity O f D r u g s ..................................................................................................... 73 6 .2 .4 G eneral Q ual it y Ra t in g s .............................................................................................. 7 4 6 .2 .5 R ecomm endat io n O f Scheme B a se d O n Q u a l it y Ra t in g ........................75 6 .3 C om para tiv e A n a ly se s o f the DM H I S ch em e s .................................................................... 76 6 .3 .1 Level O f C om m u n ic a t io n ................................................................................................7 7 6 .3 .2 A tt itude O f St a f f .................................................................................................................78 6 .4 O ther R e la ted Is su e s Em erg in g from the S tu d y ..................................................................81 6 .3 .3 C om pla in t s A n d T he H a nd l in g O f C o m pl a in t s ............................................. 81 6 .4 .1 U nexpected E xper iences O f R e s p o n d e n t s ......................................................... 82 6 .4 .2 B est T h ing A bout N his A t T he H ealth Fa c il it y ...........................................82 6 .4 .3 W or se T h ing A bo ut N his In T he H ealth Fa c il it y ........................................83 ix University of Ghana http://ugspace.ug.edu.gh 6 .4 .4 R ecom m endat io n s For M eet ing N eed s O f S u b sc r ib e r s ...........................83 6 .5 Q u a lity B e fo r e th e In troduction o f th e S c h em e s ............................................................84 6 .7 C o n c lu s io n ................................................................................................................................................84 Chapter Seven................................................................................ 86 Summary, Conclusions and Policy Implications................. 86 7.1 In trod u c tio n ............................................................................................................................................. 86 7 .2 D is c u s s io n s .............................................................................................................................................. 86 7 .3 R es ta tem en t o f O b je c t iv e s ............................................................................................................... 92 7 .4 Summ ary o f K ey F in d in g s ..............................................................................................................93 7 .5 C o n c lu s io n s .............................................................................................................................................95 7 .6 P o lic y Im p lic a t io n s o f the S tu d y ................................................................................................. 96 7 .6 .1 Im pl icat io n s For Further Re s e a r c h ...................................................................9 8 7 .7 C o n c lu s io n s .............................................................................................................................................99 R e fe r en c e s ...................................................................................................................................................... 100 A p p en d ix 1.......................................................................................................................................................112 A p p en d ix I I .................................................................................................................................................... 116 A p p en d ix I I I ..................................................................................................................................................117 A p p en d ix IV ..................................................................................................................................................119 A pp end ix V .................................................................................................................................................... 120 A pp en d ix V I ..................................................................................................................................................121 x University of Ghana http://ugspace.ug.edu.gh Table 6.1: Gender Distribution o f Respondents........................................................... 67 Table 6.2: Age Distribution o f Respondents................................................................. 68 Table 6.3: Level o f Education o f Respondents.............................................................68 Table 6.4: Occupation o f Respondents........................................................................... 69 Table 6.5: Type o f Health Facility U sed ........................................................................70 Table 6.6: Rating o f Quality Based on Level o f Communication............................71 Table 6.7: Rating o f Quality Based on Attitude o f S ta f fs ..........................................72 Table 6.8: Availability and Effectiveness o f Drugs under DMHI schem es...........73 Table 6.9: General Quality R a ting .................................................................................. 75 Table 6.10: Rating o f Quality and Recommendation o f schem es............................ 76 Table 6.11: Comparison on Level o f Communication................................................78 Table 6.12: Comparison on Attitude o f S ta ffs ..............................................................80 Table 6.13: Complaints on Handling o f Com plain ts................................................... 81 L IST OF TABLES University of Ghana http://ugspace.ug.edu.gh FIGURE Figure 3.1: A Diagram Conceptualising the Variables Used to Assess Subscribers’ Perception o f Health Care Q ua lity .................................................................................. 39 University of Ghana http://ugspace.ug.edu.gh L IST OF ACRONYMS AND ABBREVIATIONS ANA - American Nurses Association BSI - British Standards Institute CBHI Community Based Health Insurance CHPS - Community Based Health Planning and Services DMHI - District Mutual Health Insurance GHS - Ghana Health Service GNP Gross National Product IGF Internally Generated Funds IMF International Monetary Fund IOM Institute o f Medicine (American) L.I - Legislative Instrument MHI Mutual Health Insurance MOH - Ministry o f Health N. Juabeng New Juabeng NHIC National Health Insurance Council NHIS National Health Insurance Scheme NLCD National Liberation Council Decree PHC Primary Health Care POW - Programme o f Work QA Quality Assurance RCH Reproductive and Child Health SAP - Structural Adjustment Programme SSNIT - Social Security and National Insurance Trust University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 BACKGROUND The newly introduced District Mutual Health Insurance (DMHI) schemes in Ghana are a source o f financing the ever-increasing cost o f medical care. The object o f these schemes according to the Policy Framework (establishing the scheme) (MOH, 2004) is to assure equitable and universal access to an acceptable quality package o f essential health care for everyone resident in Ghana. The issues o f accessibility and affordability are closely linked to that o f quality o f health care services provided. When users o f health care services perceive such services provided as being o f good quality and hence valuable, their propensity to pay (financial accessibility) for and utilise these services increases. Understanding the way subscribers perceive the quality o f health care services under these schemes may be considered a first step in assessing the sustainability o f the schemes in the country. The cost o f health and medical care has increased in the past decade due to expensive medical equipment, buildings, medical malpractice and increasing labour cost o f hospitals. The economics o f health care systems are however not configured to limit these costs o f health care provision (Dorfman, 1987). Health insurance, having been identified as an efficient way o f financing health care is also plagued by the problem o f increasing health care cost, which in turn threatens the sustainability o f health insurance schemes. These threats o f sustainability could lead to the insolvency (bankruptcy) o f these schemes. Insolvency is a function o f several factors including poor quality o f services provided by the schemes. 1 University of Ghana http://ugspace.ug.edu.gh Quality in health care provision has different perspectives to its meaning depending on the person defining it. Generally however, there are two common ways o f measuring health care quality: the technical quality and the functional quality measures (Gronroos, 1984: Baker, 1995; Zineldine, 2006). Asubonteng, McCleary and Swan (1996) described technical quality as concerning the competence (professional expertise and qualification) o f the service provider and patient outcomes (rate o f cure, mortality and disability rates) and Donabedian (1980) describes functional quality as involving the process in health care delivery, such as the quality o f nurse-patient interaction, the level o f communication and in Africa in particular, the availability o f drugs (Baltussen, Haddad, & Sauerbom, 2002). It is thought by many involved in health evaluation that the technical aspect o f health care quality exceeds the full understanding o f most patients (Baker, 1995; Asubonteng et al., 1996). The functional quality however, is what forms the perception and subsequent behaviour of consumers o f health care services as this quality is easily accessible by users o f health care services. In the Ghanaian Times o f October 17, 2006 (Abdul-Majeed, 2006) it was reported that members o f the Nanumba District Mutual Health Insurance Scheme in the Northern Region o f Ghana accused hospital staffs o f sabotaging the scheme in the district. By sabotage, the members meant that nurses shouted at them unnecessarily upon presenting o f insurance cards; doctors prescribed drugs to be purchased from the open market; and subscribers were asked to wait for long hours before being attended to. In another development, the Ghanaian Times o f October 20, 2006 (Abdul-Majeed, 2006) carried a report that, the Board o f Directors o f Mfantseman Mutual Health 2 University of Ghana http://ugspace.ug.edu.gh Insurance Scheme appealed to government to increase the premium from 72,000.00 to 100,000.00 so the scheme could be sustained. On October 25, 2006, the same paper reported that at a conference organised by the Association o f Certified Chartered Accountants (ACCA) a participant argued that if more Ghanaians did not join the National Health Insurance Scheme, it would collapse (Atagra, 2006). The concerns raised in the preceding paragraphs indicate that the DMHI schemes could be at risk in terms o f quality o f the delivery process as expressed in the Nanumba report, collapse because o f low premiums and non-enrolment in the second and third reports. The issues o f low-premiums and non-enrolment may be a consequence o f poor quality, as a high quality o f health services may justify increase in premiums and increase enrolment rates for the sustainability o f the scheme. According to Wiesmann and Jutting (2000), low and unstable tax revenue and cutbacks in public budgets including health care have led to deterioration in the quality o f health care services, poorly paid and less motivated staffs as well as shortage o f drugs and medical equipment in public health care facilities. These difficulties have led to the introduction o f DMHI schemes, based on the concept o f Community Based Health Insurance (CBHI) schemes. CBHI schemes or Mutual Health Insurance (MHI) schemes (Atim, Diop, & Bennet, 2005) emerged as a means o f financing health care at the community level made up o f people usually not covered by national schemes because o f their informal nature1. The 1 Informal na tu re re la tes to peop le w ork ing in the informal secto r, from whom co llection o f p rem ium s for a national health in su rance schem e is usually d ifficu lt because o f th e d ifficu lty in defin ing the people in th is sector. 3 University of Ghana http://ugspace.ug.edu.gh Nkoranza Mutual Health Insurance scheme in the Brong Ahafo region is an example o f such a scheme. Health insurance as a health financing mechanism has many benefits. Bennet, Gamble, Brant, Raj and Salamat (2004) assert that CBHI schemes are very important because they provide benefits such as improving quality o f care through mobilization o f additional financial resources. The additional revenues generated for the health care facilities may be used to purchase essential pharmaceuticals, pay supplementary staff, or enhance supplies all o f which improve quality o f care. The CBHI schemes also provide the health facilities with more reliable cash flow to facilitate planning. In addition to the above, the CBHI schemes improve quality by strengthening lines o f accountability and providing avenue for open dialogues between providers and community members. Perhaps this form o f quality assurance is more important than sheer financial resources in terms o f improving quality o f care. The CBHI schemes offer a forum for discussing quality and providing feedback to health care providers and also for creating more formal health care consumers. It must however be said that this happens when CBHI schemes and providers share common vision and platform. In spite o f all these benefits from health insurance schemes, in some African countries where it has been operational, there have been frequent complaints raised about shortage o f drugs and other supplies, rude personnel, dirty hospitals and poor security (Batusa, 1999). The complaints can lead to unwillingness to pay premiums by community members, as the feeling o f absence o f value for money becomes apparent. 4 University of Ghana http://ugspace.ug.edu.gh Wiesmann and Jutting (2000) argue that, quality, as an issue in health care provided by health insurance schemes would have to be addressed first and not be an outcome o f resource mobilization via insurance. It should also be considered as a necessary pre-condition for a successful implementation o f CBHI schemes. An important aspect o f quality o f care that they advocate is a positive attitude o f hospital staff towards insured patients. The introduction o f the DMHI schemes in Ghana has brought about concerns about the quality o f service provided. One o f the principles underlying the design o f the National Health Insurance Scheme is quality care (Ministry o f Health, 2004). Under this, the designers o f the scheme believe that subscribers to the scheme would utilize the scheme if they perceived providers o f service under the scheme to be providing quality service and that subscribers are having value for their money. There is therefore the need to determine the perceived quality o f care under the scheme as one o f the preludes to findings explanations for the low subscription rate o f about 35% o f the total Ghanaian population o f about 21 million (GBC2 telecast, December 15, 2006). The quality in health care services especially under a health insurance scheme is particularly important because, it could affect its sustainability through renewal as well as new subscription rates. Six times more people hear about a negative customer service experience than hear about a positive one. A positive statement can be a very powerful tool for attracting new customers and negative statement can have a devastating impact on the credibility and effectiveness o f organizations to attract new 2 G hana B roadcasting C orporation 5 University of Ghana http://ugspace.ug.edu.gh customers (Kim, Kim, Im, & Shin, 2003). The sustainability o f these schemes may thus be threatened in one way or another. 1.1 PROBLEM STATEMENT Consumers o f a product or service o f an organisation hold the key to the survival and success o f such an organisation. The issue is in no way different where health care services are concerned. When users o f health care services perceive such services provided as being o f good quality and hence valuable, their propensity to pay for and utilise these services increase. This was reiterated by Wiesmann and Jutting (2000) when they argued that the issue o f quality in health care affects the implementation o f health insurance schemes if not addressed. Sixma, Kerssens, Campen, and Peters (1998) assert that patient satisfaction with health care services plays an important role in maintaining relationships between patients and health care providers, compliance with medical regimens, and continued use o f medical services. Compliance with medical regimes brings about favourable health outcomes, which is then translated into increased productivity and reduction of poverty. Mutual Health Organisations have been operating in various communities in the country before the introduction o f the DMHI schemes. The MHO are organised by Non-Governmental Organisations (NGO) in collaboration with the communities in which they are established. Subsequent evaluations o f these schemes however concentrated on issues such as contributions o f the schemes to the creation o f access, equity, mobilisation o f resources, level o f community participation and potential financial viability other than quality (Atim et al, 2000; Atim et al, 2001; Baku, et al, 6 University of Ghana http://ugspace.ug.edu.gh 2006; Agyepong, 1999). Where there is an assessment o f quality, it only forms a relatively small portion o f evaluation o f these schemes. A dearth o f knowledge on subscriber perception o f quality under health insurance schemes in the country is evident in these evaluations conducted in the country. The introduction o f the DMHI schemes has necessitated the need to do an in-depth study into subscribers’ perception o f the quality o f the services provided. This study therefore is a modest attempt to bridge this knowledge gap by assessing subscriber perception o f quality o f service under the DMHI schemes in Ghana using the New Juabeng and Ketu districts as case studies. 1.2 OBJECTIVES OF THE STUDY The main aim o f this research was to determine the perception o f subscribers on the quality o f health care services under the New Juabeng and Ketu District Mutual Health Insurance Schemes in Ghana. To achieve this general objective, the following specific objectives were examined: 1. Subscribers’ current perception o f the quality o f health care services under the New Juabeng and Ketu DMHI schemes in Ghana in relation to; a) the level o f communication at health care facilities b) the attitude o f staffs towards subscribers and c) the availability o f drugs. 2. The relevant service quality dimension(s) used by beneficiaries to evaluate service quality. 3. The particular areas o f health care services under the DMHI schemes subscribers consider as most important at the health care facility. 7 University of Ghana http://ugspace.ug.edu.gh 1.3 THE RESEARCH QUESTIONS Following from the research objectives, the research assumption was that the successful implementation and sustainability o f the DMHI schemes in Ghana was threatened by a perceived poor quality o f services provided by the schemes. To determine whether this assumption was true, research sought to answer a major question. What are subscribers’ perceptions o f the quality o f service under the New Juabeng and Ketu DMHI schemes? In answering this question, some minor questions were answered. These are, 1. What is subscribers’ perception o f the level o f communication with medical staff? 2. How do subscribers perceive the attitude o f the staffs o f the health facilities they attend? 3. What is subscribers’ perception o f availability o f the essential drugs promised under the schemes? In operational terms, The following indicators were considered under the quality dimensions chosen: 1. Level o f communication considered; a) the thoroughness with which patients conditions were explained to them b) the level o f explanations on medical tests before they were taken c) whether doctors insisted on follow-up from patients and 8 University of Ghana http://ugspace.ug.edu.gh d) the level o f explanations on the side-effects o f prescribed medications. 2. A ttitude o f staff considered; a) the level o f help given to subscribers b) the courtesy o f the nursing staff towards subscribers c) the level o f interest expressed by doctors in patients d) the courtesy o f the dispensary staff and e) the difference in treatment if any as experienced by subscribers 3. The availability o f essential drugs considered; a) whether prescribed drugs were available in the health care facility b) whether prescribed drugs were considered effective A likert scale o f 1 to 5 anchored ‘very good’ and ‘very poor’ with 1 being ‘very good’ and 5 ‘very poor’ was used to measure the quality dimensions. The quality dimensions, which the research questions sought to answer, were further elaborated upon in chapter three o f the study. 1.4 SIGNIFICANCE AND JUSTIFICATION FOR THE STUDY One o f the principles underlying the design o f the National Health Insurance Scheme is quality care (Ministry o f Health, 2004). Health insurance, so far the best form o f financing health care, must be sustained and one o f the ways in which it could be sustained is when subscribers have a positive perception o f the quality o f health care services provided under the scheme. 