ASSESSING CLIENTS’ SATISFACTION WITH HEALTH SERVICES AT KASOA POLYCLINIC IN AWUTU SENYA EAST MUNICIPAL ASSEMBLY, GHANA BY RUFUS LAWRENCE KELLY (10444626) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF M.A. DEVELOPMENT STUDIES DEGREE NOVEMBER 2014 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Rufus Lawrence Kelly, hereby declare that this thesis entirely consists of my own work except for the references used and that no part of this publication or the whole has been presented elsewhere for another degree. ……………………………... ………………………. Rufus L. Kelly Date (Student) ……………………………….. ………………………… Professor Augustin K. Fosu Date (Supervisor) University of Ghana http://ugspace.ug.edu.gh ii DEDICATION To God above To my lovely parents To my dear wife To my daughter Ruletha To my son Eugene To my brothers, sisters and family University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENTS My profound gratitude goes to God Almighty for his favor and blessings, and for bringing my dreams into reality in life. Many thanks and appreciation is attributed to Professor Augustin K. Fosu who patiently served as my supervisor throughout this project with his valid contributions towards my success. I sincerely thank the Ministry of Health & Social Welfare, Republic of Liberia for granting me this scholarship and World Learning-USAID project for their sponsorship. Forever being grateful is ascribed to the Director, the Coordinator of M.A. Program, management and staff, and all lecturers of the Institute of Statistical, Social and Economic Research (ISSER) who took out their time to impact knowledge unto me. Also, I am grateful to the Kasoa Polyclinic administration for their willingness to undertake this study at their facility. Finally, I am pleased to acknowledge the moral, spiritual support and encouragement rendered by my parents, daughter, siblings, pastors and friends during my course of study. University of Ghana http://ugspace.ug.edu.gh iv Table of Contents DECLARATION ........................................................................................................................................... i DEDICATION .............................................................................................................................................. ii ACKNOWLEDGEMENTS ......................................................................................................................... iii List of Tables .............................................................................................................................................. vii List of Figures ............................................................................................................................................ viii List of Abbreviations ................................................................................................................................... ix Abstract ......................................................................................................................................................... x CHAPTER ONE ........................................................................................................................................... 1 1.1 Introduction ............................................................................................................................................. 1 1.2 Background of the Study ........................................................................................................................ 1 1.3 Statement of the Problem ........................................................................................................................ 5 1.4 Research Questions ................................................................................................................................. 6 1.5 Objectives of the Study ........................................................................................................................... 6 1.6 Significance of the Study ........................................................................................................................ 7 1.7 Scope and Limitations of the Study ........................................................................................................ 7 1.8 Organization of the Study ....................................................................................................................... 8 1.8 Operational Definitions ........................................................................................................................... 8 CHAPTER TWO .......................................................................................................................................... 9 LITERATURE REVIEW ............................................................................................................................. 9 2.1 Introduction ............................................................................................................................................. 9 2.2 Meaning and Measurement of Clients’ Satisfaction ............................................................................... 9 2.2.1 Benefits of Clients’ Satisfaction .................................................................................................... 14 2.2.2 Determinants of Clients’ Satisfaction ............................................................................................ 16 2.2.3 SERVQUAL Model ....................................................................................................................... 20 2.2.4 Criticism of the SERVQUAL Model ............................................................................................. 24 2.3 Conceptual framework .......................................................................................................................... 25 2.4 Theoretical Review ............................................................................................................................... 26 2.4.1 Healthcare Quality Theory of Donabedian .................................................................................... 26 2.5 Kasoa Polyclinic ................................................................................................................................... 28 University of Ghana http://ugspace.ug.edu.gh v CHAPTER THREE .................................................................................................................................... 32 METHODOLOGY ..................................................................................................................................... 32 3.1 Introduction ........................................................................................................................................... 32 3.2 Research Design .................................................................................................................................... 32 3.3 Study Population ................................................................................................................................... 33 3.4 Sample Size and Sampling Technique .................................................................................................. 33 3.5 Data Sources ......................................................................................................................................... 34 3.6 Method of Data Collection .................................................................................................................... 35 3.7 Method of Data Analysis ...................................................................................................................... 35 3.8 Ethical Consideration ............................................................................................................................ 37 3.9 Profile of Awutus Senya East Municipal Assembly ............................................................................. 38 3.9.1 Introduction .................................................................................................................................... 38 3.9.2 Background of the Assembly ......................................................................................................... 38 3.9.3 Geographical Location and Size of Awutu Senya East Municipal Assembly ............................... 38 3.9.4 Topography and Drainage .............................................................................................................. 41 3.9.5 Climate and Vegetation .................................................................................................................. 41 3.9.6 Population ...................................................................................................................................... 42 3.9.7 Religion .......................................................................................................................................... 42 3.9.8 Economic Activities ....................................................................................................................... 42 3.9.0 Education ....................................................................................................................................... 43 3.9.11 Health ........................................................................................................................................... 44 CHAPTER FOUR ....................................................................................................................................... 45 PRESENTATION OF DATA AND DISCUSSION OF FINDINGS ......................................................... 45 4.1 Introduction ........................................................................................................................................... 45 4.2 Demographic Characteristics of respondents ........................................................................................ 45 4.2.1 Sex and Age of respondents ........................................................................................................... 45 4.2.2 Marital status of respondents ......................................................................................................... 46 4.2.3 Religious Affiliation ...................................................................................................................... 48 4.2.3 Educational Level of respondents .................................................................................................. 48 4.2.4 Occupation of the respondents ....................................................................................................... 50 4.2.5 Level of Income of Clients............................................................................................................. 52 4.3 SERVQUAL DIMENSION IMPORTANCE SCORES ....................................................................... 55 4.4 PERCEPTION SCORE AS A MEASURE OF SATISFACTION ....................................................... 56 University of Ghana http://ugspace.ug.edu.gh vi 4.5 SERVQUAL RESULTS BY DIMENSION ......................................................................................... 59 4.5.1 Tangibility ...................................................................................................................................... 59 4.5.2 Responsiveness .............................................................................................................................. 62 4.5.3 Reliability ....................................................................................................................................... 64 4.5.4 Assurance ....................................................................................................................................... 66 4.5.5 Empathy ......................................................................................................................................... 68 4.6 SERVQUAL FINDINGS BY DIMMENSION .................................................................................... 70 4.7 Recommendations to Improve Service ................................................................................................. 74 Chapter Five ................................................................................................................................................ 77 Summary of Findings, Conclusions and Recommendations ....................................................................... 77 5. 1 Introduction .......................................................................................................................................... 77 5.2 Summary of Key Findings .................................................................................................................... 77 5.3 Conclusion ............................................................................................................................................ 79 5.4 Recommendations ................................................................................................................................. 80 References ................................................................................................................................................... 82 Appendix: Questionnaire ............................................................................................................................ 96 University of Ghana http://ugspace.ug.edu.gh vii List of Tables Table 3.1: Zonal Councils, Towns and Communities in Awutu Senya East Municipal Assembly……………………………………………………………………………………..40 Table 4.1: Age and Sex of Respondents………………………………………………………46 Table 4.2: Marital Status by Gender…………………………………………………………..47 Table 4.3: Education by Gender………………………………………………………………49 Table 4.4: Occupation by Gender……………………………………………………………..51 Table 4.5: Income Level………………………………………………………………………53 Table 4.6: How Clients Pay Their Clinic Bills………………………………………………..54 Table 4.7: Tangibility Dimension SERVQUAL Results……………………………………...61 Table 4.8: Responsiveness Dimension SERVQUAL Results…………………………………63 Table 4.9: Reliability Dimension SERVQUAL Results……………………………………….65 Table 4.10: Assurance Dimension SERVQUAL Results………………………………………67 Table 4.11: Empathy Dimension SERVQUAL Results……………………………………......69 Table 4.12: Overall Level of Satisfaction………………………………………………………73 University of Ghana http://ugspace.ug.edu.gh viii List of Figures Figure 2.1: SERVQUAL Model adapted ………………….…………………………………. 25 Figure 2.2: Services Departments at Kasoa Polyclinic………………………………………...31 Figure 3.1: Map of Zonal Councils in Awutu Senya East Municipality ………………………39 Figure 3.2: Local Economy Distribution………………………………………………………43 Figure 4.1: Religious Affiliation……………………………………………………………….48 Figure 4.2: Weight of SERVQUAL Dimension……………………………………………….56 Figure 4.3: Illustration of zone of loyalty……………………………………………………....57 University of Ghana http://ugspace.ug.edu.gh ix List of Abbreviations ANC Antenatal Care ASEMA Awutu Senya East Municipal Assembly CHPS Community Health Posts KPC Kasoa Polyclinic OPD Out-Patient Department PMTCT Prevention of Mother to Child Transmission PNC Postnatal Care VCT Voluntary Counseling and Testing WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh x Abstract This study was conducted to assess clients’ satisfaction with health services at Kasoa Polyclinic in Awutu Senya East Municipal Assembly. The researcher employed a quantitative research methodology, where a survey was conducted to interview 80 people who had visited the polyclinic more than once. The data gathered were presented using descriptive statistical tools such as crosstab, tables, graph and charts. A SERVQUAL analysis model was used to examine the satisfaction of clients with regards to the services they receive from the Kasoa Polyclinic. The results reveal that the expectation of the clients’ exceeds their perception in all the five SERVQUAL dimensions of customer satisfaction except one. The expectation of clients on Tangibility, Responsiveness, Assurance and Empathy, exceeded what was actually experienced at the hospital. But expectation on Reliability was equal to the perception. The quantitative analysis on the level of satisfaction show that customers were dissatisfied with the Tangibility and Assurance aspect of the polyclinic but were satisfied with Responsiveness, Reliability and Empathy aspects. On the whole, clients were satisfied with the services provided at the hospital. Based on the findings, the researcher recommended for infrastructural development at the polyclinic as well as capacity building of the hospital staff on how to treat clients to enable them have assurance in the polyclinic. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.1 Introduction The current chapter presents a background of the study, followed by a problem statement. It also provides the research questions, objectives of the study, significance of the study, its scope and limitations, organization of the study and operational definitions relating to the study. 