9 University of Ghana http://ugspace.ug.edu.gh The study would contribute to existing knowledge on patients’ perception o f health care quality and would form the basis for further research with respect to the national health insurance scheme. The study would also help the providers o f health care services, which were used in the study to know their status regarding consumers’ perception o f their service. Knowledge o f this would help them take any corrective measures necessary. Since government spends huge amounts money every year on quality assurance in public health care facilities, this study is especially important to public health care providers under the scheme in determining whether the efforts being put into assuring quality are indeed improving quality. 1.5 STRUCTURE OF THE STUDY This study was divided into seven chapters. The first chapter gave an overall picture o f the treatise, discussed the study problem, the objectives o f the study and the significance o f the study. Chapters two and three gave a theoretical and empirical review o f literature on the issue and provided a basis o f a working conceptual model which informed the data collected. Chapter four reviewed the development o f the DMHI schemes by looking at health policies and the modes o f financing them since independence in 1957. Chapter five concentrated on the methods and techniques o f data collection. Chapter six presented the findings o f the research. The last chapter discusses the findings and the policy implications o f these findings on the DMHI schemes. 10 University of Ghana http://ugspace.ug.edu.gh 1.6 CONCLUSION This chapter provided the overall outline o f the study and discussed the rational for the research, with concentration on the problem to be studied, objectives and research questions to be answered in arriving at the objectives. This work was however limited by the fact that only evidence from two districts was gathered. The two districts used for the study were chosen because they had been in operation for a year when the research was initiated. The relatively younger status o f the other schemes as well as time and resource constraints did not permit a wider coverage. This limitation does not however invalidate the findings o f this study. 11 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO CONCEPTIONS, DETERMINANTS AND IMPORTANCE OF QUALITY IN HEALTH CARE 2.0 INTRODUCTION This chapter presents a review o f the concept o f quality and its relation to health care, its determinants and the importance o f measuring it. The aim o f the chapter is to provide a theoretical framework within which the study was conducted. 2.1 THE CONCEPT OF QUALITY Various definitions o f the concept o f quality can be deduced from literature. Amongst them is the British Standards Institute’s (BSI) definition which views quality as the totality o f features and a characteristic o f a product or service that bears on its ability to satisfy stated or implied needs. Additionally, the Institute recommends that any usage o f the term quality should involve a degree o f excellence, reflect on the measurement o f a product in terms o f departure from an ideal and demonstrate fitness for purpose relating to the ability to meet stated needs (La Monica, 1994). This definition o f quality is looking at the ability o f a product to perform the function for which it was produced. In health care parlance, this is known as the outcome o f health care or technical quality, which is restoring the individual to a healthy position. The definition o f quality has however evolved to include the processes involved in the delivery o f the product and more importantly, processes involved in service delivery. This process involved in service delivery is best assessed by the consumer o f the service and is believed to be a major determinant o f the survival o f service 12 University of Ghana http://ugspace.ug.edu.gh organisations such as health insurance schemes (Wiesmann and Jutting, 2000). The focus o f this study is the quality o f the process involved in health care delivery, as the consumer o f the service perceives it. Quality according to Peter and Donnelly (1998) is the degree o f excellence or superiority that an organizations’ product possesses. It encompasses both the tangible and intangible aspects o f a firm’s product or services and could refer to such traits as features, performance, reliability, durability, aesthetics, serviceability and conformance to specifications. They further assert that although quality can be evaluated from different perspectives, the customer is the key perceiver o f quality as it is his/her purchase decision that determines the success o f an organizations product or service and even the fate o f the organisation itself. This definition o f quality appears to encompass the delivery process in addition to the features and performance o f a product. The consumer, who appears to lack the technical knowledge involved in assess the quality o f services relies on the aspects that are experienced such as quality associated with personal contact. 2.2 DETERMINANTS OF SERVICES QUALITY It would be impossible to define or even ensure service quality without first determining the salient aspects that are incorporated under the term. Ghobadian, Speller and Jones (1994) argue that quality is a multidimensional phenomenon and service or product quality cannot be ensured without determining its salient aspects. This observation is reflective o f both previous and current thought on the subject matter as can be inferred from the empirical works, which are discussed in the succeeding sections. 13 University of Ghana http://ugspace.ug.edu.gh Sasser, Olsen, and Wyckoff (1978) cited seven service attributes, which they believe satisfactorily embraces the concept o f service quality. These attributes are: security, consistency, attitude, completeness, condition o f the facility, availability o f the service and training on the use o f the service. Security is an assurance o f confidence in and physical safety o f the service or product being offered. When consumers perceive that there is a high level o f security in a service that is being sold or purchased, quality would be inferably rated high or very good. Consistency has to do with receiving the same service in the same form each time. This means that irrespective o f the time or circumstance o f the purchase or use o f a service, the consumer is assured o f the same service in the same form. Attitude is in respect o f the interaction between the provider and recipient o f a service and is often perceived in a subjective manner. Examples include courtesy shown to the customer and the amount o f explanation provided in terms o f what needs to be done amongst other things. The rest includes completeness o f the services as the provision o f ancillary services is also used as a determinant o f service quality. Condition o f the facility in which the service is being provided is also considered a determinant o f the quality o f services provided. The condition is viewed in terms o f physical circumstance o f the reception area, its neatness, user friendliness and appearance o f the site amongst others. Availability o f the service in terms o f access, location and frequency is another determinant o f quality. The service must be easily accessible financially and geographically and must be available at anytime for consumers. Training on the use o f the service is the seventh determinant o f quality according to Sasser et a\. (1978). 14 University of Ghana http://ugspace.ug.edu.gh Gronroos (1983) identified three dimensions o f service quality. These are the functional quality o f the service encounter, the corporate image and the technical quality o f outcome. The functional quality is the same as the attitude and interactive quality discussed earlier. Lehtinen and Lehtinen (1992) also contend that service quality has three dimensions, physical quality, corporate quality and interactive quality. A close look at the works o f Gronroos (1983) and Lehtinen and Lehtinen (1992), appears to suggest a consensus on corporate image and interactive quality as fundamental aspects o f determining service quality in principle but a question o f terminology in their explanations. The technical quality o f outcome is the actual outcome o f the service encounter. This has to do with whether what the consumer sets out to get was actually gotten, that is, healing from ailment. Parasuraman, Zeithaml, and Berry (1985) in extending the preceding works, provided a criterion for determining quality o f a service. According to them, reliability, responsiveness, credibility, competence, access, security, courtesy, communication, tangible and understanding form the criterion that customers o f a service use in determining its quality. Reliability means that the firm performs the service right the first time. It also means keeping it words concerning what it has promised to provide. Reliability also involves accurate billing, accurate record keeping and performance o f services at the designated time. Responsiveness concerns the willingness or readiness o f employees to provide the service. It involves, for example, the immediate mailing o f transaction slip to 15 University of Ghana http://ugspace.ug.edu.gh consumers, calling the customer back quickly, dealing effectively with complaints and giving prompt service. Credibility involves trustworthiness, believability and honesty, having the customers’ best interest at heart. The service providers’ name and reputation and the personal traits o f the frontline staff all contribute to credibility. Competence means the staff must possess the necessary skills, knowledge and information to perform the service effectively. This involves knowledge and skills o f the contact personnel, operational support personnel and the research capability o f the organization. Access, used in determining quality o f services provided, involves approachability and contact that is, the convenience o f opening hours, telephone accessibility and the convenient location o f the service facility. Courtesy in determining quality according to Parasuraman et al (1984) means the politeness, respect, consideration and friendliness shown to customers by the contact personnel. Security, as a determinant o f service quality, means freedom from danger, risk and doubt. It involves personal safety, financial security and confidence in the service being rendered. 16 University of Ghana http://ugspace.ug.edu.gh Communication involves keeping customers informed about the service in a language that can be understood by them and listening to them as well. It may mean that the company has to adjust its language for different customers - increasing the level o f sophistication with a well-educated customer and speaking simply and plainly to a novice. It involves explaining the service itself, explaining how much the service would cost, explaining the trade-offs between service and cost and assuring the customer that a problem will be handled. Tangibles involve the state o f the facilities, goods, physical condition o f the buildings and the environment, appearance o f the personnel as well as the conditions o f the equipments. Understanding the customer involves making the effort to understand the customers’ needs and specific requirements, providing individualized attention and recognizing the regular customer. The various factors explained above are used in determining the criteria to be used in determining and measuring health care quality. The definition o f quality at any time would therefore be dependent on the criteria that the person wanting to measure it uses. Philip & Hazlett (1996) advised that in examining the determinants o f service quality, it is necessary to differentiate between quality associated with the process of service delivery and quality associated with the outcome o f service judged by the consumer after the service is performed. 17 University of Ghana http://ugspace.ug.edu.gh It can be observed from the literature on the determinants o f service quality that, the authors seem to have a consensus on what factors determine service quality. However, it is the terminologies that are different. What has been observed is that communication with providers o f the services rings out as a dominant determinant and so also does the physical condition o f the facility. 2.3 QUALITY AS AN ISSUE IN HEALTH CARE In the previous section, the concept o f quality and the determinants o f service quality were discussed. This subsection explores the quality issue further. It attempts to look at quality in health care in general as well as the definition o f quality by the different groups involved in the provision and delivery o f health care. The definition, measurement and improvement in health care quality have been important issues with no definite definitions. Health care is the diagnosis, treatment or rehabilitation o f a patient under care, accomplished on a one-on-one basis (Gordon, 1993). Health care services are therefore those activities that involve the diagnosis, treatment or rehabilitation o f a patient under care. The Institute o f Medicine (IOM)3 (1994) defines quality o f care as the degree to which health services, individuals and populations increase the likelihood o f desired health outcomes that are consistent with current professional knowledge. An explanation of the definition would give a better understanding o f the terms used in the definition. 3 IOM is a com ponent o f the Am erican N ational A ssocia tion o f Sciences in W ashington DC 18 University of Ghana http://ugspace.ug.edu.gh ‘Health services’ refers to services that affect physical and mental illness, prevention o f diseases and promoting health and well-being as well as acute, long-term rehabilitative and palliative care. “Individual and population” refer to how specific episodes o f care are provided to the individuals and how this is reflected in the health status o f the population as a whole. “Desired health outcomes” refer to health outcomes that the patient desires and highlights the link between how care is provided and its effect on health, alternative medicines and consideration o f patients and family satisfaction with health care services. The phrase “increase the likelihood” means that quality is not identical to positive outcomes. Individual difference can bring about poor outcomes even when best care is provided. Good outcomes could also result when poor care is provided. This means that both the process and outcome o f health care are important in assessing quality in health care. The expression, “current professional knowledge” as used in the literature, emphasises the point that health care professionals must be abreast with current developments in their various fields and use such knowledge appropriately to achieve better health outcomes. The IOM’s definition is very comprehensive and includes technical as well as functional measurements o f health care quality. The phrase “desired health outcome” 19 University of Ghana http://ugspace.ug.edu.gh refers to how patients’ desire health care (that is the process involved in the delivery o f the service) and it is a very important aspect o f the definition o f health care quality as it determines the satisfaction o f patients with health care services. A patient satisfied with the delivery process according to Sixma et al. (1998) is more likely to comply with medical regimes and continue using health services. The assessment o f quality from the patients’ perspective, therefore, can be effectively done by looking at the delivery process involved. This delivery process is mainly concerned with the interpersonal relationship between patient and the health professional encountered in the process o f acquiring health care. Apart from the IOM ’s definition, parties interested in health care also have their own definitions o f health care quality. Camilleri and O ’Callaghan (1998) and 0vretveit (1992) identified three parties interested in health care quality. The parties identified are the providers o f the service (that is, the health care professionals); the users o f the service (that is, the patients); and those who manage the services (that is, the health service managers). A fourth party made up o f purchasers o f the service and policy makers has been identified (Morgan and Everett, 1990). 2.3.1 Different Perspectives in Health Care Quality The providers o f health care are the professionals such as medical doctors, nurses, pharmacists, and other health care professionals who provide health care services. Historically, quality has meant to the health care provider, clinical quality o f care offering technically competent, effective, safe care that contributes to an individual’s 20 University of Ghana http://ugspace.ug.edu.gh well being. Health care professionals tend to define quality in terms o f the attributes and results o f care provided and received by patients. The perspective o f the health care professional emphasis the technical excellence with which care is provided (Blumenthal, 1996). Bannerman, Tweneboa Offei, and Acquah (1992) provide the following as specific concerns o f quality for health care providers: outcome o f treatment like speedy recovery, mortality rate, and low reattendance rates and motivation factors such as transport, accommodation, sick benefits, good salaries as well as training and development. Although the perspective o f the health care professional is important in defining quality in health care, other perspectives are also important. According to Blumenthal (1996), health care plans and organizations include both private and public health insurance plans and public programmes that purchase health care for the poor and aged in the society. This group o f parties interested in quality o f health care concentrate on the health o f enrolled members and on attributes o f care that reflect the functioning o f organisational systems. This includes accessibility, measured by how long patients wait for an appointment or whether specialists services are available within a given health care organization. The clients are those who go to providers for cures to various ailments that afflict them. According to Kols and Sherman (1998), clients’ quality depends largely on their interactions with providers and attributes such as waiting time, level o f privacy and access to care. Quality from the clients’ perspective is being redefined as the way clients are treated by the system (Bannerman et al. 2002). When health care systems put clients first, they offer services that do not only meet technical standards o f quality 21 University of Ghana http://ugspace.ug.edu.gh but also satisfy the client’s need for other aspects o f quality such as respect, relevant information, access and fairness. The concerns o f clients include good staff attitude, maintaining clients’ dignity, respecting clients, comprehensive information about services and fees and a follow-up with clear instructions amongst others (Bannerman et al. 2002). The different perceptives o f these groups o f people on the quality o f health care would reflect how it is measured. Whilst health care plans and organizations are interested in quality from attributes such as accessibility and availability o f specialist services, health care providers are interested in the technical excellence o f the service provided. Though concentration on the technical excellence o f the service provided is important, the consumer does not have the technical knowledge to be able to assess it. The attributes that the consumer can effectively assess are the interactive attributes in the hospital. Quality measures in this dimension although subjective are the focus o f this study. 2.4 IMPORTANCE OF QUALITY AND ITS MEASUREMENT Health care services also have the attribute o f services in general - inseparability - as being produced and consumed at the same time (Gabbot & Hogg, 1999). It is therefore very important to know how users perceive it all the time. Assurance o f good quality in health care service delivery is an ethical obligation o f health care providers, as well as organisers o f health plans (Koenig, Hossain, & Whittaker, 1997). The importance o f having such knowledge all the time is discussed in the succeeding paragraphs. 22 University of Ghana http://ugspace.ug.edu.gh Sweeney, Brooks and Leahy (2003) identifies three relevance o f measuring patients’ perceptions o f health care quality, it serves as a structured mechanism for patient feedback and communication. It also serves as an important performance indicator o f subsequent health related behaviour and overall organizational effectiveness. Evaluation o f health care provision is essential in the ongoing assessment and consequent quality improvements o f medical services (Jenkinson, Coulter, Bruster, Richards, & Chandola, 2002). Service quality affects the repurchase intentions o f both existing and potential customers. Research (Tschol, 1994) has shown that customers dissatisfied with a service will divulge their experiences to more than three other people. In another research, it was established that, six times more people hear about a negative customer service experience than those that hear about a positive one. Positive statements about a product or service can be a very powerful tool for attracting new customers. Negative statements can also have devastating impact on the credibility and effectiveness o f the organizations efforts to attract new customers (Ghobadian, Speller, & Jones, 1994). 2.5 THE CONTEXT OF QUALITY ASSURANCE IN GHANA Assuring quality is important in ensuring continuous use o f health care and compliance with medical regimes amongst others. A fall in the quality o f health services can result in patients waiting for ailments to aggravate before seeking health care. When this happens, the results include increase in treatment costs and complications that patients suffer as a result o f late treatment. Compliance with medical regimes reduces the probability o f diseases becoming resistant to drugs. Compliance prevents the situation where resistance leads to the production o f more 23 University of Ghana http://ugspace.ug.edu.gh drugs at extra cost to health care delivery. The problems associated with poor service delivery have led to the introduction o f the concept o f quality assurance. Quality Assurance (QA) in health care is a planned, systematic approach for continuously monitoring, measuring and improving quality o f health services with the available resources, to meet the expectations o f both providers and users (Bannerman et al, 2002,). St. Martin (1986), in the American Nurses Association (ANA, 1986), defines QA as activities to estimate and increase the level o f excellence in the alteration o f the health status o f consumers, attained through review o f providers’ performance o f diagnostic, therapeutic, prognostic or other health care activities. Quality Assurance is cyclic, intermittent and retrospective (St. Martin, 1996). A management concept, developed by Juran (1992) for assuring quality in health care is in the form o f a triangle. Each o f the three points o f the triangle represents quality design, quality control or quality improvement. These points are essential and interrelated and mutually reinforcing components o f quality assurance. Quality design is the planning process in quality assurance. It defines the organization’s mission, clients and services. It allocates resources and sets the standards for service delivery. Quality control consists o f monitoring, supervision and evaluation that ensure that every worker and unit meets those standards and consistently deliver good quality services. Quality improvement aims to increase quality and raise standards by continually solving problems and improving processes. 24 University of Ghana http://ugspace.ug.edu.gh Concerned with the low utilization levels and poor quality o f health services in government and mission health facilities in Ghana, the Eastern Regional Health Administration in 1992 investigated the quality o f health care issue in two districts in the Eastern Region o f Ghana. It was found out that the quality concerns o f the people included: 1. Poor quality care to the public. 2. Delay in attending to emergency cases. 3. Shortage o f vital drugs. 4. Lack o f maintenance o f hospital facilities. In the Ghanaian Quality Assurance Manual (2002), the effects o f poor health care quality were listed as including loss o f customers, loss o f lives, loss o f revenue, loss o f material resources, loss o f time, loss o f morale, loss o f staff, loss o f trust, loss o f respect and loss o f recognition. In 1994, therefore, a set o f quality indicators were developed and tested in some health care facilities. These indicators were found to be valid, reliable, sensitive to variations in the different socio-cultural practices o f Ghanaians and feasible for health staffs to measure. A Quality Assurance document was therefore developed in April 2002, and it is currently being used to monitor the level o f health care quality in the country. In the Ghanaian Quality Assurance Manual, the dimensions o f quality listed are: access, equity, amenities, technical competence, efficiency, effectiveness, safety, continuity o f service and interpersonal relations in health care. In substance, the 25 University of Ghana http://ugspace.ug.edu.gh Ghanaian model has been fashioned along the lines o f propositions o f the researchers discussed earlier. However, it can be observed from the quality dimensions in the Ghana Quality Assurance Manual that factors that measure both technical and functional qualities are part o f the quality indicators established. This can be seen as an attempt to measure service quality in its totality. Whilst this document was made to assess health care quality in the various health care establishments in the country, it could be used to assess quality o f care provided under the health insurance scheme operational in the country. However, since the focus o f this study is quality from the user perspective. 2.6 CONCLUSION This chapter has reviewed thoroughly quality in health care, the different perspectives o f quality in health care and its importance as well as the importance o f measuring it. The development o f quality assurance in Ghana has also been discussed. This has formed the basis for the theoretical review on health care quality measurement and a further development o f a conceptual framework in the succeeding chapter. 26 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE MEASURING HEALTH CARE QUALITY: THE CONTEXT OF THE STUDY 3.0 INTRODUCTION Some theoretical and operational definitions o f health, quality in health care and ways o f measuring quality in health care are critically examined. In the context o f the definitions, a framework is then formulated within which this research is cited. 3.1 MEASURING HEALTH CARE QUALITY The measurement o f health care quality is an elusive but achievable goal. This is because health care is not a single product but it entails several components and different professionals are involved in its provision (Bodenheimer, 1999). While some measures use the process involved in its delivery, others focus on the outcome to the client o f the service. Whichever measure is used, however, the ultimate aim is to determine the quality or otherwise o f the health care provided. Donabedian (1966) proposed a triad perspective for assessing health care services. These are: structure, process and outcome. Studying the settings in which health care takes place and the instrumentalities used in the provision o f care is the assessment o f structure. This assessment o f structure is concerned with such things as the adequacy o f facilities and equipment, qualification o f the medical staff and their organization, the administrative structure and operations o f programmes. Here the assumption is that, given the proper settings and instrumentalities, good medical care will follow. According to Bannerman et al. (2002) structure quality refers to the availability and 27 University of Ghana http://ugspace.ug.edu.gh quality o f inputs needed to carry out an activity or deliver a service, the numbers and types o f personnel, how well-trained they are and what systems there are to motivate, develop and retain them. Examination o f the process itself rather than the outcome is another measure o f quality o f health care services. This is justified by the assumption that one is interested not in the power o f medical technology to achieve results but in whether what is now known to be ‘good’ medical care has been applied. Judgments are based on considerations such as appropriateness, completeness and redundancy and information obtained through clinical history, physical examination, diagnosis and tests, justification o f diagnosis and therapy, continuity o f care, acceptability o f care to the recipient amongst others. The estimates o f quality one obtains using this method is less stable and less final than those that are derived from the measurement o f outcomes. They may however, be relevant to the research question at hand, how consumers perceive the quality o f health care provided. Process quality is the manner in which services are actually rendered to meet expectations. Examples o f process issues in delivery o f care are: waiting time, information flow and rapport with patients, receiving patients, privacy, adherence to professional standards and guidelines (Bannerman et al., 2002). Widtfeldt and Widtfeldt (1992) explained process in health care parlance as connoting examining what must happen, when, by whom and in what sequence. It is the interaction amongst staff and clients (individual, family and the community). It takes place in both the administrative and clinical areas (in the community health centre). 28 University of Ghana http://ugspace.ug.edu.gh The outcome o f medical care, which includes recovery, restoration o f function and survival, is frequently used as an indicator o f quality o f health care. Examples are studies on prenatal mortality, surgical fatality rates and social restoration o f patients discharged from psychiatric hospital. The advantage o f using outcome, as a measure o f health care is that the validity o f outcome is seldom questioned. Outcomes also tend to be fairly concrete and as such seemingly amenable to more precise measurement. Bannerman et al. (2002) express outcome quality as being measured by the results o f care which are, satisfaction o f patients with services, recovery o f patients, utilization, re-attendance, and re-admissions complications and deaths. The relationship between structure and process and structure and outcome is often not well established (Brook, McGlynn, & Cleary 1996; Flynn & Ray, 1987). According to Brook et al. (1996), if quality o f care criteria based on structural or process data is to be credible, it must be demonstrated that variations in the attribute they measure lead to differences in outcome, and if outcome criteria are to be credible, it must be demonstrated that differences in outcome will result if the processes o f care under the control o f the health professional are altered. The concepts o f structure, outcome and process are interactive and they all influence the overall quality o f health care services. Other literatures cite two ways o f measuring health care quality. These two methods relate closely to Donabedian’s structure and process measures o f health care. They are Technical and Functional Quality (Gronroos, 1984; Baker, 1995; Zineldine, 2006) respectively. Technical quality also known as Clinical Performance Measures (Zineldine, 2006) or Physical Quality (Asubonteng et al., 1996), in the health care environment is defined 29 University of Ghana http://ugspace.ug.edu.gh on the basis o f the technical accuracy o f the diagnosis and procedures, the application o f science and technology o f medicine to the management o f the personal health care problem (Donabedian, 1980). Even when outcome is specific, the consumer does not know if the health care service has been delivered in the most effective or efficient way. For example, the patient would know his/her symptoms have been relieved but not that he/she has been cured. Technical quality o f care is said to have two dimensions, the appropriateness o f the service provided and the skill with which appropriate care is performed (Palmer, 1991; Blumenthal, 1996). Various techniques for measuring technical quality have been proposed and are currently in use in health care organizations. Because this information is not generally available to the consuming public, knowledge o f the technical quality o f health care services remains within the purview o f health care professionals and administrators (Bopp, 1990). This measure o f health care quality, because o f its technical nature, and the fact that the health care consumer has little information on what criteria to use in assessing it is not the actual focus o f this study Functional quality also referred to as “Consumer Ratings” (customer satisfaction) in some literature is the manner in which health care service is delivered to the patient. This involves interpersonal relationships - that is the social and psychological interaction between the client and the practitioner (Donabedian 1980). Functional quality also refers to the facilitating goods that enable service to be performed, the relationship aspects, the willingness to help, the knowledge and courtesy o f staff and the individualized attention to customers (Gabbot & Hogg, 1999). Since patients are often unable to accurately assess the technical quality o f a health care service, 30 University of Ghana http://ugspace.ug.edu.gh functional quality is usually the primary determinant o f patients' quality perceptions (Donabedian, 1980; 1982; Kovner & Smits, 1978; La Monica, 1994). There is growing evidence to suggest that this perceived quality is the single most important variable influencing consumers' value perceptions. These value perceptions, in turn, affect consumers' intentions to purchase products or services (Bolton & Drew 1988; Zeithaml, 1988; Blumenthal, 1996). 3.2 MODELS FOR MEASURING QUALITY OF HEALTH CARE SERVICE The determinants o f service quality established by Parasuraman et al. (1985) were further developed by them in 1988, into a five dimensional construct o f perceived service quality known as SERVQUAL. Its purpose was to provide an instrument for measuring service quality that would apply across a broad range o f services with minor modifications in the scale to suit a particular service industry. The five dimensions are: (1) tangible physical facilities, equipment, and appearance of personnel; (2) reliability ability to perform the promised service dependably and accurately; (3) responsiveness willingness to help customers and provide prompt service; (4) assurance knowledge and courtesy o f employees and their ability to inspire trust and confidence; and (5) empathy - caring, the individualized attention the service provider offers its customers. The scale contains 22 pairs o f items. H alf o f these items are intended to measure consumers' expected level o f service for a particular industry (expectations). The other 22 matching items are intended to measure consumer perceptions o f the present level o f service provided by a particular organization (perceptions). Both sets o f items are presented in seven-point Likert response format, with the anchors "strongly agree" and 31 University of Ghana http://ugspace.ug.edu.gh "strongly disagree." Service quality is measured on the basis o f the difference scores by subtracting expectation scores from the corresponding perception scores. The premise o f SERVQUAL is the assumption that the difference (gap) between a patient’s expectation and a patient’s perception reflects the quality performance o f a given service (Camilleri & O ’Callaghan, 1998). The main critics o f this model have been Cronin and Taylor (1992) who argues that, little if any theoretical or empirical evidence supports the relevance o f the expectation-performance gap, as the basis for measuring service quality. Expectation, they argue, plays no significant role in the conceptualization o f service quality. They therefore came up with a model that measures performance only (perception only). Cronin and Taylor (1992) proposed an alternative to SERVQUAL, a model for measuring service quality termed “SERVPERF”. This is a performance (perception only) based measure o f service quality. It is composed o f a 22-perception item scale like the SERVQUAL with the same five item construct but excludes any considerations for expectation, which is dominant in the SERVQUAL measure. The perception only measure o f service quality appears to have higher convergence and predictive validity (Buttle, 1996). According to Collier and Bienstock (2006) current studies into service quality have started to show more support for the exclusion o f expectations in measuring service quality. The dimensions o f service quality attributes on both the “SERVQUAL” and “SERVPERF” measure functional quality. However, constructs such as tangibles and reliability are not o f particular importance to the subject matter o f this research. The National Health Insurance Scheme is too young for the study to include factors such 32 University of Ghana http://ugspace.ug.edu.gh as physical facilities, equipment, and appearance o f personnel since the old facilities are the ones still in use. However attributes such as responsiveness, assurance and empathy which only need attitudinal change are o f major concern to the researcher. 3.3 CONCEPTUAL FRAMEWORK FOR THE STUDY As the developers o f SERVQUAL have pointed out, the model could be adapted or supplemented to fit the characteristics or specific research needs o f particular organisations (Parasuraman, Zeithaml, & Berry, 1988). In adherence to this therefore, a framework has been developed within which service quality would be examined in this study. As discussed in the preceding chapter, attitudinal or interactive quality is very important in determining health care quality. This quality comes in the form o f the level o f communication and attitude o f staffs. This two attributes have been taken from the literature and from empirical evidence o f other researches a third attribute has been added which is that availability o f drugs. These constructs have been fully discussed in the succeeding paragraphs. 3.3.1 Level o f Communication Communication is the process by which information is transferred from one person to another. According to Eyre (1983) communication is not just the giving o f information, but is the giving o f understandable information and receiving and understanding the message. It is the transferring o f a message to another party so that it can be understood and acted upon. Communication involves actions (sharing o f information), reactions (a response to the shared information) and interactions 33 University of Ghana http://ugspace.ug.edu.gh (exchange o f messages between senders and receivers) (James, Ode & Soola, 1999). The communication process is very important in the delivery o f health care services because the sender o f the message, the health care provider, needs to let the patient, the receiver o f the message, know about the processes involved in the treatment and there need to be a reaction from the patient to show understanding so that treatment regimes would be complied with. Service operations depend on consumers to articulate their needs or provide information. The accuracy o f the information and the ability o f the service provider to interpret this information correctly have a significant influence on the consumers’ perception o f service quality. According to Andeleeb (1998), communications with patients can greatly affect the healing process. He argued that if a patient felt alienated, uninformed, or uncertain about health outcomes he/she could take longer to heal and that communication was vital to delivering service satisfactions in the hospital setting. Information given to clients enables users (example o f a family planning product) to employ the method effectively and to appreciate the methods’ potential to create physical changes, healthy or unhealthy feelings and the impact o f these experiences on daily activities and the most intimate aspects o f partnerships (Bruce, 1990). Bruce (1990) advises that the client/provider contact should be characterized by two­ way communication question-asking and flexible guidance (as opposed to authoritarianism) on the part o f the provider should be encouraged. She mentions that 34 University of Ghana http://ugspace.ug.edu.gh the desired outcome from this interaction from the point o f view o f the provider may be that the client reports a belief in the competence o f the provider, trust o f the personal nature and willingness to make contact again them, and even refer others. Under the rights o f the patient in the Patients Charter produced by the Ministry o f Health o f Ghana in February 2002, a patient is entitled to full information on his/her condition, management and the possible risks involved except in emergency situations when the patient is unable to make such a decision and the need for treatment is urgent. The patient is also entitled to know o f alternative treatment(s) and other health care providers within the Service (Ghana Health Service) if these may contribute to improved health outcomes (Ministry o f Health, 2002). 