1.2 Background of the Study Service delivery is a paramount issue in the development of any sector, which can determine the continuous anticipation of customers to obtain service provision or their lack of interest in obtaining services from any given entity. When customers are given good service by an entity, the cost of advertisement and use of other business strategies in encouraging customers are reduced (Gursoy et al., 2007) and also customers who are repeatedly visiting an institution are considered more profitable than those who carry out a single transaction with the institution (Reichheld & Sasser, 1990). Client satisfaction is generally defined as the customer’s view of services received and the result of the treatment. It has been used by program evaluators to enhance health care providers’ ability to render equitable and quality services that meet consumers’ needs (Campbell, 1999). The satisfaction of the clients within any given transaction triggers the possibility of more customers, thus increasing profit and improving services in the long run. The health sector is one of the many service providers rendering one of the most important services to clients, University of Ghana http://ugspace.ug.edu.gh 2 and conspicuous to the desire of any health facility is that of those whom they serve, their clients. The primary function of the hospital is to care for patients. It serves as one of the many ways being used to measure the success of services that it produces. Effectiveness of the hospital relates to provision of good patient care as intended. Society is now aware that users view plays an important role in services delivery and has used a range of methods to identify the views of patient and public (Wensing & Elwyn, 2003). The use of clients’ satisfaction methods in health care has become popular with the introduction of clients’ right movement (Williams, 1994), which carried out a broad debate pertaining to relationships of clients’ satisfaction assessment of the caring process and that of technical care being established. With the availability of these methods, complaints are surfacing globally. A common complaint in many countries about public sector health workers focuses on their rudeness and arrogance in relations with patients (as cited in World Health Organization, 2000). For instance, prior to 1990, the Soviet health system became highly impersonal and inhuman in the way it processed people. Recognizing responsiveness as an intrinsic goal of health systems establishes that these systems are there to serve people, and involves more than an assessment of people’s satisfaction with the purely medical care they receive. Also, the systems are available to offer due respect to their clients (World Health Organization, 2000). According to the 1948 Universal Declaration of Human Rights Article 25, health is being seen as part of adequate standard of living for all persons. In the light of its importance, its recognition was again supported by the International Covenant on Economic Socio and Cultural Rights in 1966. University of Ghana http://ugspace.ug.edu.gh 3 Health care has been changing over the years, with the many initiatives undertaken as an important measure by government, organizations and health partners in trying to address the challenges faced, though some systems are highly unresponsive. Most countries are now focusing on the cost and access to health services because it needs to be distributed appropriately and equitably (Stephen et al., 2003). Clients’ expectations have grown proportionately with the rising wealth of the population resulting in strong societal pressure to adopt policies on satisfying consumers’ expectations (Donabedian, 1988). The objectives of health care changed with the requirement of society and availability of resources and technology. Medical care is not only to improve health status but also to respond to patients’ needs and wishes and to ensure satisfaction with care (Ahmed et al., 2004). The World Health Organization Alma Ata conference on supporting Health for All, held in 1990, defined development in health to be human centered (Khan, 2007). It is now a global trend in healthcare development toward integrating subjective user satisfaction into the evaluation of medical service quality (Ivf et al., 2006). A recent study conducted on client satisfaction revealed that though findings from satisfaction studies are used by administrators, much emphasis is being placed on the environmental surrounding, while less is being seen in terms of inter-personal communication skills and the organization of care for clients by service providers (Boyer et al., 2006). The use of clients’ satisfaction surveys by hospital administrators over the years has led to the improvement of the service environment, clients care and the facilities at large (Turnbull & Hembree, 1996). University of Ghana http://ugspace.ug.edu.gh 4 The government of Ghana considers that the enjoyment of the highest attainable level of health is a basic right of all citizens. Its mission is to “provide and prudently manage comprehensive and accessible health service with special emphasis on primary health care at regional, district and sub- district level in accordance with approved national policies” (http://www.ghanahealthservice.org). With efforts being made by the government of Ghana and her health partners in strengthening the health sector of the country in terms of salary increment, recruitment of qualified staff, introduction of health scheme amongst others, less attention is being paid to the supervision and monitoring of health facilities to ascertain their functions as inscribed in the code of ethics which defines the general, moral principles and rules of behavior for all service personnel in the Ghana Health Service. This study examines clients’ satisfaction with health services at the Kasoa Polyclinic. Satisfaction with provided services includes five dimensions; tangibility, reliability, responsiveness, assurance and empathy. A better understanding of clients’ satisfaction will help policy makers, administrators and health care providers implement programs that will improved clients needs and help them receive their best encounter with health care delivery system (Daniel, 2009). University of Ghana http://ugspace.ug.edu.gh http://www.ghanahealthservice.org/ 5 1.3 Statement of the Problem According to the South African Black Population study 76% rely on public hospital and the facilities are overcrowded, understaffed and under resourced, contributing to waiting of more than one hour to see a health provider (Veonda, 2001). This confirms the fact that clinical staffs are one of the most important sources of satisfaction. Health facilities in Ghana are not immune to the need to develop sustainable quality in their operations. Studies have noted that the Ministry of Health in Ghana has been concerned about quality of care, but improvement of said quality has been slow partly due to prioritization (Yue & Turkson, 2009). Many problems which include poor quality of service, clients’ mortality, crunch on revenue, material resources, staff, recognition, trust and respect in individual and communities’ apathy towards health services, are contributing to lowered effectiveness and efficiency (Turkson & Gunning, 2013). While it can be argued that many studies have focused on assessing clients’ service quality specifically or generally (Turkson, 2009, Atinga et al., 2011), there are still questions that remain unanswered with a gap in literature regarding the perceptions and expectations of clients using the SERVQUAL model in relation to healthcare encounter. The availability of such gap creates the condition for proper research opportunity. Patients persistent complains about services quality in hospitals have led to the current study analyzing the expectations and perceptions of patients in a government health center in Ghana with the sole purpose of understanding the satisfaction of clients. University of Ghana http://ugspace.ug.edu.gh 6 1.4 Research Questions a. What are the fissures between clients’ expectations regarding health services offered by Kasoa Polyclinic and their perceptions towards the actual services being delivered? b. What are the implications of these gaps on service delivery at the Kasoa Polyclinic? 1.5 Objectives of the Study Overall objective: To assess clients’ satisfaction with health services at the Kasoa Polyclinic Specific Objectives: i. To identify and describe the expected and perceived fissures influencing health services at Kasoa Polyclinic ii. To identify the level of satisfaction and its effects on services at the Kasoa Polyclinic iii. To provide a research document that government, health partners and service providers can use to improve health services delivery University of Ghana http://ugspace.ug.edu.gh 7 1.6 Significance of the Study Studying clients’ satisfaction with health services is not just to develop a document for review by readers, but will serve as a working tool in providing adequate information on the satisfaction of clients in relation to health services. It will be seen as a policy tool for future policy documents in the health sectors by government and its health partners in augmenting the sector for better provision of services during implementation. Moreover, health workers will recognize their importance in the service provision chain at health centers and clients will understand their full rights and benefits when assessing services. 1.7 Scope and Limitations of the Study The study is centered on the Kasoa Polyclinic in the Municipality of Awutu Senya East. Time constraint was one of the major limitations to the study. It took a week to have the various departments in the polyclinic informed about the purpose of the research and its impact on the facility as they were sometimes away on official duties. The major limitation was the language barrier experienced during the collection of data. Most respondents speak one of the most widely spoken local dialects, Twi. Therefore, colleagues who are native of the dialect assisted in getting the interviews done along with two hired interviewers. University of Ghana http://ugspace.ug.edu.gh 8 1.8 Organization of the Study Organization of the study is subdivided into chapters. The present one covers an introduction, followed by the background of the study, problem statement, Research questions, objectives of the study, significance of the study, scope and limitations, operational definitions and the organization of the study. Chapter two is concerned with the review of theoretical literatures and empirical work relevant to the study. Chapter three focuses on the demographical composition of the Awutu Senya East Municipality and research methodology, while chapter five presents the data, analysis and interpretations. Chapter six covers the discussion of findings, summary and policy recommendations for improvement of clients’ satisfaction with health services. 1.8 Operational Definitions Cognizance of the possibility of individual and vague interpretations of concepts relating to this research, the researcher provides the following definitions: Client: used in this research refers to a client who visits a health facility for medical services. Satisfaction: means the desire developed by a client after receiving a good or service from a service provider, to return for more and even encourage others to access goods and services from that same provider. Indicators of satisfaction in relation to the study consist of tangibility, reliability, responsiveness, assurance and empathy. University of Ghana http://ugspace.ug.edu.gh 9 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter presents a review of existing literature in relation to studies of clients’ satisfaction with health services. 2.2 Meaning and Measurement of Clients’ Satisfaction The understanding of satisfaction and service quality has, over the years of vast programs, been recognized as critical to developing service improvement strategies. The inaugural quality assurance work of Donabedian (1980) identified the importance of patient satisfaction as well as providing much of the basis for research in the area of quality assurance in healthcare. In the health sector, the importance of measuring clients’ satisfaction is well articulated (Lin & Kelly, 1995). Patient satisfaction surveys are an instrument in monitoring hospital’s quality of care in relation to cost and services. It is a significant indictor of quality of care. To evaluate and improve the quality of care provided, it is vital to investigate the quality of care in context of health care. Satisfaction might be influence by socio-economic factors, accessibility to the services and experience towards the health services (Lislie 1983). Clients’ satisfaction have been studied and measured extensively as a stand-alone construct and in particular in quality care assessment studies (Sofaer & Firminger, 2005). Clients’ satisfaction as cited by Jackson et al., (2001) as an important health outcome is used for four but distinct related purposes: First, to compare different health care programs or University of Ghana http://ugspace.ug.edu.gh 10 systems; second, to evaluate the quality of care; third, to identify which aspects of a service need to be changed to improve patient satisfaction; and fourth, to assist organizations in identifying clients likely to dis-enroll. Kotler (2003) advances a discussion that explains satisfaction as a person’s feeling or happiness or displeasure as a result of comparing a product’s outcome in relation to his or her expectations. Clearly stated, client satisfaction is described as the result of a cognitive and affective evaluation, where some comparison standard are determined and compared to the actual performance. Should the expected performance happen to exceed the perceived performance, then customers become dissatisfied. On the other hand, if expectation is more than perceived performance, customers become satisfied. If the perceive performance is equal to the expected, clients are neither satisfied nor dissatisfied, creating what he termed as neutral stage. From a managerial perspective, Dansky and Miles (1997) stated that client satisfaction with health service is important for various reasons. First, satisfied clients are more likely to maintain a consistent relationship with a specific provider. Second, by identifying sources of patient satisfaction, an organization can address weakness, and improve it risk management. Third, satisfied patients are more likely to follow specific medical regimes and treatment plans. Finally, clients’ satisfaction measurement adds important information on system performance, thus contributing to the organizations’ total quality management (Gagallah et al., 2003). While it serves as the most common method used, a recent finding review of the patient satisfaction literature concluded that none of the instruments reviewed could be considered satisfactory (Hawthrone, 2006). University of Ghana http://ugspace.ug.edu.gh 11 Accordingly, it is a multidimensional concept, not yet tightly defined, and part of an apparently yet-to-be determined complex model (Hawthrone, 2006). Hawthrone indicated that there were thousands of client satisfaction measures available, which have been developed on an “ad-hoc” basis, with insufficient evidence of their psychometric properties. In furtherance of such finding, most studies in the healthcare sector have largely drawn attention to the clinical perspective with little or no attention to the client’s perception of service quality. Likewise, the literature conveys to us that the concept of client satisfaction is complicated (Heidegger et al., 2006). Another study in relation to measurement of client satisfaction noted that questionnaires used for satisfaction survey have been viewed as the most common method in soliciting clients’ perceptions of healthcare since their development more than thirty (30) years, but only in the last five (5) years have there been serious attempts to ensure that the validity of the instrument is well grounded (Gonzales et al., 2005). According to Crowe et al., (2002), the subjective affective component of the client satisfaction construct makes its measurement “probably a hopeless quest” and its study largely fraught as it has lacked precision, at the expense of exact science, with many researchers having undertaken studies of a purely exploratory nature. Despite of controversies surrounding its validity and reliability, many studies have been conducted on client satisfaction in the health sector using the SERVQUAL model (Newman, 2001). A study conducted by Youseff (1996) applied SERVQUAL in National Health Service Hospital in the UK and found that the reliability was the most important dimension affecting the patients’ overall quality perceptions. Empathy was the second important dimension closely followed by responsiveness and assurance. It was found that tangibility was the least important of the five SERVQUAL dimensions. University of Ghana http://ugspace.ug.edu.gh 12 Sewell (1997) in his study with National Health Service Hospital found that the most important quality of dimension was reliability followed by assurance. Empathy and responsiveness were rated as almost equal. Tangibles were identified as the fifth dimension. Lam (1997) conducted a case study in a hospital in Hong Kong. The study concluded that the highest gap score was registered by the empathy dimension followed by responsiveness, assurance and reliability. Lim and Tang (2000) applied SERVQUAL scale in a hospital located in Singapore and concluded that responsiveness was the dimension with the highest gap score, followed by assurance and reliability. Karassaviduo et al., (2009) applied SERVQUAL model to measure a service quality on three dimensions a). Human aspects b). Physical environment and infrastructure of the care unit and c). Access. They applied modified version of SERVQUAL model where demographic features of patients have been taken into account. With the model, researchers measured gaps between patients’ expectation and perception for the above three-dimensions. The result pointed out that the human aspect is the most important area where the relationship of patients with physicians and other staff of hospital occupy the central place of the health care system. In Romania, Popa et al. (2011) assessed the services quality of Oradea that resulted in highest gap score for empathy followed by reliability and assurance. A study by Prattans et al. (2013) in Thailand found out that the current service quality in term of tangibility is high whereas the service quality of the assurance dimension