3.3.2 Attitude o f the staff The attitude o f staff in this study is concerned with the demeanour o f the staff towards consumers o f health care services. The attitude o f staff is in relation to courtesy, respect and their helpfulness. When relating to customers, the general demeanour o f the staffs’ in the various service settings can have a significant impact on customer satisfaction (Andaleeb & Simmonds, 1997). Again, in the hospital environment, past studies have shown that the manner in which the staff interact with patients and the staff sensitivity to patients’ personal experience are most important to customer satisfaction (Andaleeb, 1998; Press & Ganey,1989). According to Ghobadian et al. (1994), the delivery o f service often involves some form o f contact between the consumer and service provider. The behaviour o f the service provider influences the consumer’s perception o f quality. It is difficult to 35 University of Ghana http://ugspace.ug.edu.gh assure consistency and uniformity o f behaviour. Moreover, it is not easy to standardize and control this facet o f service delivery. In effect what the firm intends to deliver may be entirely different from what the consumer receives. In a research conducted in a District Hospital in the North-West England under the British National Health Service (NHS) in 1999 on patients and relatives experience and perspective o f “good” and “not so good”, it was established that the nature o f care provided and the interpersonal aspects o f caring emerged as key quality issues for patients. Good quality care was characterized as individualized, patient-focused and related to need; it was provided in a humanistic manner, through the presence o f a caring relationship by staff that demonstrated involvement, commitment and concern. “Not so good” care was regarded as routine, not related to need and delivered in an impersonal manner, by distanced staff that did not know or involve patients (Attree, 2001). In another survey conducted on the Dodowa (Dangme West) Community. Health Insurance Scheme, which was a pilot project for the National Health Insurance Scheme, Atim et al. (2001) found that non-subscribers, when asked why they had not enrolled explained that there was a problem with the quality o f care. The non­ subscribers defined the quality o f care as health worker discriminating against the insured. 3.3.3 Availability o f Drugs The availability o f drugs in any health care facility is very important, as patients go to health care facilities to be diagnosed and treated, mostly with drugs. Assurance o f the 36 University of Ghana http://ugspace.ug.edu.gh availability o f drugs in a health care facility could boost confidence in utilising such facilities. The cost o f drugs is normally on the increase and with a national health insurance scheme, what subscribers would naturally expect would be the availability o f drugs for their illness. In a study conducted in Burkina Faso by Baltussen et al. (2002) on quality o f primary health care services, it was discovered that the quality and adequacy o f resources and services was valued as relatively poor. Respondents were said to have criticized the absence o f drugs for all diseases on the spot. Other studies (Abu-Zaid & Dann 1985; Waddington & Enyimayew, 1989; Parker & Knippenberg, 1991; Litrack & Bodart, 1993; Bitran, 1995) conducted in several African countries, reveal that drug supply is a very important determinant o f the utilization o f health service. These studies suggests that appropriate drug policies are likely to be amongst the single most important policy actions that could improve quality o f health care. In a study conducted in Ogun State, Nigeria on the cost o f health care and its effect on utilization, it was found out that improvement in drug availability elicited large responses. Full availability o f drugs in both public and private health care facilities induced patients to move from self-care and the private sector to public care in substantial proportions (Wouters, 1991). Factors identified as affecting patients’ perception o f health care quality in Ghana are accessibility to health care facility, distance from the facility, ease o f getting to the facility, convenience, costs, humanness, technical competence, information provision to clients, bureaucratic arrangements and efficient, physical facility, continuity o f 37 University of Ghana http://ugspace.ug.edu.gh care, outcome o f care, availability o f drugs, supplies o f essential drugs and equipment. Agyepong (1999), reporting on a pilot NHIS in the Dangme District in Ghana, again reiterated that, there was the continuous problem o f clients being asked to buy drugs outside the health care institution. This has caused inconvenience and 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 private drug sellers, making sure patients buy drugs privately so the public workers can get a percentage o f the profit - otherwise, why should hospitals run short o f a drug that is readily available on the market? In another evaluation done on the Nkroranza Mutual Health Insurance Scheme, several perceptions relating to quality were noted particularly by 15 focus groups of non-subscribed members. These perceptions were the cause o f respondents not joining the scheme. Six groups out o f the fifteen said they experience discrimination against insured members, seven groups said non-insured received better treatment, six groups complained about staff attitude towards insured which they considered discouraging amongst other complaints (Atim & Madjiguene, 2000). From the discussions in the preceding paragraphs, the dependent variable in this study is the perception o f subscribers o f the quality o f health care services provided under the DMHI schemes in two districts. The independent variables are the level o f communication experienced in the health care facilities, the attitude o f the staff towards insured clients and the availability o f drugs in the various facilities operating under the National Health Insurance Scheme. 38 University of Ghana http://ugspace.ug.edu.gh A model for easy conceptualization o f the variables used in determining the subscriber perception o f quality o f health care services provided under the DMHI scheme has been provided in figure 3.1. F igure 3.1 - A d iag ram conceptualizing the variab les used to assess subscribers’ perception o f health ca re quality Level o f Communication - is examined in the context o f how much information about patients medical conditions are relayed to them. The study seeks to find out whether the patient is allowed to thoroughly explain his condition before prescription is given, information regarding the side-effects o f drugs are given, whether reasons for medical examinations are given. A ttitude of S taff - The attitude o f the staff according to literature is said to affect utilization rate, compliance with treatment and recommendation o f a product or 39 University of Ghana http://ugspace.ug.edu.gh facility to others. This study attempts to find out if the hospital staffs are responsive and courteous to the needs o f patients and whether there is a difference in the way subscribers and non-subscribers are treated. Availability o f d rugs - drugs are deemed very important in the treatment o f diseases and most people go to the hospital for the right drugs to be prescribed for their condition. The NHIS is said to cover 90% (Ministry o f Health, 2004) o f all diseases and hence the drugs to treat them. The study is an attempt to find out if drugs prescribed are available in the health facility. The assumption is that the variables level o f communication, attitude o f staff and the availability o f drugs in a health care facility would shape the perception o f users o f health services under the DMHI schemes. The perception created could be a good perception which would then be translated into continuous utilization, compliance with treatment regimes, increase in enrolment and ultimately lead to the sustainability o f the health insurance scheme (Sixma, el al. 1998) or a bad perception. On the other hand, however, if a poor perception is created based on the variables, the implications are; fall in utilization levels, non-compliance with treatment regimes, fall in enrolment rates and probable collapse o f the health insurance scheme. These implications are expressed by Rust, Zahorik and Keiniingham (1996) when they stated, “ if we view the organization as a service, then what matters is quality as perceived by the consumer; if the consumer perceives quality as bad, it matters little then that “objective” quality may be good” (p.228). 40 University of Ghana http://ugspace.ug.edu.gh It is believed that the perception o f the three independent variables would lead to the determination o f quality o f health care being either very good or poor. 3.4 OPERATIONAL DEFIN ITIONS OF TERMS D istric t M utual H ealth In su rance (DMHI) scheme is a fusion o f Social Health Insurance Scheme for the Formal Sector workers and the traditional Mutual Health Insurance Organizations for the Informal sector organized in the various districts o f the Ghana. It would thus incorporate members from for the formal and informal sector. P erception is defined in the study as a positive or negative feeling towards quality care. Quality health ca re service in this study refers to the highest grade o f excellence o f care from the subscribers’ point o f view. The dimensions used to determine quality o f health care service in this study are level o f communication between patients and hospital staff, the attitude o f the staff as perceived by the patient and availability o f essential drugs as provided by the scheme. P atien t/ Subscriber: It refers to recipient o f health care services who is enrolled under any o f the two DMHI schemes mentioned in the study and who has used a health care facility under the scheme for at least two times. Essential D rugs: this refers to drugs that have been labelled as such under the scheme. 3.5 CONCLUSION The measurement o f health care quality is very important in determining whether health systems goals are being achieved. Different groups interested in health care 41 University of Ghana http://ugspace.ug.edu.gh have different perspectives on what they look out for in terms o f quality. However, according to Baltussen et al. (2002) patients’ perception o f quality o f care is critical to understand the relationship between quality o f care and utilization o f health services and it is increasingly being treated as an outcome o f health care. In this chapter, different perspectives on measurement o f quality and health quality in particular measurement o f health care services out o f which a framework has been developed within which this research would be conducted. No pre-determined or universal standards exist for the evaluation o f the quality o f a service - that is services are subject more to social, cultural and national boundaries. Therefore when designing or developing a model that is intended at measuring service quality, these boundaries and many other factors must be taken into account (Philip & Hazlett, 1996). This has been observed in the development o f the framework described above. This framework is reflected in the process involved in data collection for this study in the succeeding chapter. 42 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR HEALTH REFORMS AND FINANCING STRATEGIES 4.0 INTRODUCTION Health care financing in Ghana has gone through a chequered history. Immediately after independence, health care provided to the people was “free” in public health facilities. However, beginning 1969, to 1985, user fees were introduced successively through legislations. The user fees were as a result o f economic difficulties during the period. The World Bank and The International Monitory Fund (IMF) advocated the introduction o f the Structural Adjustment Programme (SAP) to restore the economy. The SAP led to the removal o f state subsidies for the public sector operations, health care services inclusive. The results were the deterioration o f health care facilities and falls in utilisation levels. In order to improve access to health care services, a law establishing a national health insurance scheme was enacted in October 2003 known as the National Health Insurance Scheme (NHIS). The national scheme was further decentralised into District Mutual Health Insurance Schemes, which are in charges o f providing mutual health insurance services at the district level. The ultimate vision o f the scheme is to assure equitab le and universal access to health care for all residents o f Ghana. The NHIS is meant to cover the 20% user-fees being charged at the point o f service provision. The remaining 80% will continue to be from tax revenues and donor funds (Ministry o f Health, 2004). 43 University of Ghana http://ugspace.ug.edu.gh This chapter traces this history further and provides an understanding o f the events leading to the introduction o f the DMHI schemes. The history would provide an insight into the need to know perceived quality, a first step in ensuring sustainability o f the health insurance scheme. 4.1 SOURCES OF FUNDS FOR THE HEALTH SECTOR IN GHANA Ghana’s health sector is financed through the Government o f Ghana, Donor Pooled funds, Donor Earmarked funds and Internally Generated Funds (IGF) (GHS, 2003) and local donations from philanthropists. The Government o f Ghana funds is from budgetary allocations o f the consolidated vote. Mission hospital gets subventions from the budgetary allocation as well. Donor pooled and earmarked funds are external aid funding for the sector. The pooled funds are from various countries and organisations that are pooled into an account for use by the health sector. The earmarked funds are also contributions by donors that are given for specific projects in the health sector. Sometimes the donations come in the form o f vaccines for immunizations. The IGFs come in the form o f user charges. The Hospital Fees Regulation L.I. 1313 o f 1985 introduced this system into public hospitals and the hospitals keep these internally generated funds to supplement the annual budgetary allocation from the Ministry of Health (Ackon, 2003). The budgetary allocations as well as the donor funds form about 80% o f the total financing for the health sector. 4.2 HEALTH REFORMS AND FINANCING IN GHANA The Ghanaian health care system has been modelled along the lines o f its colonial master, the British. The first government health services in Ghana can be traced back to 1880 when the Gold Coast Medical Department was established and concentrated 44 University of Ghana http://ugspace.ug.edu.gh on providing health care for the European population and government official in particular (Dummett, 1993). The system was focused on curative rather than preventive health services. Funding o f health care was the sole prerogative o f the colonial government at the time, or the missionaries where they were involved in the provision o f health services. After independence from colonial rule in 1957, the government at the time, embarked on massive development in infrastructure and human resource for health. As a result, by 1963, health centres in the country totalled forty-one and health personnel totalled 3169 and these include 379 doctors, 28 dentists, 954 midwives 1453 nurses and 355 pharmacists (Twumasi, 1975). Health services were in public health facilities free and funding o f the health sector was entirely from government budget. Commoditisation o f Health Services in Ghana However, between the 1970s and early 1980s, the global oil crisis from the sudden hike in oil prices on the international market severely affected the country. This immediately resulted in balance o f payment difficulties, heavy debt burden and general economic disequilibrium. As a result, the World Bank4 and the International Monetary Fund (IMF5) proposed structural changes to improving the economy, which suggested withdrawal o f state subsidies. This led to declines in the health budget, putting the health sector under severe economic pressure (World Bank, 1993). According to Bawumia (1998) government budget fell from 18.3% to 10.1% o f Gross National Product (GNP) between 1972 and 1982 resulting in a fall in real expenditure 4 W orld B ank is a spec ia lized U nited N ations (UN) agency th a t lends m oney to its m em bers for reconstruction and developm ent. 5 A no ther UN spec ia lized agency, which p rom otes in ternational econom ic corpora tion to facilitate in ternational trade am ongst m em ber nations. 45 University of Ghana http://ugspace.ug.edu.gh in the education and health sectors o f the economy. Equipments in health institutions fell into disrepair due to lack o f spare parts, basic drugs such as nivaquine and aspirin, as well as consumerables such as bandages, needles and syringes were in desperately short supply and were often unavailable in rural clinics. This led to what can be termed as commoditisation o f health services. Commoditisation refers to the forces of demand and supply determining health care provision. The supply was determined by the user fees charged and the demand by the ability o f the people to pay. In spite o f the growth in manpower and health facilities between 1957 and 1963, a review o f the health sector in 1977 revealed high infant (131 deaths per 1000 live births) and child mortality (40% o f children die before school going age) rates and the existence o f communicable diseases such as yaws and cholera. The policy adopted for the period was the Primary Health Care (PHC)6. The PHC was a concept adopted from the Alma A ta Declaration o f WHO in the same year. The adoption o f this policy was aimed at bringing health care to the doorsteps o f Ghanaians. It was organized at three levels in the country: the Community (Level A), the Local council Areas (Level B) and the Districts (Level C) (MOH, 1978). During this period also, government continued to fiind health care services. However, as discussed earlier, expenditure on health by this time had reduced considerably. In 1985, the government at the time introduced a cost recovery programme known as the user-fees system . Laws enabling the charging o f fees dates back to 1969 with the 6 PHC is concep t tha t encom passes multi-sectoral approach, appropria te techno logy , focus on preven tive and p rom otive health , community partic ipation in health decision -m ak ing and equitable distribution o f health serv ices. 46 University of Ghana http://ugspace.ug.edu.gh introduction o f the Hospital Fees Decree, 1969 NLCD7 360; Hospital Fee Decree, 1969 (Amendment) Act, then, the 1970 (Act 325); then again the Hospital Fees Act, 1971 (Act 387). These charges were however token fees charged compared to the 1985 legislation which raised the fees above token levels (Smithson, Asamoa-Baah, & Mills, 1997). There were however, exemptions for antenatal and family planning and communicable diseases (Nanda, 2002). These exemptions were, however, not taken advantages o f because there were no guidelines for implementation and consumers were unaware o f the existence o f the exemptions. Compliance level by health staffs was also poor (MOH, 2004). The introduction o f user fees greatly reduced the utilization o f health services because most people could not afford the user fees and the fees were also not matched with improvement in quality o f services provided. In spite o f the introduction o f the user fees, government still bore a considerable proportion o f the expenditure in health care. In 1992, the government, in conformity with the Bamako Initiative8 o f 1988 introduced the Revolving Drug Fund, which officially introduced the Full Cost Recovery Policy for drugs as a way o f generating revenue to address the shortage o f drugs. It was envisaged that, the cost recovery process would contribute about 15% o f the health sector resources. A review o f the process in the First Five Year Programme o f Work (1997-2001) o f the MOH revealed that the contribution o f the cost recovery process to the county’s health sector financing was below 10%. The application o f the revolving drug fund policy was popularly termed 'cash and c a r ry ’ system. The cash 7 NLCD is th e N ationa l L iberation Council D ecree - th e m ilitary governm en t w hich overth rew the governm ent o f N krum ah . * W orld H ealth O rgan ization Conference in Bam ako, w here it w as decided that peop le should pay for drugs in pub lic health care facilities. 47 University of Ghana http://ugspace.ug.edu.gh and carry system caused a decline in the utilization o f health care services especially for the very poor who needed the services most, since this represented financial barrier to access Health care (Arhin-Tenkorang, 2000). In 1997, the 1977 PHC strategy was reviewed and a new one introduced. The new strategy was known as Five Year Programme o f Work (POW 1) (Ministry o f Health, 1996). The aims o f this reform were amongst other things to significantly reduce infant child and maternal mortality rates, increase access to health care especially in the rural areas, control risk factors that exposed individuals to major communicable diseases and the strengthening and effective management o f health systems. To these ends, the MOH adopted strengthening o f inter-sectoral collaboration, strengthening o f the hospital management teams, re-orientation o f secondary and tertiary health service delivery to support primary health services and several other strategies. The second Five Year Programme o f Work (POW II) (Ministry o f Health, 2001) commenced in 2002. The objective o f this strategy was to reduce the inequalities in health between the northern and southern parts o f Ghana, between urban and rural areas, and gender. 4.2.1 The National H ealth Insurance Scheme In order to improve access to health care services, a law (Act 650, 2003) establishing a national health insurance scheme was enacted in October 2003 known as the National Health In su rance Scheme (NHIS). This is with the ultimate vision o f assuring equitable and universal access to health care for all residents o f Ghana (Ministry o f 48 University of Ghana http://ugspace.ug.edu.gh Health, 2004). The types o f health insurance schemes that are operational in Ghana 1. Social Health Insurance Schemes, these are District Mutual Health Insurance Schemes - are health insurance schemes organised at the district level and managed by members o f the district. People in all the towns and villages that form a district and are interested in the scheme join the scheme. Premiums are paid to the schemes and the scheme contracts health care facilities for its members and Private Mutual Health Insurance Schemes - this is also health insurance by people who have a common interest and therefore come together to have a health insurance. These people choose their own scheme managers to whom premiums are paid. The management is responsible for the contracting o f health services for the group. Example could be members o f a credit union having a mutual health insurance scheme for themselves. 