is low. Another study conducted by Abu-Kharmeh (2012) using the SERVQUAL model found out that assurance was identified as the second best predictor of service quality. GrÖnross (2000) study of client satisfaction found out that the willingness of employees to provide better service enhances quality of health care delivery. University of Ghana http://ugspace.ug.edu.gh 13 Another study by Ndamnsa (2013) applied SERVQUAL model to assess patients’ perceptions of service quality and the level of satisfaction obtained from the services rendered by the Norrlands Universitets Sjukhuset. Findings proved that tangibility was the highest of the five dimensions scores implying that although people expected quite much from the hospital, they expressed a satisfactory level on the tangibility dimension (physical facilities, equipment and appearance of personnel). In the assessment of service quality of public health care services in Romania, Purcarea et al., (2013) concluded that tangible dimension lured out to have had the highest gap score, followed by responsiveness and reliability. In developing countries, Andaleeb (2001) proposed and tested a five dimensional instrument for assessing perceptions of patients availing of hospital services in Bangladesh. Results indicated that a significant relationship is found between the five factors and patient’s satisfaction. The discipline factor, encompassing “tangible” and “assurance”, had the greatest impact on patients’ satisfaction, while the baksheeh (tips) factors had the lowest effect. University of Ghana http://ugspace.ug.edu.gh 14 2.2.1 Benefits of Clients’ Satisfaction Satisfied Clients Generate New Customers One of the ways to help obtain loyalty from clients is by having products and services that are so good that there is very little chance that clients’ requirement will not be met. Establishing professional relationship with clients empowers institutions with the knowledge of what clients need. Study conducted in a major New York hospital found that clients in departments who are more satisfied with service providers are more likely to inform and encourage others to seek medical attention or services at that facility (Peltier & Daw, 2009). Client Satisfaction Encourages One Stop shopping Clients who are satisfied with services do not only contribute to growth of new business through word of mouth communication, they also purchase product from the institution. Their preferences are as the result of more economical opportunities for placing multiple orders with a firm, convenience, and uncertainty of doing business with an unknown dealer. Clients who are satisfied with services are in the willingness to pay for benefits they do receive and are likely to be tolerant with increases in price (Anderson et al., 1994). Moreover, in order to maintain clients, institutions need to ensure that the right products and services, supported by the right promotion and making it available at the right time for customers, are in place (Munusamy et. al., 2010). University of Ghana http://ugspace.ug.edu.gh 15 Repeat Buying Results in Lower Cost Competitive strategies for the retention of existing clients leads to a company or institution investing less in extracting new customers, especially in mature markets with deep-rooted competition (Gursoy et al., 2007). In addition, clients who are repeatedly visiting an institution are considered more profitable and beneficial in terms of encouraging other clients to access services at that institution (Reichheld & Sasser, 1990). Spinelli & Canava (2000) revealed that the satisfaction of clients is important in the line of business due to it being a precondition for clients’ loyalty and word-to-mouth behavior. An empirical study confirmed that “customer satisfaction is a function of service quality (staff services and corporate image), price, innovativeness and convenience” (Athanaassopoulos, 2000) and is a key internal performance-enhancing success factor for any service company (Chi & Gursoy, 2009). Though client satisfaction is being seen as the expectation or need of every organization, heads of agencies/ institutions should also first and foremost take into consideration the satisfaction of their employees (Gandi & Kang, Accessed: http://www.ajbms.org/articlepdf/ajbms_2011_1127.pdf ). University of Ghana http://ugspace.ug.edu.gh 16 2.2.2 Determinants of Clients’ Satisfaction The concept of satisfaction has a long history of controversy and debate. Yet it remains a topic of scientific investigation. But little is known about its relations and importance regarding the monitoring of the right to health (Mpinga & Chastonay, 2011). Donabedian (1988) defines satisfaction as the expression of patient’s judgment on the quality of care received in all aspects, but particularly as concerns the interpersonal process. Hulka et al., (1970) based his assessment on only three dimension namely, personal relationship, convenience and professional competence. Also, GrÖnroos (1984) considered service quality of the service encountered as two different dimensions, one being technical or output quality and the other functional or process quality. These dimensions were assessed according to attitudes and behavior, appearance and personality, service mindedness, accessibility and approachability of customer contact personnel. Patient satisfaction according to Tucker and Adams (2001) are determined by factors relating to empathy, care, reliability and responsiveness. Furthermore, Ware et al. (1978) identified dimensions of clients’ satisfaction as efficiency, physician conduct, service availability, continuity, confidence and outcomes. There are also other dimensions being introduced to highlight clients’ healthcare evaluations (Fowdar, 2005), including: - Core services; - Customization; - Competence; - Professional credibility; and communications University of Ghana http://ugspace.ug.edu.gh 17 Client satisfaction can be derived from a product that relates to the customer’s evaluation of product performance based on such characteristics as durability, dollar value, technical sophistication, and ease of use consumption experience and price (as cited in Gandi & Kang, Accessed: http://www.ajbms.org/articlepdf/ajbms_2014_1127.pdf). In other study, customer satisfaction is considered a prerequisite for customer retention and loyalty, and obviously helps in economic goals like profitability, market share, return on investment, etc (Hackl and Westlund, 2000). Sureshchandar et al. (2001) identified five factors of service quality as critical from the customers’ point of view, namely: - core service or service product; - Human element of service delivery; - Systematization of service delivery; non-human element; - Tangibles of service-service scapes; - Social responsibility A study conducted by Johnston (1995) added another determinant, flexibility, after carrying out further research on these seventeen (17) determinants in retail banking. This was used to describe “a willingness and ability on the part of the service worker to amend or alter the nature of the service or product to meet the needs of the customer” (Johnston (1995). Camilleri and O’Callaghan (1998) focused on the appropriate dimensions for measuring hospital service quality such as follows: service personalization, patients’ amenities, price, environment, professional and technical care, accessibility and catering. University of Ghana http://ugspace.ug.edu.gh 18 Another study conducted by Andaleeb (1998) focused on only five dimensions: cost, facility, competence, communication and demeanor. Chahal (2000), in his tri-component model, pointed out that the loyalty of patients towards particular provider of medical service can be measured on the basis of three dimensions: 1. Using providers again for the same treatment (UPAS), using providers again for different treatment (UPAD) and referring providers to others (RPO). In the tri- component model, Chahal proved that all of the above-mentioned loyalty measures depend on the overall service quality. He explained service quality of medical care with three latent constructs. These are physicians’ performance, nursing performance, and operational quality. Hasin et al., (2001) identified five dimensions which are responsiveness, courtesy, cost, communication, and cleanliness. Moreover, Walters and Jones (2001) also established several elements to be measured in hospital service quality such as security, aesthetics, convenience, performance, economy and reliability. As studies report, Clients’ satisfaction is influenced by a number of factors and according to Peprah (2014), the following factors play an important role in the satisfaction of clients: the capacity of prompt service delivery without wasting time; the attitudes of nurses towards patients; the ability to share information to clients and availability of modern equipment. Others are the availability of 24 hours services; the patience of the doctor to explain what was