2. Private Commercial Health Insurance Schemes The private commercial health insurance schemes are insurance schemes or policies usually sold by insurance companies. These policies are either sold to individuals or groups and it is for profit. The profit element differentiates it from the social type health insurance. Example is the health insurance policy for private individuals and corporate entities being offered by Ghana Life Insurance Company (GLICO) in Ghana. 49 University of Ghana http://ugspace.ug.edu.gh Equity - this means every subscriber has access to a minimum benefit package irrespective o f ones socio-economic background. Risk-equalization - this means that allocation o f financial resources to geographical areas would be based on disease patterns and burdens. Cross-Subsidisation - payment o f premiums have been put in a hierarchical form with the poor paying less and the rich paying more. The healthy would also cross- subsidise the sick. Quality o f care - this is a principle underlying the scheme. It is believed that if quality o f care were perceived to be good, it would lead to increase in utilization o f services. Solidarity - unity in upholding the national health insurance scheme. Efficiency - this is to be in the collection o f premiums from the informal sector and reimbursement to service providers. Community or subscriber ownership - this means the community must be involved in decision making for the health services delivered in the area. Partnership - this is with government especially since it would be bridging the gap between expected premium payments and actual premium payments. Reinsurance - has to do with the setting aside o f central funds in times o f catastrophic events such as epidemics and natural disasters. Sustainability - involves management o f the scheme in terms o f fraud control and risk management. Health care facilities accredited and providing health services to insured members o f the scheme include teaching, regional and district hospitals. Quasi-govemmental The principles underlying the design o f the NH1S include: 50 University of Ghana http://ugspace.ug.edu.gh hospitals and clinics, mission hospitals as well as pharmacies, shops and drug stores are also included. Benefit package under the NHIS is a minimum health care benefit that includes outpatient services, in-patient services, oral health services, eye care services, maternity care and all forms o f emergencies (MOH, 2004). Please refer to Appendix II for details o f the benefit package. 4.3 DISTRICT MUTUAL HEALTH INSURANCE SCHEMES IN GHANA In the previous sections, the history o f health reforms and financing strategies and events leading to the birth to health insurance schemes in Ghana were outlined. This section continues the discussion and looks at the DMHI schemes. The scheme is a fusion o f two concepts, social health insurance scheme for formal sector workers and the traditional mutual health insurance organization for the informal sector. It is made up o f members from both the formal and informal sectors o f the economy. Each district is divided into Health Insurance Communities, which are responsible for the collection o f contributions and managing the affairs o f health insurance in the community. Each community consisting o f a Chairman, Secretary, Collector, Publicity Officer and a Member constitutes a Health Insurance Committee. These committees would then form the District Health Insurance Assembly. The Assembly is the highest decision making body in the district and it provides policy guidelines for the operation o f the scheme for the district. The Assembly also appoints a Board o f Directors for the district (Ministry o f Health, 2004). 51 University of Ghana http://ugspace.ug.edu.gh Premium from subscribers to the DMHI schemes would be made up o f 2.5% o f the 17.5% contribution to Social Security and National Investment Trust (SSNIT) for formal sector workers deducted at source and transferred to a central fund. Non- SSNIT contributors would contribute directly to the scheme o f their choice and according to the schedule provided (see appendix III). A fund known as the National Health Insurance Fund has been established into which a 2.5% Value Added Tax (VAT) is contributed. This fund is under the control o f the National Health Insurance Council (NHIC) (Refer to appendix IV). The NHIC was established by the NHIS Act 650, and is headed by an Executive Secretary who is mandated with the object o f ensuring that policy decisions taken by the council are duly implemented. The council reports to the president o f the country through the ministry o f health. The council for the purposes o f its functions has four units that aid in its efficient and effective operations. These comprise a Policy, Planning, Monitoring and Evaluation unit; Licensing and Accreditation unit; Administration, Management support and Training unit and Fund Management and Investment unit. It can be observed from the preceding that the DMHI scheme concept was adopted as the benefits derived from them are in line with some o f the health system goals o f the country. 4.3.1 Case Study 1 - The New Juabeng Municipal Health Insurance Scheme The New Juabeng Municipal Health Insurance Scheme is situated in the Eastern Region o f Ghana. The municipality is located in the Eastern Regional capital, 52 University of Ghana http://ugspace.ug.edu.gh Koforidua, which also doubles as the municipal capital. The municipality is bounded to the northwest by East Akyem District, to the east and south by Akuapem North District, northeast by Yilo Krobo District and to the west by Suhum-Kraboa Coaltar District (New Juabeng Municipal Health Directorate, 2006). The municipality covers an area o f about 98.8 square Kilometres and has a population o f about 146,618 and is demarcated into four sub districts namely Oyoko/Jumapo sub­ district, Effiduase/Akwadum sub-district, Koforidua/Zongo and Medical village/Old Estate sub districts with about 150 different communities (Municipal Health Directorate, 2006). The scheme was officially launched on the 28th o f April, 2005, and started operations in May o f the same year. It has a total registered number o f 54, 000 members as at January 2007. The New Juabeng Scheme has a Board o f Directors, a General Assembly and a Management Team. Major challenges cited as facing the scheme include complaints from members about the six months waiting period after registration and the inadequacy o f the minimum benefit package (Scheme Manager, 2007). The municipality has one regional hospital, one mission hospital, two health centres, 11 private clinics, three private maternity homes, ten Reproductive and Child Health (RCH) centres, 80 trained birth attendants six Community Based Health Planning and Services centres and 70 chemical shops. There are also 387 nurses, 38 doctors and 5 pharmacists in the public sector and 6 doctors and 8 pharmacists in the private sector. 53 University of Ghana http://ugspace.ug.edu.gh All the Reproductive and Child Health centres in the municipality as well as the only mission and regional hospitals, the two health centres have been contracted in the New Juabeng Municipal Health Insurance Scheme. Five o f the eleven private clinics, two o f the three maternity homes and five o f the 70 chemical shops have also been contracted by the Scheme to provide services to its subscribers. 4.3.2 Case Study 2 - The Ketu District Mutual Health Insurance Scheme The Ketu district on its part is located in the southern eastern part o f the Volta Region, in Ghana. It shares common boundaries with the Republic o f Togo to the east, Akatsi district to the northwest and to the southwest by the Keta district. On its southern border is the G ulf o f Guinea Atlantic Ocean9. The district has a population o f about 260,674, a projection from the March 2000 population census with a growth rate o f about 1.9 and occupies an area o f 962 square kilometres (Ketu District Health Directorate, 2006). The district capital is Denu10. There are nine towns constituting the Ketu district. These are Afife, Aflao Urban, Aflao Wego, Dzodze, Klikor, Penyi, Some Wego, Some Fugo and Weta sub district. The scheme was officially launched on the 8th o f August, 2005, but started operations in September o f the same year. As at January 2007, only 57,854 people were active members (those who had renewed their premiums) out o f about 260,674 people living in the district. 9 (www .ghanad istric ts.com 1 10 fwww .ghanadistricts.com ') 54 University of Ghana http://ugspace.ug.edu.gh Like all other schemes, the Ketu scheme also has a Board o f Directors, General Assembly, Community Health Insurance Committee, District Complaints Committee to resolve complaints, a Service Providers Committee, Medical Review Committee which is charge with overseeing claims administration and a Quality Assurance Control Committee charged with ensuring that quality is ensured with all contracted health service providers in the district. Major challenges cited as facing the scheme was the influx o f Togolese nationals and Beninois who pay for services at point o f usage competing for the same services with members o f the scheme, inadequate health professionals to match the upsurge in attendance and inadequate staff strength at the secretariat. The district has one government hospital, one mission hospital, four private clinics, sixteen health centres, five Reproductive and Child Health centres and four maternity homes (Ketu District Health Directorate, 2006). O f these, the Ketu District Mutual Health Insurance Scheme operates with the district and mission hospitals, all the 16 health centres, one maternity home out o f the four, two o f the four private clinics, two chemical shops and one pharmacy shop (Ketu Health Insurance Scheme, 2007). 4.4 CONCLUSION The chapter was concerned with the financing o f health care in the country, the various health policies since independence until the current NHIS and a brief history and operations o f the two districts, which are the focus o f this study. The health policies and the modes o f financing them are all aimed at the provision o f affordable health care for economic development. The background as provided in the succeeding 55 University of Ghana http://ugspace.ug.edu.gh paragraphs is aimed at providing understanding on the need to sustain the current scheme by addressing the quality issue. 56 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE METHODS AND TECHNIQUES OF DATA COLLECTION 5.0 INTRODUCTION This chapter represents a detailed description o f and justification for the methodology adopted in the conduct o f the research. In order to draw valid conclusions and make meaningful suggestions in any research work, it is imperative for the researcher to employ appropriate scientific techniques in its conduct. This research therefore follows the scientific methods as much as is applicable with some limitations. 5.1 RESEARCH DESIGN The research design is multidimensional in nature. Combinations o f exploratory and descriptive research designs were used. Exploratory research involves the discovery o f ideas and insights. This is to generate possible explanations to a research problem (Saunders, Lewis, & Thornhill, 1997). In the data collection instrument used, there were attempts to discover features o f the DMHI schemes at the health care facility level that were o f particular concern to subscribers. Descriptive research on the other hand is concerned with determining the frequency with which something occurs and the relationship between two variables. It describes the characteristics o f a particular groups based on information gathered such as income, sex, age, and educational level amongst others; or estimates the proportion o f people in a specified population who behave in a certain way (Saunders, et al., 1997). The study made use o f this type o f design to determine the view o f respondents on 57 University of Ghana http://ugspace.ug.edu.gh quality and determine variables that are likely to determine quality o f health care services for respondents. The survey technique was used in the collection o f primary data for this study. Surveys provide a methodology (questionnaires and interviews) for asking people to provide information about themselves, their attitudes and beliefs demographics and facts, past or intended future behaviour (Cozby, 2003). The survey method has proven over time to be very useful in examining a sample from a population. According to Babbie (1973), a survey method ensures among other things population validity, accurate results o f subsequent assessment o f the attributes o f the same sample and generalisation o f findings. One o f the features o f the survey method involves designing and administering o f questionnaires. The administration o f the data collection instrument (questionnaire in this study) could be done through the telephone, group administration, mail, Internet or focus group interviews (Cozby, 2003). For the purposes o f this research, the self­ administration technique was adopted. This option was taken based on the opportunity it created for meeting respondents and persuading them for more and timely responses. 5.2 STUDY POPULATION The study population o f a research applies to the collection o f all possible individuals, objects or measurements o f interest (Mason, 1999). Identification o f the population of the research in question was necessary in narrowing down to the specific objects that were the subject matter o f the study. 58 University of Ghana http://ugspace.ug.edu.gh The DMHI schemes are new schemes in line with the government’s policy o f making health care accessible to Ghanaians. The study population consisted o f only people who had subscribed to the New Juabeng Municipal Health Insurance Scheme and the Ketu District Mutual Health Insurance Schemes, under the NHIS and had used the facility at least two times. An objective assessment o f the quality o f health services provided was important in arriving at valid conclusions. 5.2.1 D emographic C haracteristics o f Respondents In the New Juabeng district, the population sampled for the research was diverse in terms o f the ages o f the respondents, their gender and occupation. There is a diversity o f peoples and cultures in the municipality. The major ethnic group is Akan. Other ethnic groups found in significant numbers in the municipality are the Ga Adangbes, Ewes and people from the northern part o f Ghana. The common language spoken in the municipality is Twi. The main occupations o f the people in the municipality were commerce, civil or public service, agriculture and wood/timber processing. The Ketu district also had a diversity o f respondents in terms o f age, gender and occupation. The diversity o f cultures and peoples observed in the New Juabeng municipality is not reflected in the Ketu district. The main ethnics group in the district is the Ewes. The main occupations o f the people in the district were commerce, trade in fish and fish products as well as civil and public services works. 59 University of Ghana http://ugspace.ug.edu.gh 5.3 SAMPLING DESIGN AND PROCEDURES Non-probability sampling design was used in selecting respondents to the survey. Non-probability research design is explained as where the sample frame cannot be defined in definite terms. In the case o f this research, subscribers who had used the health facility two or more times could be identified from the secretariat o f the schemes; however, locating such subscribers was very difficult as post numbers were used and most streets in Ghana are not named and houses also not numbered for easy identification. Even though probabilistic sampling technique is theoretically upheld as being superior, non-probabilistic sampling technique is also accepted in the fields o f business and social sciences and has its own merits. For example, a non-probabilistic sampling design is most appropriate if a definite sample frame cannot be identified; this study was a classical example. This sampling technique is also convenient, cost efficient and time saving. Respondents were made up o f only subscribers who had used health services under the two DMHI scheme two times or more. This criterion was chosen because subscribers who had used health care services under the scheme two or more times would be able to give a relatively more objective assessment o f quality. The selection was in line with one o f the attributes o f judgmental or convenient sampling, which enables the researcher select cases, which aid in answering research questions and thus meet set objectives (Saunders et al., 1997). 60 University of Ghana http://ugspace.ug.edu.gh The questionnaires were given to respondents based on the number o f times health care facilities had been used since joining the DMHI scheme. The New Juabeng municipality is divided into subdistricts, namely Oyoko/Jumapo sub-district, Effiduase/Akwadum sub-district, Koforidua/Zongo and Medical village/Old Estate sub districts with about 70 different communities. All the 70 communities were visited and information was solicited from at least 6 respondents in each community. The nine towns Afife, Aflao Urban, Aflao Wego, Dzodze, Klikor, Penyi, Some Wego Some Fugo and Weta that constitute the Ketu district had a minimum o f 45 respondents each from them. The expected sample sizes for the two schemes were 450 and 450 for the New Juabeng and Ketu districts respectively. This made a total o f total o f 900 respondents. The sample size was informed by statistical methods used in the determination o f the minimum size o f a sample from a finite population with a 95% level o f confidence. The 95% confidence level meant that from the sample chosen from the population, valid statistical inferences could be confidently made to represent the total population with only an error margin o f 5%. According to Krejoie and Morgan (1970) a population size o f between 50,000 and 75, 000 would need a sample size o f about 381 respondents to be able to make inference at a 95% confident level. The New Juabeng scheme had as at the time o f collecting the data, 54,000 subscribers to the scheme and Ketu had 57, 854 active members between January and March 2007 when the data was collected. 61 University of Ghana http://ugspace.ug.edu.gh 5.4 QUESTIONNAIRES AND INDICATORS The study primarily made use o f questionnaires and interview to collect the data needed. The questionnaire was written in simple clear language devoid o f technical terms and enquired from respondents their perception o f quality o f health services provided by the two selected schemes within the conceptual framework developed. The questionnaire was divided into two sections, A and B. Section A enquired about respondents demographic characteristics and the B was concerned with the respondents perception o f quality o f health care services provided with respect to level o f communication, attitude o f staff, availability o f drugs and general information on the National Health Insurance Scheme. The questions on the variables (level o f communication, attitude o f staff and availability o f drugs) were closed ended (Likert Scale type questions) and the open-ended aided in achieving the objective o f determining the particular areas o f health care quality subscribers considered important at the health care facility under the NHIS. The Likert scale had five points ranging from “very good” to “very poor”. The Likert scale type o f questionnaire has been recommended for measuring attitude type questions, which is the type the researcher was involved in (perception). The interview questions were structured and enquired about quality o f health care services (in relation to the variable identified) provided before the introduction o f the scheme in the two districts. The interview was conducted after respondents had answered the questionnaires. 62 University of Ghana http://ugspace.ug.edu.gh 5.4.1 Pre-Testing o f Questionnaire The questionnaire was pre-tested at the Out Patients Department (OPD) o f the Achimota Hospital. The Achimota Hospital is a district hospital in the Greater Accra Region. Twenty subscribers who had used the scheme at least two times were asked to fill the questionnaires and were interviewed afterwards on quality o f health care before the scheme. This took place outside the pharmacy department, which is the last point o f service in the hospital before a subscriber leaves the hospital. Some wordings in the questionnaire were revised and a question was eliminated because it could be implied from an earlier question. Some o f the respondents to the questions felt intimidated in the hospital setting. They asked that their names should not be written. This attitude confirmed earlier decision o f the researcher not to interview subscribers in the hospital setting for fear o f bias as a result o f the intimidation some subscribers would feel by the mere fact o f being in the hospital at the time o f filling the questionnaires. The final questionnaire was then presented to subscribers in the New Juabeng and Ketu Districts. The pre-testing o f the questionnaire enhanced validity. This is because poorly worded and poorly understood questions were identified and restructured or eliminated. To ensure reliability, the same questionnaire, based on the conceptual framework developed was given to the respondents in the two districts. 5.4.2 Administration o f Questionnaires and Interviews The questionnaires and interviews were conducted in the homes, workplaces o f the respondents and on the streets o f the two districts. According to Zikmund (1996) 63 University of Ghana http://ugspace.ug.edu.gh door-to-door interviews conducted in respondents’ homes or offices increases participation rates. Thus the research was conducted using the door-to-door approach. The hospital setting, which would have been convenient, was avoided as it was noticed at the pre-testing stage that there was the tendency for respondents to be apprehensive. 5.5 DATA PROCESSING AND ANALYSIS Likert scale responses were coded and the Statistical Package for Social Sciences (SPSS) was used to analyse responses. Descriptive statistics covering measures o f central tendencies and relative dispersions are computed based on the likert scale response ratings. Given the approximately normal distribution o f the responses, the mean responses along the likert scale o f “very good-1”, “good-2”, ‘fair-3”, “poor-4’ and ‘very poor-5” on an overall basis approximated the consensus views o f the respondents. Therefore, the overall average Perceptual Ratings were used to determine how respondents perceived the services provided under the various quality dimensions. Tables were used for the presentation o f the data. The descriptive analysis made use o f averages, frequencies and percentage distributions in drawing inferences and related conclusions. Open-ended responses were tabulated and frequencies determined then supportive and/or suggestive views could be elicited. This was considered important so as to provide opportunity and basis for incorporating the subjective views o f respondents which are nonetheless vital in their appraisal o f the services they receive. 64 University of Ghana http://ugspace.ug.edu.gh 5.6 ETHICAL CONSIDERATIONS On the questionnaire was a brief introduction o f the purpose o f the research and the rights o f the respondents to participate or not. Very clear instructions on answering the questions were provided in order to avoid ambiguity. Anonymity o f participants was guaranteed because the names o f respondents were not solicited. Respondents were orally asked if they were interested in participating in the survey. Those not interested were left alone. 5.7 LIMITATIONS OF THE RESEARCH METHOD The strength o f this research finding could be limited by the unwillingness o f the respondents to provide truthful and accurate answers. Again, the judgemental sample used for the study may affect representativeness o f the views o f the entire population as there exist the possibility that objectivity o f the assessment may not be based on the number o f times subscribers may have used the facility. 5.8 CONCLUSION In the preceding sections, the methods used in collecting data for the study has been outlined. The research design, the choice and size o f the sample as well as the data collection instruments have been thoroughly discussed in the preceding paragraphs. It would thus be observed from the chapter that, this study attempted to use the scientific method in arriving at conclusions drawn. This chapter forms the basis for the presentation o f the data and its analysis. 65 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX PRESENTATION OF FINDINGS 6.0 INTRODUCTION This chapter presents the findings o f the study. For a survey, a response rate o f at least 50% is adequate for analysis and reporting. A response rate o f 60% is good whilst that o f 70% is very good and 90% raises no question for analysis and reporting (Babbie, 1989). This research had a response rate o f 89%, which could be considered as very good. A larger sample size o f 450 instead o f the 381 was used for the study to ensure that response rates were high. 6.1 DEMOGRAPHIC CHARACTERISTIC OF RESPONDENTS Respondents’ demographic characteristics in the areas o f gender, age, educational level and occupation were carefully examined. These characteristics provide information that helps in assessing whether the social, economic and other circumstances o f subjects impact on their behavioural activities and to what extent. This is particularly important because perceptions and attitudes are behavioural qualities that are largely informed by the social constructions surrounding the individual. The results in this category have been analysed both within and across the two districts so that a good comparison could be made. From Table 6.1, it can be observed that o f the 400 respondents interviewed in the Ketu district (197 approximately 49%), were male while in the New Juabeng District, 39.5% o f the respondents were male. Approximately 45.6% o f the total respondents for the two districts were males. The results reveal a relatively higher female to male respondent’s ratio for both districts. Whilst this may not provide conclusive evidence 66 University of Ghana http://ugspace.ug.edu.gh o f the male female enrolment levels, it could give an indication in that direction although the difference may appear insignificant. Table 6.1: Gender Distributions o f Respondents D IST R IC T S G EN D ER M ALE FEM A LE TO T A L N JU A B EN G 168 (4 2% ) 232 (5 8% ) 400 KETU 197 (4 9% ) 203 (5 1% ) 400 TO TA L 365 (4 6% ) 435 (5 4% ) 800 O f the 365 males out o f the 800 respondents to the survey, 357 rated overall quality o f health services (question 12 in appendix I). Quality o f services was rated as “fair” by 115 respondents, who constituted about 32% o f the 357 respondents. About 33% o f the total male respondents rated quality as good and only 23 (6%) rated it as very good. In comparison, 409 out o f the 435 females responded to question 12. In rating quality, 42% rated it as fair, 25% as good and 14% rated it as very good (appendix VII). The age distribution o f respondents in the Ketu district, as observed from table 6.2 appears to fall between the age categories o f 35 and 49 years, the youthful stage. A similar phenomenon was observed in the New Juabeng district. The age group with the lowest number o f respondents was the 18 and 24 group. This age group forms the proportions that are usually in school or have just finished school. 67 University of Ghana http://ugspace.ug.edu.gh Table 6.2: Age D istribu tions of Respondents D IST R IC T A G E G R O U P O F R E SPO ND EN TS 18-24 25-34 35-49 50-64 65 > t o t a l N JUA BENG 46 89 104 93 68 400 K ETU 52 70 145 82 51 400 t o t a l 98 159 249 175 119 800 A clear difference could be seen in the level o f education o f respondents in the two districts (Table 6.3). In the Ketu District, for example, 26.5 % o f the respondents have had secondary level education, whilst New Juabeng seems to have a majority o f its respondents having the Junior Secondary or Middle School as their highest level in education. In spite o f these differences in the levels o f education, in both localities, commerce appears to be the dominant occupation o f the respondents. Table 6.3: Level o f Education of Respondents D IST R IC T S L EV E L O F EDUCAT ION NO EDU . PR IM . j s s /m id d SEC TE R T IA R Y TO TA L N JUA BENG 32 (8% ) 92 (2 3% ) 130 (3 2% ) 78 (2 0% ) 68 (1 7% ) 400 KETU 30 (7 .5% ) 99 (2 5% ) 78 (2 0% ) 106 (2 7% ) 87 (2 1% ) 400 TO TA L 62 (8% ) 191 (24% ) 208 (2 6% ) 184 (2 3% ) 155 (1 9% ) 800 A large proportion o f respondents in both localities were employed in one form or the other (Table 6.4). This could mean that unless one was employed, access to the health insurance scheme was impossible because o f premiums to be paid. The exemptions to this phenomenon were if one was 70 years or more, or was below 18 years and whose 68 University of Ghana http://ugspace.ug.edu.gh parents are registered. Most o f those employed in the districts were mostly artisans who were informal sector workers. These included carpenters, hairdressers, mechanics, labourers, electricians and seamstresses. Others were bakers and famers. These respondents constitute approximately 76% (Refer to Table 6.4) o f employed respondents in New Juabeng and approximately 84% o f employed respondents in Ketu. Table 6.4: O ccupations o f Respondents D IST R IC T S O C CU PA T IO N EM PLO Y ED UNEM PLOY ED R E T IR ED STU DEN T TO TA L N JUA BENG 306 (7 6% ) 53 (1 3% ) 10 (3% ) 31 (8% ) 400 K ETU 337 (8 4% ) 28 (7% ) 4 (1% ) 31 (8% ) 400 TO TA L 643 (8 0% ) 81 (1 0% ) 14 (2% ) 62 (8% ) 800 The unemployed constituted 13% and 7% o f total respondents in the New Juabeng and Ketu district respectively. Respondents on retirement constituted approximately 3% and 1% and students constituted 8% each for New Juabeng and Ketu. The rest o f the respondents were made up o f public sector workers (health workers, teachers and civil servants), bankers and housewives. Table 6.5 provides an indication o f the type o f health care facilities used in the two localities. It can be observed that, majority o f the respondents patronise government health facilities. These health care facilities include regional or district hospitals, health centres, Reproductive and Child Health (RCH) centres, and Community Based Health Planning and Services (CHPS) centres. 69 University of Ghana http://ugspace.ug.edu.gh The Ketu and New Juabeng districts have approximately 57% and 64% o f their respondents using government facilities respectively. New Juabeng seems to have private health facilities as the second highest frequented by respondents. Ketu has a lot more respondents using the only Mission health facility in the area than private health care facilities. Table 6.5: Type o f Health Care Facility Used D IST R IC T TY PE O F H EA L TH C A R E FA C IL IT Y USED G O V ’T PR IV A TE M ISS IO N TO TA L N JUA BENG 254 (6 4% ) 75 (1 9% ) 71 (1 7% ) 400 KETU 226 (5 7% ) 60 (1 5% ) 114 (2 9% ) 400 TO TA L 480 (6 0% ) 135 (1 7% ) 185 (2 3% ) 800 The type o f health care facility used is important in assessing health care quality as the state and quality o f the facility bear directly on the continual use o f service by subscribers. 6.2 AVERAGE PERCEPTUAL JUDGMENTS The means for the variables on which quality o f health services is determined are provided and analysed in the succeeding paragraphs. 6.2.1 Level o f Communication Adequate and relevant knowledge on the part o f health service beneficiaries plays a central role in ensuring speedy treatment o f ailments (Andeleeb, 1998). Administering health service and its related therapeutic prescriptions are quite technical and require 70 University of Ghana http://ugspace.ug.edu.gh expert knowledge. Therefore, the transfer o f this knowledge (communication) to patients goes a long way to improve health service quality. On average, subscribers in the New Juabeng district appeared to have a consensus that the quality o f service was good, as the mean perception rating approximates 2.0 (Table 6.6), which corresponds with good (2) on the likert scale. Subscribers in Ketu however, appeared to have a mean rating o f approximately 3.0 (fair on the likert scale). The 2.0 rating in New Juabeng indicated that subscribers perceived the level o f communication as good. In Ketu however, the level o f communication appeared to be insufficient as it was rated fair by respondents. Table 6.6: Rate o f Quality Based on the Level o f Communication THOROUGHNESS OF EXAMINATION EXPLANATIONS ON MED. TESTS INSISTENCE ON FOLLOW -UP EXPLANATIONS ON SIDE EFFECTS N. JU A B ENG 2.378788 2 .377215 2 .384416 2.385787 NO OF RESPONSES 396 395 385 394 KETU 3.013514 3 .008219 3.013514 3.016349 NO OF RESPONSES 370 365 370 367 6.2.2 Attitude o f Staffs The demeanour o f the staffs is very important in determining whether patients continue to utilize a particular health service. Clients want to be treated with respect, friendliness, helped and an interest expressed in their condition. These are interpreted by clients as being treated equal (Kols & Sherman, 1998). 71 University of Ghana http://ugspace.ug.edu.gh In the New Juabeng municipality, the mean perceptual judgment o f subscribers on the attitude o f staffs approximates 2.0 (which is good (2) on the likert scale) (Table 6.7). In Ketu however, the average rating is 3.0 (fair on the likert scale). This the ratings means that respondents on the two schemes rate the attitude o f the staff towards them as good and fair in the New Juabeng and Ketu respectively. Table 6.7: Rate o f Quality Based on Attitude o f Staff HELPFULNESS OF NURSES COURTESY OF NURSES LEVEL OF INTEREST OF DOC. COURTESY OF DISPENSER DIFFERENCE IN TREATMENT YES NO N/S N. JUA BENG 2.378788 2.378788 2.409326 2 .400517 231 64 79 NO OF RESPONSES 396 396 386 387 K ETU 3.013514 3.05042 3 .051282 3.050847 237 143 15 NO OF RESPONSES 370 357 351 354 However in establishing the specific factors that determine the attitude o f staff, respondents in New Juabeng appeared indifferent between the helpfulness and courtesy o f the nursing staff (Table 6.7). This means that to the respondents, the courtesy and help shown by the nursing staff are major determinants o f the attitude o f the staff. In Ketu however, respondents were certain that, the help extended to them by the nursing staff, was a major determinant o f the attitude o f the staff. Differences in treatments between the insured and uninsured were not rated on a Likert scale. It was based on yes, no and not sure. This rating was used to test the subjective experiences o f respondents. In both districts, the yes response appears to dominate (Table 6.7). 72 University of Ghana http://ugspace.ug.edu.gh 6.2.3 Availability o f Drugs The availability o f drugs in a health care facility can greatly affect utilization o f health services (Baltussen et al., 2002). Medications are considered as a major element in the recovery process and therefore a determinant o f quality in health care services. The ratings on availability o f drugs was on a yes, no or not sure bases. The dominant response was “yes” in the New Juabeng municipality for the availability and effectiveness o f drugs (Table 6.8). However, in the Ketu district, 44% o f the 400 respondents asserted that drugs prescribed for them were readily obtainable at the dispensary o f the health facility. Table 6.8: Availability and Effectiveness of Drugs under the DMHI Schemes A VA ILA B IL ITY O F D RUG S YES NO N O T SURE M ISS IN G TO TA L N. JU A BENG 253 (6 3% ) 143 (36% ) 3 (0 .0 07% ) 1 (0 .0 0 3% ) 400 K ETU 177 (4 4% ) 219 (55% ) 1 (0 .0 03% ) 3 (0 .0 0 7% ) 400 TO TA L 430 (5 4% ) 362 (4 5% ) 4 (0 .0 0 5% ) 4 (0 .0 0 5% ) 800 E F FEC T IV EN E S S O F D RUG S N. JU A BENG 292 (7 3% ) 84 (2 1% ) 12 (3% ) 12 (3% ) 400 K ETU 278 (7 0% ) 54 (1 4% ) 5 (1% ) 63 (1 6% ) 400 TO TA L 570 (7 1% ) 138 (1 7% ) 17 (3% ) 75 (9% ) 800 Considering that availability o f drugs in a health care facility is very important and people go to hospitals to be diagnosed and cured, the views o f minority in the case of New Juabeng and majority in Ketu are equally important. Approximately 36% o f the respondents in New Juabeng did not have access to all o f their prescribed drugs at the dispensary o f the health facility they utilised. On the other hand, 219 out o f 400 (Table 73 University of Ghana http://ugspace.ug.edu.gh 6.8) respondents in the Ketu district did not have access to most o f the prescribed drug in the health care facility. Overall, approximately 54% o f a total o f 800 respondents appeared to have access to drugs prescribed for them at the health care facilities. The other respondents numbering 362 (Table 6.8) did not have access to drugs prescribed for them in the health care facilities. Approximately 71% o f the respondents attested to the efficacy o f the drugs prescribed for them under the schemes in the two districts irrespective o f whether these were given at the hospital or not. While a total o f 138 o f the 800 (Table 6.8) respondents expressed reservations about the efficacy o f the drugs, 3% were not sure about the efficacy o f drugs they had used under the schemes and 75 people out o f the 800 did not respond to the question. 6.2.4 General Quality Ratings Table 6.9 sums up the total quality rating o f respondents. A total o f 82 (approximately 10%) respondents o f the two schemes rated quality o f health care as very good, approximately 28% o f the respondents (226 out o f 800) rated the scheme as good whilst 41% (328) respondents rated it as fair. About 13% o f the respondents rated it as poor with the majority o f these respondents (96 out o f 111) in the Ketu district. Approximately 2% o f the respondents rated quality as very poor. Interestingly, all o f these respondents are from the Ketu districts. Approximately 4% o f respondents did not respond to the question on the overall rating o f quality. 74 University of Ghana http://ugspace.ug.edu.gh Table 6.9: G enera l Q uality Rating RA T IN G O F O V ER A LL Q U A L ITY RA TE V. GOOD G OOD FA IR PO O R V. PO O R M ISS ING TO TA L N. JUABENG 76 (1 9% ) 109 (2 7% ) 196 (4 9% ) 15 (4% ) 4 ( 1 % ) 400 KETU 6 (2% ) 117 (2 9% ) 132 (3 3% ) 96 (24% ) 19 (4% ) 30 (8% ) 400 TO TA L 82 (1 0% ) 226 (2 8% ) 328 (4 1% ) 111 (1 4% ) 19 (3% ) 34 (4% ) 800 6.2.5 Recommendation o f Scheme Based On Quality Rating Recommendation o f the scheme was matched with how respondents rated the quality o f services provided (Table 6.10). All the 82 (approximately 11%) respondents from both localities who rated the scheme as being “very good” declared they were willing to recommend the scheme to those who had not joined. O f the 223 respondents who rated overall quality o f the scheme as being good, 69% o f them said they would recommend the scheme. However, 59 out o f the 223 respondents said they would not recommend the schemes and 3 o f them were not sure about recommending the scheme. 75 University of Ghana http://ugspace.ug.edu.gh Table 6.10: R ate o f Quality and Recommendation o f Scheme RA TE O F Q UAL ITY R ECOMM ENDA T IO N YES NO NOT SURE TO TA L VERY G O OD 8 2 (1 4% ) - - 8 2 (1 1% ) G OOD 161 (2 8% ) 59 (3 9% ) 3 (1 9% ) 223 (30% ) FA IR 247 (4 3% ) 59 (3 9% ) 1 3 (8 1% ) 319 (4 3% ) PO O R 71 (1 2% ) 31 (2 2% ) - 102 (1 4% ) V ERY PO O R 17 (3% ) 1 (0 .006% ) - 18 (2% ) TO TA L 578 (7 8% ) 150 (20% ) 16 (2% ) 744 A rating o f fair was made by about 319 respondents out o f a total o f 743 who responded to the question. O f this number, 43% o f them said they would recommend the scheme and 39% said they would not recommend the scheme at all. However, 4% o f them were not sure about recommending the scheme. O f the 102 respondents who rated the scheme as being poor in the two localities 12% o f them, in spite o f their ratings, reported they would recommend the schemes (Table 6.10). 6.3 COMPARATIVE STUDY OF THE DMHI SCHEMES A comparative analysis o f the findings is the focus o f succeeding paragraphs. New Juabeng is a municipality and is located in the Eastern Regional capital, Koforidua; it has a diversity o f people living there because o f its strategic position. Ketu on the other hand is a district located in the south-eastern part o f the country, sharing boundaries with Togo. It is also known to be a stronghold o f the opposition to the 76 University of Ghana http://ugspace.ug.edu.gh 6.3.1 Level o f Communication On the level o f communication at the various health facilities in the two localities, there appeared to be consensus among respondents that, they were examined adequately (Table 6.11). This forms approximately 92% o f 800 respondents, who rated the thoroughness o f examination as “very good”, “good” and “fair” . The rest rated the thoroughness o f examination as poor. It is interesting to note that none o f the respondents rated the communication variable as very poor. O f the 92% respondents who said they were thoroughly examined before medication was administered, 48% were from the Ketu District and 52% were from the New Juabeng Municipality. Approximately 5% and 11% o f respondents in New Juabeng and Ketu rated the variable as poor. The explanation on medical tests also received a consensual response as “good” in the two localities. These respondents constituted approximately 46% o f the total respondents. Explanations on side effects had majority o f respondents in both localities (approximately 39%) alluring to it being “fair” and both districts have most o f their respondents choosing it as fair. A close look at Table 6.11 indicates that 38 more people in New Juabeng than Ketu appear to agree that their physicians insisted on a follow-up after their visits to the health care facility under the scheme whilst 39 more people in Ketu than New Juabeng appear to be holding an opposing view. There however appear to be a consensus (47% o f total respondents) that physicians under the scheme insisted on follow-up. 77 University of Ghana http://ugspace.ug.edu.gh Table 6.11: Com parison on Level o f Communication TH O RO U G HN E SS O F EXAM INA T ION RATE V. GOOD GOOD FA IR PO O R V. PO O R M ISS IN G TO TA L N. JUABENG 121 (30%) 178 (45%) 82 (21%) 19 (5%) - 400 KETU 126 (32%) 167 (42%) 63 (15%) 44(11% ) 400 TO TA L 247 (31%) 345 (43%) 145 (18%) 64 (8%) 800 EX PLANA T IO N S ON M ED IC A L TESTS N.JUABENG 35 (9%) 200 (50%) 151 (38%) 13 (3%) 0 1 (0.003%) 400 K etu 23 (6%) 169 (42%) 125(31%) 74 (19%) 1 (0.003%) 8 (2%) 400 TO TA L 58 (7%) 369 (46%) 276 (35%) 87(11%) 1 (0.001%) 9(1% ) 800 EX PLA NA T IO N S ON S ID E E F FEC T S N. JUABENG 33 (8%) 108 (27%) 169 (42%) 86 (22%) 2 (0.005%) 2 (0.005%) 400 K ETU 7 (2%) 107 (27%) 144 (36%) 121 (30%) 16 (4%) 5 (1%) 400 TO TA L 40 (5%) 215 (27%) 313 (39%) 207 (26%) 18 (2%) 7 (0.008%) 800 IN S IS T EN C E ON FO L LOW -U P YES NO NOT SURE M ISS ING TO TA L N. JUABENG 202 (51%) 168 (42%) 19 (5%) 11 (3%) 400 KETU 164 (41%) 207 (52%) 28 (7%) 1 (0.003%) 400 TO TA L 366 (46%) 375 (47%) 47 (6%) 12 (1%) 800 6.3.2 Attitude o f Staff Approximately 35% and 37% o f the respondents in Ketu rated the helpfulness and courtesy o f nurses as “poor” respectively (Table 6.12). In New Juabeng, 9% and 50% o f respondents rated helpfulness and courtesy o f the nursing staff as fair respectively. It is apparent in New Juabeng however (Table 6.12), that the nurses are perceived to be more helpful than courteous whilst in Ketu there was not much difference in the ratings o f courtesy and helpfulness. 