wrong with a client before treatment; provision of detail information about medication; and the attractiveness and cleanliness of the facility. Because most patients lack the medical expertise for the evaluation of the technical attributes, the service marketing approach which focuses on the functional quality perceived by clients has been widely used to evaluate health services (Dursun & Cerci, 2004). University of Ghana http://ugspace.ug.edu.gh 19 Many dimensions discussed so far in relation to determinants of clients’ satisfaction are closely related to the “SERVQUAL” model developed by Parasuraman et al. (1985) used in the current study. From its initial stage, it contained ten (10) dimensions of service quality which later was reduced to five (5) dimensions. According to Zeithaml et al. (1990), the criteria used to evaluate any service quality are much similar regardless of the service type. These criteria are: - Tangibility: involves the appearance of physical evidence (physical facilities, appearance of personnel, tools or equipment use to provide services, other customers in the facility and communication materials). - Reliability: ability to perform the promised service dependable and accurately (keeping clients’ records correctly, performing services at the appropriate time). - Responsiveness: willingness to help customers and provide prompt service. - Assurance: knowledge and courtesy of employees and their ability to convey trust and confidence. - Empathy: the caring, individualized attention the facility provides its customers (access, communication, understanding the customers). University of Ghana http://ugspace.ug.edu.gh 20 According to Kang and James (2004), it is very difficult for a client to understand the technicalities of treatment and hospital services. In other to understand the difficulties of technical services, accurate diagnosis and procedure of treatment can be measured by functional quality since it is built upon the technical components of health services, using the SERVQUAL instrument (Babakus & Mangold, 1992). Functional quality can be defined as a way of delivering health care service to a client (eg. Attitudes of doctors and nurses toward clients, the cleanliness of facilities, time management of delivering services, quality of food, amongst others). Therefore, the current study gives more emphasis on functional aspect of health care services. University of Ghana http://ugspace.ug.edu.gh 21 2.2.3 SERVQUAL Model There are many models, which are available to measure service quality, particularly in the health sector; SERVQUAL (Parasuraman et al., 1985), Kano Model (Kano, 1990) and SERVPERF (Cronin and Taylor, 1992) to name a few. The SERVQUAL model is the most widely accepted measure of assessing service quality in the healthcare sector and other services (Lam, 1997; Rohini & Mahadevappa, 2006). The model proposes that the basic for clients satisfaction is based on five dimensions; namely; reliability, responsiveness, assurance, empathy, and tangibles. The SERVQUAL instrument consists of 22 statements that are used to assess the satisfaction of clients regardless of the kind of services offered at any given time (Zeithaml et al., 1990). Each statement appears twice. One measures customer expectations and the other measures the perceived level of service provided by an individual organization in that industry. The four factors identified by Zeithaml et al. (1990) that influence the expectations of clients are: word-of-mouth communications; personal needs; past experience; and external communications. A gap is then created as a result of the perceived service delivered not meeting the expectations of the clients. This gap is addressed by the identification and implementation of strategies that affect perceptions, or expectations or both (Parasuraman et al., 1988). The SERVQUAL model emphasizes five gaps in any service delivery: - Gap 1- The difference between actual customer expectations and management’s ideas or perception of customer expectations - Gap 2- Mismatch between manager’s expectations of service quality and service quality and service quality specifications University of Ghana http://ugspace.ug.edu.gh 22 - Gap 3- Poor delivery of service quality - Gap 4- Differences between service delivery and external communication with customer - Gap 5- Differences between expected and perceived quality Since the developers have stated that the SERVQUAL model could be used as a diagnostic tool to enable management identify shortfalls in service quality and measure gaps in quality, the gap score is obtained by the deduction of the perceptions statements from the expectations. If any of the gaps turn out to be negative, it shows that the expectations of clients were not met, and if positive, it then implies that expectations are being exceeded. A suggestion by Parasuraman et al. (1988) depicts that what clients expect of a service is what they think should be offered rather than what the service provider thinks might be offered. This serves as a way of managers knowing if they are really rendering services that are inadequate or running into surplus that they need to readjust their strategies and provide resources for the areas they underperformed (Wisnieski, 2001). Since its development it has been used to evaluate customer’s expectations before service delivery and their perception after service delivery .To identify and prioritize performance improvements that are required for clients’ needs and expected to be met, both perceptions and expectations of services are to be measured (Accounts Commission for Scotland 1999a, Parasuraman et al. 1988). This supports that the use of service quality dimensions provides both a structure for designing a service quality measurement instrument and a framework for prioritizing results and findings (Hart, 1996). University of Ghana http://ugspace.ug.edu.gh 23 According to Pravakaran and Satya (2003), customers’ dissatisfaction arises due to three reasons: - When service providers are not aware about service dimensions which are important to customers - When service providers do not know how customers prioritize the service dimensions on the basis of their importance - When service providers are unaware of service attributes that create service dimensions SERVQUAL results can be used in many ways (Scotland, 1999a): - Understanding current service quality; - Comparing performance across different customer groups; - Comparing performance across different parts of the service; - Understanding the internal customers; - Comparing performance across services; and - Assessing the impact of improvement initiatives The SERVQUAL model helps understand what the customer value is all about and how well an organization meets the needs and expectation of consumers of hospitals. This makes it an important instrument being used in the current study to assess health services in a government health facility in Ghana. University of Ghana http://ugspace.ug.edu.gh 24 2.2.4 Criticism of the SERVQUAL Model Even though the SERVQUAL model serves in a variety of sectors in obtaining relevant information, it has also been subjected to numerous criticisms. Most of these criticisms made by academics are in light of the concepts and methodology of the SERVQUAL model (Buttle, 1996; Babakus & Boller, 1992). Buttle (1996) write that: Critics have raised a number of significant and related questions about the dimensionality of the SERVQUAL scale. The most serious are concerned about the number of dimensions, and their stability from context to context. Baharun et al., (2012) asserts that though the SERVQUAL model is the most used and recognized model in studying service quality, it is not comprehensive and suitable for different applications in research. Despite its criticisms, the SERVQUAL model has been used extensively to measure service quality in various contexts (Ladhari, 2009). With some studies failing to render support to its structure, it was defended in terms of the different dimensions, based and conceptual and practical grounds Parasuraman et al. (1998). Furthermore, Parasuraman et al. (1998) pinpointed out that the SERVQUAL model can be used for a variety of services even when it is deemed necessary to paraphrase some of the items to suit the context for which it is being used. University of Ghana http://ugspace.ug.edu.gh 25 2.3 Conceptual framework CLIENT GAP 5 SERVICE PROVIDER GAP 4 GAP 3 GAP 1 GAP 2 Figure 2.1: SERVQUAL Model adapted (Zeithaml et al., 1990) Past Experience Personal Needs Expected Service Perceived Service Word of Mouth Communication Management Perceptions of Consumer Expectations Translation of Perceptions into Service Quality Specifications External Communication to Consumers Service Delivery (Including pre-and post- contacts) University of Ghana http://ugspace.ug.edu.gh 26 2.4 Theoretical Review There are about five basic theories of client satisfaction published during the 1980s which are now being largely “restated” in the literature (as cited in White & Gill, 2009). These are: Discrepancy and Transgression Theories, Expectancy-value Theory, Healthcare Quality Theory of Donabedian, Determinants and Components Theory, Multiple Models Theory. This study is based on the Healthcare Quality Theory of Donabedian due to its significant application in health service delivery. 