78 University of Ghana http://ugspace.ug.edu.gh The courtesy o f the dispenser was rated as ‘fair’ in both New Juabeng and Ketu, with the respondents constituting approximately 38% and 40% in the two districts respectively. Whilst 34% o f the respondents in Ketu rated the courtesy o f the dispenser as poor, approximately 17% o f the respondents in New Juabeng rated it as poor. It is apparent that a lot more respondents in Ketu were unsatisfied with how they were treated by dispensers. On the level o f interest expressed by the doctor in them, 57% o f the respondents in New Juabeng and 37% o f the respondents in Ketu rated it as good whilst approximately 33% in New Juabeng and 51% in Ketu rated the level o f interest expressed in them by the doctors as fair (Table 6.12). Whilst approximately 6% o f the respondents did not respond to this question in Ketu, only about 3% o f the respondents in New Juabeng did not respond it. Approximately 58% and 59% o f respondents in New Juabeng and Ketu respectively answered, “yes” to being treated differently or observing others being treated differently whilst 21% and 36% (approximate) responded no respectively (Table 6.12). About 20% and 4% o f the respondents in New Juabeng and Ketu respectively were unsure whether they experienced or noticed any difference in the way insured and uninsured health care users were treated. It could be inferred that respondents in Ketu were more observant o f any differences that existed in their health care facilities. 79 University of Ghana http://ugspace.ug.edu.gh Table 6.12: Com parison on A ttitude o f S taff H EL PFU LN E SS O F NURSES RA TE V . G O OD GOOD FA IR PO O R V . P O O R M IS S ’G TO TA L N. JU A B ENG 24 (6% ) 136 (34% ) 195 (4 9% ) 34 (8% ) 11 (3% ) - 400 K ETU 35 (9% ) 93 (2 3% ) 116 (2 9% ) 138 (3 5% ) 18 (5% ) - 400 TO TA L 59 (7% ) 229 (2 7% ) 311 (3 9% ) 172 (2 2% ) 29 (3% ) 800 CO UR TESY O F NURSES N. JUA BENG 19 (5% ) 119 (30% ) 201 (50% ) 50 (1 3% ) 11 (2% ) 400 K e tu 17 (4% ) 109 (27% ) 85 (2 1% ) 147 (3 7% ) 28 (7% ) 14 (4% ) 400 TO TA L 36 (5% ) 228 (29% ) 286 (3 5% ) 197 (2 4% ) 39 (5% ) 14 (2% ) 800 CO URTESY O F D IS P EN SER N. JU A B ENG 26 (7% ) 146 (37% ) 153 (3 8% ) 66 (1 6% ) - 9 (2% ) 400 K ETU 13 (3% ) 46 (1 2% ) 160 (4 0% ) 136 (3 4% ) 19 (5% ) 26 (6% ) 400 TO TA L 39 (5% ) 192 (2 4% ) 313 (3 9% ) 202 (2 5% ) 19 (2% ) 35 (4% ) 800 L E V EL O F IN T E R E S T D ISPLAY ED BY D O C TO R V . H IG H H IG H FA IR LOW V. LOW M ISS IN G TO TA L N. JUA BENG 14 (4% ) 230 (5 8% ) 130 (3 2% ) 16 (4% ) 10 (2% ) 400 K ETU 4 (1% ) 147 (3 7% ) 205 (5 1% ) 18 (5% ) 3 (0 .0 0 7% ) 23 (6% ) 400 TO TA L 18 (2% ) 377 (4 7% ) 335 (4 2% ) 34 (4% ) 3 (0 .003) 33 (4% ) 800 D IF F ER EN C E IN T R EA TM EN T YES NO N O T SURE M ISS IN G TO TA L N. JU A BENG 231 (5 8% ) 84 (21% ) 79 (2 0% ) 6 (1% ) 400 K ETU 237 (5 9% ) 143 (3 6% ) 15 (4% ) 5 (1% ) 400 TO TA L 468 (5 8% ) 227 (2 8% ) 94 (1 2% ) 11 (1% ) 800 80 University of Ghana http://ugspace.ug.edu.gh 6.4 OTHER RELATED ISSUES EMERGING FROM THE STUDY The variables used in assessing the quality o f health care services for this study concentrated on level o f communication, attitude o f staff and the availability o f drugs. However, there were particular concerns o f respondents that could not have been covered by the quality dimensions used for the study. Therefore some general questions were asked to help determine which quality aspects respondents considered important under the schemes. 6.3.3 Complaints and the Handling o f Complaints In Table 6.13, there appears to be a low level o f complaints in the two localities. Only 37 out o f 400 respondents in New Juabeng had ever made complaints to their scheme and o f this only 12 o f them were satisfied with the way the complaints were handled. Table 6.13: Complaints and the Handling o f Complaints C OM PLA IN T S M ADE YES NO NO T SURE M ISS IN G TO TA L N. JU A B ENG 37 (9% ) 277 (69% ) 4 (1% ) 82 (21) 400 KETU 69 (1 7% ) 217 (5 5% ) 25 (6% ) 89 (22) 400 TO TA L 106 (1 3% ) 494 (62% ) 29 (4% ) 171 (2 1% ) 800 HAND L IN G O F C OM PLA IN T S N. JU A B ENG 12 (3% ) 6 (2% ) 1 (0 .0 03% ) 381 (9 5% ) 400 K ETU 53 (1 3% ) 12 (3% ) 1 (0 .0 03% ) 334 (8 4% ) 400 TO TA L 65 (8% ) 18 (2% ) 2 (0 .0 03% ) 715 (8 9% ) 800 81 University of Ghana http://ugspace.ug.edu.gh In Ketu only 69 out o f the 400 respondents had ever made complaints. Even though this is on the low side, when compared to complaints made in New Juabeng however, it is high. O f the number o f respondents who had ever made complaints, 53 o f them were happy with the way their complaints were handled and only 12 o f the 37 respondents in New Juabeng had been satisfied with the handling o f complaints in the municipality (Table 6.13). 6.4.1 Unexpected Experiences of Respondents Respondent were asked whether anything has happened on any o f their visits to the health care facilities that was unexpected. Responses to such unexpected experiences under the scheme were few. However, respondents who responded stated among other things they were surprised when they were directed to specific health care facilities to obtain drug, pay for some services while others did not pay anything at the health facility. These apparently contrast respondents impressions formed following television adverts on the scheme that drugs were obtainable free o f charge. 6.4.2 Best Thing about NHIS at the Health Facility There is the need to know the things subscribers find good about the health insurance scheme in term o f quality. A large proportion o f respondents to the question on the best thing about the NHIS indicated among other things they enjoyed not paying for any service at the health facility; having prescribed drugs available and for “free”; and the sympathetic attitude o f the hospital staff towards their children. Some also asserted that the drug stores in the community were no longer their first point o f contact in case o f illness. 82 University of Ghana http://ugspace.ug.edu.gh 6.4.3 Worse Thing about NHIS in the Health Facility Knowledge o f the dislikes o f consumers o f a service is important to ensure continuity o f use o f that service by consumers. This question gave an indication o f the quality dimensions that respondents used in determining the quality o f services provided under the schemes. Generally, respondents were disappointed that not all diseases were covered by the insurance scheme; not all prescribed drugs were covered; and the fact that the schemes were networked to ensure access in to health care in districts other than theirs. Some stated that doctors, unlike before, did not request laboratory tests as often as they used to and nurses were disrespectful to insured patients. In New Juabeng, in particular the concern was the unfriendly nature o f the workers o f the records department where patient folders were kept. This sentiment was reiterated by a lot o f respondents in the same district. In Ketu, respondents concerns were that Togolese patients continued to be treated better than Ghanaian insured patients. In general respondents from the two localities stated that there was constant shortage o f prescribed drugs at the health facilities, constant delays in being attended to and doctors did not often request or insist on follow-up. 6.4.4 Recommendations for Meeting Needs of Subscribers Having identified the concerns o f respondents about the scheme in the health facilities, it was important to know what they would want done to solve these problems. The recommendations made included expansion o f the health facilities to 83 University of Ghana http://ugspace.ug.edu.gh accommodate the increase in attendance rate as a result o f the health insurance, that nurses be patient, respectful and friendly; the desire that the number o f doctors be increased and they should insist on follow-up and the wish that prescribed drugs be available at the health facilities and the wish that dispensers be patient with patients. In Ketu, in particular, respondents recommended that Ghanaian patients, especially those insured, be given preferential over or at the least equivalent treatment as Togolese and Beninios patients. 6.5 QUALITY BEFORE THE INTRODUCTION OF THE SCHEMES An interview was conducted to ascertain the quality o f health care services in the two districts, before the introduction o f the schemes. The quality dimensions enquired from respondents (also respondents o f the questionnaire) revealed that o f the quality in terms o f level o f communication and o f the attitude o f staff was good. The exception being that some nurses occasionally were unpleasant and impatient towards patients. On the availability o f drugs most respondents were o f the opinion that drugs were almost always available at the health care facilities and these drugs were bought. This is in contrast to some the statement some respondents made under the DMHI schemes that covered drugs were constantly in short supply at the health facilities. On how they would rate quality o f health care services provided before the introduction o f the health insurance scheme, respondents were o f the view it was fair. 6.7 CONCLUSION The chapter has presented the data collected. On a likert scale o f 1 to 5 with 1 being “very good” and 5 “very poor”, quality o f health care under the DMHI schemes appeared to be fair. This quality rating has implications for decisions to be taken at the 84 University of Ghana http://ugspace.ug.edu.gh various schemes. Ketu in particular appeared to have more respondents not satisfied with the attitude o f staffs and having to compete for the attention o f the hospital staff with Togolese and Beninios nationals who use Ghanaian health facilities. The succeeding chapter discusses the findings and their implications and provides recommendations. 85 University of Ghana http://ugspace.ug.edu.gh CHAPTER SEVEN SUMMARY, CONCLUSIONS AND POLICY IMPLICATIONS 7.1 INTRODUCTION This concluding chapter discusses the findings made in the study, relates the findings to the objectives o f the study brings out possible policy implications o f the findings o f the study and outlines areas o f further research. 7.2 DISCUSSION The discussion considers how the demographic characteristics o f respondents reflect on their perception o f quality along the level o f communication, attitude o f staff towards insured patients, availability and effectiveness o f prescribed drugs, as well as the willingness o f respondents to recommend the schemes to others. Gender o f Respondents The gender o f the respondents from the findings shows a higher female to male ratio in the two localities. There appear to be a consensus among the male and female respondents on the overall rating o f health care quality (Tables 1 and 2 in Appendix VI). Majority o f the two sexes rated quality as fair. Approximately 4% and 3% o f male and female respondents respectively in New Juabeng rated quality as poor. In Ketu, approximately 27% o f male and 36% o f female respondents rated quality as ■poor’ and 'very poor’. Thus a lot more male and female respondents in Ketu appeared to be unsatisfied with the quality o f health care services received than in New Juabeng. 86 University of Ghana http://ugspace.ug.edu.gh Age of Respondents The findings indicate that the NHIS does not cover people 18 and 69 years who are informal workers and have not paid premiums. Tables 3 and 4 in Appendix VII indicates that more than half o f the respondents falling within the 25 and 64 age groups rated quality o f health care services as being below “good” on the likert scale. Occupation o f Respondents The employment levels o f respondents in the two localities appear to be high. The occupation o f respondents gives an indication o f the type o f people enrolled on the DMHI schemes. The lowest proportion as presented in table 6.4 indicates that unemployed constituted only 6% o f the respondents, students ranged between 6% and 8 % in the two districts and those on retirement ranged between 4% and 7% in the two districts. This indicates that, to be a member o f the scheme, one had to be employed to be able to pay premiums hence the low percentage o f unemployed respondents. Ghanaians between the ages o f 61 and 69 years are not covered especially if they are informal sector workers. This could account for the low number o f retirees among respondents. Level o f E ducation o f Respondents The level o f education o f respondents appeared to have an effect on quality ratings. In New Juabeng for instance, respondents with primary, junior and senior secondary education rated quality o f health care below good. Those with tertiary education however rated quality or being good. This difference could be explained by the probing attitude o f people with higher education and therefore they have understanding o f issues that those with relatively lower education may not have. In 87 University of Ghana http://ugspace.ug.edu.gh Ketu, respondents o f all the educational levels rated quality as being below good. The level o f education did not have effect on the rating o f quality in the district (see Tables 5 and 6 in Appendix VII). Number o f times Health Services have been Utilised The number o f times a health care facility has been used appeared to have an effect on the quality ratings. In the two districts, respondents who had used health services under the schemes between two and five times has a lower quality rating than those who had used it six and more times. Quality was rated higher with more use. This could have been as a result o f the uncertainty o f respondents as a result using the services for the first time under the schemes. Level o f Communication Though rating for the level o f communication in the two districts were “good” and “fair” in New Juabeng and Ketu respectively, respondents under the two schemes appeared to have a consensus on explanations to medical test as being a determinant o f the level o f communication in the health care facilities. It is apparent that subscribers in the two districts value explanations o f medical tests to be taken by them as a very important factor in the communication process. These findings reiterates the importance o f communication expressed by Bruce (1990) when she asserted that information given to clients enables users to adhere to medical regimes and understand complications associated with certain diseases. 88 University of Ghana http://ugspace.ug.edu.gh Attitude of Staff towards Insured Patients The attitude o f staff was rated as “fair” in Ketu and “good” in New Juabeng. However in establishing the specific factors that determine the attitude o f staff, respondents in New Juabeng appeared indifferent between the helpfulness and courtesy o f the nursing staff. This means that to the respondents, the courtesy and help shown them is a major determinant o f the attitude o f the staff. In Ketu however, respondents were certain on that the help extended to them by the nursing staff, was a major determinant o f the attitude o f the staff. This appears to be in line with the arguments o f Bannerman et al. (2002) when they argued that concerns o f clients include good staff attitude, maintaining clients’ dignity, respecting clients, comprehensive information about services and fees and a follow-up with clear instructions amongst others Respondents in response to how they were treated differently from uninsured patients gave the following: in the new Juabeng municipality for instance, the 231 respondents ( Table 6.12) who agreed to having been treated differently or observed the treatment o f others, gave the following as the form in which the discrimination occurred: long queues at the dispensary, delays in being attended to (in the health care facility), availability o f drugs to those paying at the health care facility and the impatience of the nurses towards insured. In Ketu, respondents said Togolese and their Beninios counterparts were treated faster and had access to all their medication at the health facility. Some respondents added that it was because they tipped the hospital staffs, a gesture they could not afford. This finding appears to be in line with the October 17, 2006 news reports o f Abdul-Majeed (2006) on the complaints o f subscribers o f the Nanumba District Mutual Health Insurance scheme in the Northern Region o f Ghana. 89 University of Ghana http://ugspace.ug.edu.gh Some respondents however confessed to positive treatments as a result o f being subscribers to the DMHI schemes. Respondents who expressed these views were in the minority. Some o f these views were: insured treated faster; nurses admonishing non-subscribers to insure; and much attention was paid to insured patients relative to uninsured. Availability and Effectiveness o f Prescribed Drugs It appeared that in the two localities, patients had equal chance o f having access to prescribed drugs. Respondents who asserted they did not have access to the prescribed drugs at the health facility said amongst other things, they had to buy the drugs. Reasons attributed to the unavailability were that the drugs were either in short supply or not covered by the schemes. Some respondents were told to buy the prescribed drugs at the facility without any explanations on why they had to buy. A few others were referred to particular drug stores to be served. The number o f pharmacies and chemical shops, contracted by the schemes to serve their subscribers, confirms this. Majority o f the total respondents attested to the efficacy o f prescribed drugs. Respondents, who did not attest to the efficacy o f the drugs, by responding either “no” or "not sure” gave several reasons for those responses, these reasons included uncertainty o f the drugs’ efficacy; return to the hospital with the same condition; going to drug store for new medication; and the belief that drugs o f better quality were not prescribed for them. Some commented that the same drug was given for the different conditions they took to the health facility. 90 University of Ghana http://ugspace.ug.edu.gh Interestingly respondents (in both localities), who rated overall quality as “very good”, were very sure o f recommending the schemes to others and the 17 respondents (Refer to Table 6.10), who rated health services as “very poor”, said they would recommend the scheme to those who had not yet joined. Those who said they would recommend the scheme gave reasons such as; riot paying at the point o f service, having an insurance cover prevents aggravation o f illness and unnecessary deaths, and in times o f financial difficulty health care services could still be accessed. In spite o f the general dissatisfaction with the quality o f health care services under the DMHI schemes, majority o f the respondents in the two districts said they would recommend the scheme. This is in sharp contrast to Sixma et al. (1998) assertion that patients satisfied with a service were more likely to comply with medical regimes and continue using health services. The euphoria associated with accessing health care services without having to pay at the point o f service, the first in Ghana after the period immediately after independence could account for this resounding acclaim o f recommendation o f the schemes. However, respondents who said they would not recommend the schemes gave, drugs not being covered and the unavailability o f covered drugs at the health facility as reasons for not recommending the schemes. Others considered unfriendly treatments and delays in being attended to as not recommending the schemes to non-subscribers. Recommendation o f the Schemes to O thers 91 University of Ghana http://ugspace.ug.edu.gh Complaints and Handling o f Complaints Making o f complaints was very low in the two localities with the lowest being the New Juabeng municipality. Enquiries made on why this was so from the manager o f the New Juabeng scheme revealed that complaints were handled as and when they were made. In Ketu however, there was a District Complaint Committee charged with the duty o f looking into complaints made. The 53 respondents who said they were satisfied with the way their complaints were handled confirm the existence o f committees set up in the Ketu district to handle complaints (Table 6.13). The importance o f enabling customers o f a service to complain is argued by Kim et al. (2003) when they asserted that complaining may increase long-term satisfaction o f clients by facilitating the venting o f the source o f dissatisfaction. 7.3 RESTATEMENT OF OBJECTIVES The objectives o f this study were to determine subscribers’ perception o f quality o f health care services under the New Juabeng and Ketu Mutual Health Insurance Schemes, determine the service quality dimension(s) used by beneficiaries to evaluate service quality and the particular areas o f health care services under the NHIS subscribers consided most important at the health care facility. The need to sustain the newly introduced National Health Insurance Scheme, an alternative to financing the ever-increasing cost o f health care services in the country necessitated this study. To achieve the objectives set, the variables used in determining the quality o f health care services included: the level o f communication between service providers and patients, the attitude o f the staff towards insured patients and the availability o f essential prescribed drugs at the health care facility. The following questions were therefore numerated as aiding the process. 92 University of Ghana http://ugspace.ug.edu.gh 1. What were subscribers’ perceptions o f the level o f communication with medical staff? 2. How do subscribers perceive the attitude o f the staff o f the health facilities they attend? 3. What were subscribers’ perceptions o f availability o f the essential drugs promised under the schemes? 7.4 SUMMARY OF KEY FINDINGS The major findings o f the study in respect o f the objectives and research questions are discussed in the succeeding paragraphs. Level o f Communication Using the average perceptual ratings, it was apparent that respondents in New Juabeng rated the level o f communication at the health care facility as good (approximately 2.0 on the Likert scale used for the study), those in Ketu rated it as fair (approximately 3.0 on the scale). Perception on the A ttitude o f S taff The ratings for the attitude o f staff towards respondents in the New Juabeng were good and (2.0 on the Likert scale) and in Ketu fair (3.0 on the Likert scale). Perception on the Availability o f D rugs Approximately, 46% o f the respondents attested to the availability o f prescribed drugs at the health care facilities they attended. About 45% o f the respondents said prescribed drugs were unavailability at the health care facilities. The percentages 93 University of Ghana http://ugspace.ug.edu.gh appeared to present a divided view on the availability o f prescribed drugs at the health care facilities. The perception o f subscribers on the availability o f drugs is that to a large extent prescribed drugs are available at the health facilities. Others Subscribers’ current perception o f quality o f health care services is good under the New Juabeng Municipal Health Insurance Scheme (based on the mean perceptual averages o f 2.0). In Ketu, subscribers perceive service quality to be fair (based on the mean perceptual average o f 3.0). Availability o f drugs and its efficacy has been rated high in both districts. The relevant service quality dimension used by subscribers to rate quality o f health care services, under the two schemes, were explanation on medical tests, the help extended to them by the nursing staff and the courtesy o f the nursing staff. The particular areas o f health care services under the NHIS considered important to subscribers arising from the study include the length o f time spent in the health care facility (considered to be too long) for insured patients, the demeanour o f the nursing staff in terms o f respect towards insured patients, availability o f prescribed drugs (considered to be constantly in short supply) at health facilities, insistence on follow- up (considered to be uncommon) and in Ketu particularly, the seemingly better treatment given to Togolese and Beniniois patients than Ghanaian health insured patients. 94 University of Ghana http://ugspace.ug.edu.gh 7.5 CONCLUSIONS The major conclusions in respect o f the quality dimensions used in the study and their implications on the health insurance scheme are discussed in the succeeding paragraphs. Level o f Communication The rating o f good, on the level o f communication in the New Juabeng municipality is favourable as it apparent that the hospital staffs communicate effectively with the respondents under the scheme. Careful consideration should however be given to the explanations on medical tests to be taken by respondents as it has been established as a major determinate o f the level o f communication under the scheme in New Juabeng. In Ketu, the perceptual rating o f fair is unfavourable. Fair implies respondents were not happy about the level o f communication from the health care staffs in the facilities they attended. However particular attention should be given to the explanations on medical examinations subscribers are requested to undertake, as respondents appeared to indicate it was a major determinant o f the level o f communication. Attitude o f Staff The attitude o f staffs o f the health care facilities in the New Juabeng municipality was rated as good, implying respondents considered it favourable. However, the courtesies o f the nursing staff as well as the help offered by them were considered a major determinant o f quality in the municipality. 95 University of Ghana http://ugspace.ug.edu.gh The perceptual rating in Ketu, for the attitude o f the nursing staff was fair. A rating o f fair is unfavourable for the scheme as respondents could easily refuse to renew their premiums. This could be attributed to the dwindling enrolment levels in the district compared to the high initial enrolment levels at the inception o f the scheme (KDMHIS Annual Report, 2007). The courtesies o f the nursing staff towards respondents were considered important in determining the attitude o f staff under the scheme. Availability o f Drugs Prescribed drugs were generally considered to be available at the health care facilities. Where the drugs were not available at the health care facility, respondents were either referred to a contracted drug store for the drugs at no cost or were asked to buy them. Explanations on why the drugs were unavailable at the facility or why they were required to buy them were not given to them. The non-existence o f explanations on why prescribed drugs were not available left room for respondents to attribute several reasons as to why the drugs were not available. Some o f these reasons included: expensive drugs were not covered; dispensers hoarded and sold NHIS drugs to non­ subscribers amongst others. 7.6 POLICY IMPLICATIONS OF THE STUDY An inter-institutional collaboration between the Ghana Health Service, the National Insurance Commission, the DMHI schemes and health care professionals in establishing provider norms, training, job description, developing clearly defined structures o f supervision and rewards, would ensure best practices in terms o f ensuring quality o f health care services. 96 University of Ghana http://ugspace.ug.edu.gh Subscribers viewed explanations on medical tests to be taken by them as a major determinant o f the level o f communication in the two districts, doctors and nurses as well as laboratory technician need to be sensitised through jo in t training programmes as described in the preceding paragraph on how to communicate effectively with patients the medical tests they are to take and the implications o f such tests to them. The courtesy o f the nursing staff was also considered a major determinant o f the attitude o f the staffs in the two districts. Institutionalisation o f reward schemes for nurses considered courteous by patients in health care facilities would motivate nurses to be courteous. In the Ketu district in particular, Ghanaian patients should be considered as important as their Togolese and Beninios counterparts in the provision o f health care services. Adequate supple o f essential drugs under the NHIS should be in constant supply at the various health care facilities providing NHIS services. More pharmacists should also be contracted to provide these essential drugs to subscribers. Continuous education o f subscribers on the fact that not all drugs are covered by the scheme should be provided. The low levels o f complaints and satisfaction with the handling o f such complaints reveal a shortcoming in this area. Institutionalisation o f proper reporting and complaint channels in the various schemes would enable complaints to be handled in a good manner and assurance o f subscribers that their welfare is o f concern to the scheme which are linkages between the subscribers and health care providers. The establishment o f special complaints committee as practiced in the Ketu district to 97 University of Ghana http://ugspace.ug.edu.gh address complaints as soon as practicable would exude confidence in the schemes and ensure quality at the health facilities contracted by the schemes. These recommendations notwithstanding, a time series analysis o f these perceptual ratings in quality o f health care services provided under the schemes over considerable periods may be helpful in establishing appropriate patterns and subsequent valid conclusions. This is because this study was conducted a little over a year into the introduction o f the DMHI schemes. 7.6.1 Implications for Further Research This study would not be complete without a recommendation for further studies on issues arising from the study. The following have been suggested as furthering the course o f quality in the NHIS, to ensure its sustainability. The Role o f the District Mutual Health Insurance Schemes in Ensuring Quality o f Health Care Services in Ghana - the DMHI schemes is the link in the NHIS between subscribers and providers o f health services. A discussion o f their role in ensuring quality would not only contribute to assuring quality but furthering academic discourse. A study into the Ghanaian patient’s definition o f health care quality would elaborate further the quality dimensions considered by Ghanaian subscribers to the scheme as o f importance thus needing particular attention. 98 University of Ghana http://ugspace.ug.edu.gh 7.7 CONCLUSIONS Ghana’s development strategy is on alleviating poverty. Poverty is believed to be both a cause and consequence o f poor health. The National Health Insurance Scheme was thus introduced to increase financial access to affordable and quality health care services. The financial access is reflected in the low premium levels charged annually (Appendix IV). Quality o f health care services can be assessed from various perspectives however, the consumer o f the service’s perspective is gaining importance, as it is a major determinant o f the survival o f organisations that provide services. The study thus set out to determine quality o f health care services under the DMHI scheme in Ghana from subscribers’ perspective with particular focus on the New Juabeng and Ketu Districts. The finding revealed that whilst respondents in New Juabeng viewed quality as good, respondents in Ketu perceived quality as fair. These ratings require measures such as institutionalization o f quality measures and reorientation o f providers o f health care services to see quality from the subscribers’ perspective and consider that as an important base for the success o f the schemes, which contracted them. When serious considerations are given to the findings o f this study, there is no doubt it would contribute to the sustaining o f the DMHI schemes in Ghana. 99 University of Ghana http://ugspace.ug.edu.gh REFERENCES Abdul-Majeed, Y. (2006a, October 17). Hospital S taff Accused o f Sabotaging NHIS. The Ghanaian Times pg 1 Abdul-Majeed, Y. (2006b, November 3). 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The Dryden Press: Harcourt Brace College Publishers. Zineldin, M. (2006). The Quality o f Health Care and Patient Satisfaction An Exploratory Investigation o f the 5Q Model at some Egyptian and Jordanian Medical Clinics. International Journal o f Health Care Quality Assurance, 19(1), 60-92. Retrieved October 12, 2006, from www.emerldinsight.com. I l l University of Ghana http://ugspace.ug.edu.gh APPENDIX I QUESTIONNAIRE: UNIVERSITY OF GHANA BUSINESS SCHOOL SURVEY OF SUBSCRIBER PERCEPTION OF QUALITY UNDER THE NHIS This survey is seeking your opinion about services you receive under the NHIS. Your candid views are important since they would help NHIS build upon its strength and improve services to patients. There is no right or wrong answer. This survey is strictly confidential. SECTION A Please tick [V ] where appropriate 1. Sex: Male [ ] 2. Age Group: 18-24 [ ] 25-34 [ ] and over [ ] 3. Level o f Education: a) No formal education [ ] b) Primary [ ] c) JSS/middle school [ ] e) Tertiary education [ ] 4. Which type o f hospital do you use? a) Government hospital [ ] b) Private Hospital [ ] c) Other (specify)_________________ __ 5. What was the nature o f your illness when you last visited the hospital? a) Medical [ ] b) Surgical [ ] c) Maternity [ ] d) Paediatric [ ] e) Emergency [ ] Female [ ] 35-49 [ ] 50-64 [ ] 65 112 University of Ghana http://ugspace.ug.edu.gh 6. How many times have you used the services under the NH IS ?________________ 7. What is your occupation?_______________________ SECTION B How would you rate the NHIS services provided at the hospital under the following features? Level o f Communication 1. The thoroughness with which the doctor examined you before writing your prescription? [a] Very Good [b] Good [c] Fair [d] Poor [e] Very Poor 2. The explanations o f the hospital staff gave you about your medical tests. [a] Very Good [b] Good [c] Fair [d] Poor [e] Very Poor 3. Did the doctor or hospital nurse insist on follow-up on your illness? [a] Yes [b] No [c] Not Sure 4. How well were possible side effects o f medications explained to you? [a] Very Good [b] Good [c] Fair [d] Poor [e] Very Poor Attitude o f S taff (workers the hospital) 5. The helpfulness o f the nurses in the hospital under the NHIS? [a] Very Good [b] Good [c] Fair [d] Poor [e] Very Poor 6. The courtesy o f the nursing staff under the NHIS? [a] Very Good [b] Good [c] Fair [d] Poor [e] Very Poor 7. The level o f personal interest expressed by the doctor in your illness? [a] Very High [b] High [c] Fair [d] Low [e] Very Low 8. The courtesy o f the dispenser when you went for your drug? [a] Very Good [b] Good [c] Fair [d] Poor [e] Very Poor 113 University of Ghana http://ugspace.ug.edu.gh 9. Would you say there is a difference in the treatment offered you as an insured patient? [a] Yes [b] No [c] Not Sure b. If yes, in what way(s) Access to Drugs 10. Do you often find prescribed drugs under the NHIS available at the dispensary? [a] Yes [b] No [c] Not Sure b. I f No, what were you asked to do?__________________________________________ 11. Would you consider the drugs given you under the NHIS the best for your condition? [a] Yes fb] No [c] Not Sure b. I f No, what w hy?____________________________________________________ General Information on NHIS 12. How would you rate the over all quality o f service provided under the National Health Insurance Scheme? [a] Very Good [b] Good [c] Fair [d] Poor [e] Very Poor 13. Have you made any complaints since you started using the hospital under the NHIS? [a] Yes [b] No [c] Not Sure 14. If yes, were you satisfied with the way the complaint was handled? [a] Yes [b] No [c] Not Suje 15. Did anything happen during your visit(s) to the hospital under the NHIS that you thought was surprising or unexpected?___________________________________________ 114 University of Ghana http://ugspace.ug.edu.gh 16 What best thing do you want to say about the NHIS at the hospital? 17. What worse thing do you want to say about NHIS at the hospital? 18. Is there anything the hospital could do better under the NHIS to meet the needs of the insured patien ts?___________________________________________________________ 19. Based on the quality o f services provided under the scheme, would you recommend the scheme to those who have not joined? [a] Yes [b] No [c] Not Sure Please give a reason_________________________________________________ T hank You 115 University of Ghana http://ugspace.ug.edu.gh APPENDIX II INTERVIEW GUIDE: UNIVERSITY OF GHANA BUSINESS SCHOOL UNIVERSITY OF GHANA, LEGON 1. What was the general level o f communication between you and the following hospital staffs before the introduction o f the National Health Insurance Scheme: (0 The doctor (ii) The nurses (iii) The drug dispenser (iv) Laboratory technicians (v) Other workers (specify) 2. What was the attitude o f the staff towards you whenever you were in the hospital before the Introduction o f the NHIS? 3. What would you say about access to the following before the introduction o f the NHIS? (i) Access to facility (ii) Access to a doctor (iii) Provision to make complaints 4. What was access to drugs and medication like before the introduction o f NHIS? 5. What general information can you give me about quality o f health care services from your perspective before the introduction o f the NHIS? 116 University of Ghana http://ugspace.ug.edu.gh APPENDIX III The Benefit Package The government has come out with a minimum benefit package o f diseases, which every district-wide scheme must cover. The package covers about 95% o f diseases in Ghana and these include among others the following; Malaria, Diarrhoea, Upper respiratory tract infection, Skin, diseases, Diabetics, Hypertension, Asthma. i. Out - Patient Services: Consultations, requested investigations, medication. • Out - patient/ day surgical operations • Out - patient physiotherapy ii. In -patient services: General and specialist inpatient care • Requested investigation: Laboratory, X - rays, ultra sound scanning etc. • Medication: prescribed drugs under NHIS • Surgical and breast cancer operations • Inpatient physiotherapy • Accommodation and feeding (where available) Other Specific services • Oral health services • Eye care services • Maternity care • Emergencies 117 University of Ghana http://ugspace.ug.edu.gh Free services • Immunization • Family planning • Mental illnesses • Tuberculosis • Confirmatory HIV test on AIDS patient Exclusion Lists These services will not be covered under the NHIS. This means health insurance schemes have the freedom to decide whether they will offer them as additional benefit to their members. They include: • Rehabilitation other than physiotherapy • Appliances prostheses (optical, hearing and orthopaedic aids, and dentures. • Cosmetic surgeries and aesthetic treatment • HIV retroviral drugs • Assisted reproduction • Echocardiography • Photography • Angiography • Mortuary services • Diagnosis and treatment abroad • Etc Source: Ministry o f Health, 2004 118 University of Ghana http://ugspace.ug.edu.gh APPENDIX IV Name o f G roup Category Who they Are M inimum C ontribu tion p.a. Core Poor A Adults who are unemployed and do not receive any identifiable and constant support elsewhere for survival. F ree Very Poor B Adults who are unemployed but receive identifiable and consistent financial support from sources o f low income £72,000.00 Poor C Adults who are employed but receive low returns for their efforts and are unable to meet their basic needs £72,000.00 Middle Income D Adults who are employed and able to receive their basic needs £180,000.00 Rich E Adults who are able to meet their basic needs and some o f their wants £480,000.00 Very Rich F Adults who are basic needs and most o f their wants £480,000.00 Source: M in istry o f H ealth , 2004 119 University of Ghana http://ugspace.ug.edu.gh APPENDIX V NATIONAL HEALTH INSURANCE FUND A Fund Flow Model Source: M inistry o f Health, (2004), National Health Insurance Policy Framework, p i 7 120 University of Ghana http://ugspace.ug.edu.gh APPENDIX VI Table 1: G ender R a ting of Quality in New Juabeng G EN D ER RA TE O F Q UA L ITY UNDER NH IS V. G OOD GOOD FA IR PO O R TO TA L M ALE 18 55 87 7 167 F EM A L E 58 54 109 8 229 TO TA L 76 109 196 15 396 Table 2: Gender Rating o f Quality In Ketu G EN D ER RA TE O F Q U A L ITY UND ER N H IS V . G O OD G OOD FA IR PO O R V . P O O R TO TA L M ALE 5 66 68 37 14 190 FEM A L E 1 51 64 59 5 180 T O T A L 6 117 132 96 19 370 Table 3: Rating o f Quality in Respect of Age in New Juabeng AG E RA TE O F Q U A L ITY V. G O OD GOOD FA IR PO O R TO TA L 18-24 20 5 21 2 46 25-34 12 33 41 2 88 35-49 26 25 47 5 103 50-64 10 31 43 7 91 65 & A BOV E 8 15 44 1 68 TO TA L 76 109 196 15 396 121 University of Ghana http://ugspace.ug.edu.gh Table 4 R ating o f Quality in Respect o f Age in Ketu AGE R A TE O F Q UA L ITY V. G O OD GOOD FA IR PO O R V .PO O R TO TA L 18-24 11 29 4 3 47 25-34 5 24 23 10 3 65 35-49 44 47 46 3 140 50-64 1 29 15 22 8 75 65& A BOVE 9 18 14 2 43 TO TA L 6 117 132 96 19 370 Table 5: Rating o f Quality in respect of Educational Level in New Juabeng ED U CA T IO N A L QUA L ITY R A T ING LEV EL V. G OOD GOOD FA IR PO O R TO TA L N O FO RM A L EDU . 18 13 1 32 PR IM A RY 15 18 57 90 JS S /M ID D L E SCH . 39 20 64 6 129 SSS /SECON . 20 18 35 5 78 T E R T IA R Y 2 35 27 3 67 TO T A L 76 109 196 15 396 122 University of Ghana http://ugspace.ug.edu.gh Table 6: R ating o f Quality in Respect o f E ducational Level in K etu e d u c a t i o n a l l e v e l QUA L ITY R A T IN G V. G O OD G OOD FA IR PO O R V. P O O R TO TA L n o f o r m a l e d u . 11 3 7 1 22 PR IM A RY 1 34 25 28 2 90 JS S /M ID D L E SCH . 17 33 21 2 73 SSS /SECON . 5 39 32 17 10 103 TE R T IA R Y 16 39 23 4 82 TO TA L 6 117 132 96 19 370 123 University of Ghana http://ugspace.ug.edu.gh