2.4.1 Healthcare Quality Theory of Donabedian (significance to the study) The Health Quality theory was designed by Avedis Donabedian (1980) proposing that satisfaction was the principal outcome of the interpersonal process of care. The significance of the approach of Donabedian Health Care Quality theory to this study of client satisfaction with health services that sets it apart from other is the fact that it adopts a pyramid approach to viewing clients’ expectations, needs and experiences. The model proposes that an organization with the right structures and process in place will produce better outcomes. Understanding the structure and process of requirements for establishing services lays the foundation for efficient, adequate and safe patient-centered care delivery. According to him, healthcare information can be drawn from three categories: structure, process and outcomes. Structure Process Outcome University of Ghana http://ugspace.ug.edu.gh 27 Structure describes the context in which care is delivered, including hospital buildings, staff, financing, equipment, and human resources, as well as organizational characteristics such as staff training and payment methods. These factors control how service providers and clients in healthcare service delivery act and are measures of the average quality of care within a facility or system. The structure of an institution is often easy to observe and measure and it may be the upstream cause of problems identified in process. Process refers to the transactions between clients and service providers throughout the delivery of healthcare. These transactions most often include diagnosis, treatment, preventive care and patient education but may be expanded to include actions taken by the clients or their families. According to Donabedian, measuring process is nearly equivalent to the measurement of quality of care because process contains all acts of service delivery. Information about process can be obtained from medical records, interview with clients and service providers, or direct observations of healthcare visits. Outcome refers to the effects of healthcare on the health status of clients and population. These include the changes to health status, behavior of both service providers and clients, or knowledge as well as client satisfaction health related quality of life. Most times outcomes are seen as the most important indicators of quality because improving clients’ health status is the primary goal of healthcare. However, having to accurately measure outcomes that can be attributed exclusively to healthcare is difficult. Drawing connections between process and outcomes often requires large sample populations, adjustment by case mix, and long-term follow ups as outcomes may take considerable time to become observable. University of Ghana http://ugspace.ug.edu.gh 28 Donabedian regarded “outcome” as the most important aspect, and stress that an outcome is not simply a measure of health, well-being, or any other state; it is a change in a patient’s current and future health status that can be confidently attributed to antecedent care (Donabedian, 1980). With its wide recognition and application in many health care related areas, Donabedian Model was developed to assess quality of care in clinical practice. The model does not have an implicit definition of quality care so that it can be applied to problems if broad or narrow scope. Donabedian notes that each of the three domains has advantages and disadvantages that necessitate researchers to draw connections between them in order to create a chain of causation that is conceptually useful for understanding systems as well as designing experiments and interventions. While it is true that Donabedian model continues to serve as a benchmark framework in health services research, researchers have suggested potential limitations, and, in some cases, adaptations of the model have been proposed. The sequential progression from structure to process to outcome has been described by some as too linear of a framework (Mitchell et al.,1998). It has been criticized due to its failure to incorporate antecedent characteristics like patient characteristics, environmental factors which are also precursors to evaluating quality care. 2.5 Kasoa Polyclinic Kasoa Polyclinic happens to be the only government health facility in the Kasoa sub-district which is located in the Awutu-Seya district of the central region. It is located at the center of Kasoa Township along the Kasoa Winneba high way, some few meters from the old police station and also next to the Main Ghana Commercial Bank Building. The center is strategically located University of Ghana http://ugspace.ug.edu.gh 29 because of its accessibility. It is patronized by clients from Kasoa and its surrounding communities as well as clients from adjoining districts such as Ga West in Greater Accra Region and Gomoa East. Historically, the center was commissioned in the year 1983. It was a small clinic proving health services to two thousand inhabitants who were mainly farmers and artisans. Its expansion came as a result of the Saudi Arabia government funds, whilst the Ministry of Health provided equipment and human resource to make it complete and functional.“Kasoa”, which is a Hausa word for the market indeed, is a very busy commercial center which can boast of having one of the largest and widely patronized market centers on the southern part of the country. The adult population of Kasoa is made up of business men and women, civil servants and artisans. The Kasoa Polyclinic now serves a population of 133,000 with a majority of the patients receiving services on insurance scheme (Administrator, KPC, 2013). The Kasoa Polyclinic currently has a total number of 132 staff attending to patients in different department listed below: 1 principal nursing officer; 4 nursing officers; 3 principal midwifery officers; 4 senior staff nurse; 7 staff nurses; 5 prescribers; 3 senior midwifery officers; 3 medical assistants; 1 senior staff midwife; 1 midwifery officer; 1 principal community health nurse; 5 senior community health nurses; 3 superintendent enrolled nurses; 2 senior enrolled nurses; 16 enrolled nurses; 24 community health nurses; 2 diploma community health nurses; 5 ward assistants; 1 accountant; 1 University of Ghana http://ugspace.ug.edu.gh 30 administrator; 1 senior physician assistant; 1 procurement officer; 1 pharmacist; 1 assistant; 1 senior dispensing technician; 2 revenue collectors; 8 health aids; 1 laboratory technologist; 1 laboratory officer; 3 oderlies; 3 biostatisticians and 14 casuals. Due to underestimation of the district population, there exist issues of inadequate logistics and facilities for service delivery at the health center, coupled with inadequate and inappropriate facilities. Moreover, the entire municipality has no hospital that will handle cases beyond the health center level. Clients have to be transferred from the district, which sometimes ends up in death while en-route to the hospital. In addition to the above, the municipality is also faced with inappropriate Community Health Posts CHPS compound at one of its sites, Ofaakor, where patients also seek medical attention, and these Community Health Posts are also inadequate in numbers with a mix of skilled and skill mix of professionals. University of Ghana http://ugspace.ug.edu.gh 31 Figure 2.2: Services Departments at Kasoa Polyclinic Source: Author’s construct. KASOA POLYCLINIC Out-Patient Department ENT EYE Ultra Sound CHPS Psychosocial PMTCT/VCT Disease Control Laboratory Diabetics FINANCE Administration Public Health Maternity (ANC/PNC) University of Ghana http://ugspace.ug.edu.gh 32 CHAPTER THREE METHODOLOGY 3.1 Introduction This chapter outlines the methodology of the research used to address the aims of the study. The chapter is structured in two parts; part one focuses on the study design, study population, sampling techniques and sample size, methods and approaches used to gather data as well as the methods used in the analysis of the data. The ethical conditions that the researcher considered are also captured in this section. The second part presents the profile of Awutu Senya East Municipal Assembly, the district in which the study was conducted. 3.2 Research Design (restructured) A descriptive survey research was chosen to provide an accurate assessment of clients’ satisfaction with health services at the Kasoa Polyclinic. The choice of this design was made to collect data from clients using the SERVQUAL structured questionnaire developed by Parasuraman et al. (1985) that helped describe precisely their expected and perceived satisfactions with services at the Kasoa Polyclinic. The researcher informally discussed with some of the clients and nurses to get in-depth understanding of their own personal experiences regarding some of the treatment they receive and render at the polyclinic, respectively. University of Ghana http://ugspace.ug.edu.gh 33 3.3 Study Population The target population was mainly clients: male and female clients (excluding children) who receive health care at the Kasoa Polyclinic, and were willing to respond to the study interviewers. Clients who could not speak (Deaf/mute), who were in critical medical condition at the time of data collection were excluded. Clients who visited the facility for at least one time were included in the study. 3.4 Sample Size and Sampling Technique (restructured) The targeted population for this study was clients who have visited the health facility more than once. The basis of clients visiting the polyclinic is dependent on several factors which includes but not limited to the following: a client experience upon first visit, review by a client on a previous visit, obtaining a laboratory result, an emergency. The researcher identified some departments of the polyclinic where the possibility of clients visiting more than once was relatively higher. The departments chosen were the Out Patient Department (OPD) and the Maternal Department which is subdivided into the Ante-natal and Post-natal care. The researcher decided to use a sample size of 80 respondents for the study, allocating a quota of 20 to clients of the OPD, and 30 each client of the Ante-natal and Post-natal Cares respectively. The decision to use a sample size of 80 respondents for the study was based on the assertion by the administrator of the polyclinic that an average of about 300 clients visiting the polyclinic on a daily basis. University of Ghana http://ugspace.ug.edu.gh 34 3.5 Data Sources The study predominately relied on primary data even though some secondary information was sourced from the Awutu Senya Municipal Assembly, books, journals and other similar articles to support findings of the study. The primary data were obtained from the interview of the clients through the use of structured questionnaire using the SERVQUAL tools developed by A. Parasuraman, Leonard Berry and Valerie A. Zeitham in the 1980s. It was developed to assess customer perceptions of service quality in service and retail businesses. The model is categorized into five dimensions of service quality deliveries in terms of tangibles, taking into consideration the physical facilities, equipment, and staff appearance; reliability, which is concerned with the ability of service providers to perform dependent services with accuracy; responsiveness, entailing the service providers willingness to respond and give help to clients; assurance, in the light of clients’ confidentiality and trust; and empathy, which involves service providers rendering individual care to clients. The tool poses questions that clients answer based on their expectation of the services, their perception and then gave a numerical weight to each of the categories within the model. The secondary data was gathered from the Awutus Seya East Municipal Assembly, extensive reading and review of academic journals and articles, books relating to the research interest, and previous research work done in relation to the topic. University of Ghana http://ugspace.ug.edu.gh 35 3.6 Method of Data Collection Due to the limited time in which the study was conducted, the researcher employed two additional research assistants to aid in the collection of the data. These assistants were trained prior to their assignment on the field. After presenting an introduction letter from the researcher’s institution to the Administrator of the polyclinic and permission granted, questionnaires were administered to the sampled respondents. Where clients were in queue, he/she was isolated from the other clients and interviewed. The researcher also recorded some of the comments that respondents gave as a way of explaining some of the responses. Events that were observed at the polyclinic, especially how nurses interacted with clients, were equally taken into consideration by taking notes in a field book. In the same way, few nurses were also engaged in an informal conversation to help understand the reasons behind some of the conducts exhibited. 3.7 Method of Data Analysis Descriptive statistical tools involving the use of frequencies, tables and graphs were used in the analysis and interpretation of the data results. Cross-tabulation analysis was done to establish relationships under study. SERVQUAL is a customer perception tool consisting of 22 statements that are grouped and related to one of the five dimensions of service quality. Each of the statements is presented in two different forms. The first set of questions look at the expectation (E) of clients in relation to the service being measured. Second appearance is involved with the perception (P) of the clients towards these services that are being assessed (Wisniewski & Donnelly, 1996). Its purpose is to “serve as a diagnostic University of Ghana http://ugspace.ug.edu.gh 36 methodology for uncovering broad areas of a company’s service quality shortfalls and strengths” (Zeithaml et al., 1998). The responses of clients are measured on a seven-point Likert scale, ranging from “strongly agree”, which is represented by a score of 7, to “strongly disagree”, represented by a score of 1, with “no strong feeling or neutral” scores attached from 2 to 6. To elicit a broader picture of the stated measurement, below is an example relating to client expectations (E) with the responsiveness dimension: “Employees of Kasoa Polyclinic should never be too busy to respond to clients’ requests.” The perceptions (P) measurement of clients in relation to responsiveness is represented as: “Employees of Kasoa Polyclinic are never too busy to respond to clients’ requests.” Since SERVQUAL is a rating and quality management tool, the responses and ratings were ranked. This ranking will help to examine the service quality dimensions that are the most important to the clients. Thus, the scores that clients gave were used to weigh the results of the SERVQUAL Q scores for each service quality construct. The weighted scores provide a greater insight as to the overall importance of the service quality construct to the patients, therefore allowing service leaders to implement more targeted service improvement initiatives in future. It also enables the service provider to compare their performance over a time period to that of other competitors. University of Ghana http://ugspace.ug.edu.gh 37 3.8 Ethical Consideration To begin with, an introductory letter from the Institute of Statistical, Social and Economic Research (ISSER) was given to the Awutu Senya East Municipal Assembly and the Kasoa Polyclinic administrator, to ask for permission in using the facility as a study site and also interview some of the clients. After the permission was granted, informed consent was ensured as all clients were informed about the purpose of the research. It was made known to them that the research is solely for academic purpose and there are no known risks involved in one’s participation. Patients were given a consent form to fill and sign to show their understanding and willingness to participate in the study. Voluntary participation is another ethical issue that was adhered to by the researcher. Patients were not forced to participate in the research. They were made aware of their voluntary participation to the research which allowed the researcher a convenient time to interview them. Again, respondents were informed about their freedom to withdraw from the study at any point in time. Another important ethical issue that was considered is confidentiality. Participants were given assurance that the information they will provide will not be disclosed to anyone and for that matter their names and identity will not be featured in the research. The researcher assured the participant that all information relating to them will be destroyed after the work has been accepted by the Graduate School of University of Ghana. Finally all references and information sources are duly acknowledged in the work. University of Ghana http://ugspace.ug.edu.gh 38 3.9 Profile of Awutu Senya East Municipal Assembly 3.9.1 Introduction This section is concerned with the profile of the study area as it is necessary in enhancing the in- depth understanding of background situations. It focuses on the background of the area, geographical location and size, typology and drainage, climate and vegetation, socio-demographic features, major economic activities, education and health. 3.9.2 Background of the Assembly Newly created as an assembly in the central region, the Awutu Senya East Municipal Assembly (ASEMA) was carved out of the former- Awutu Senya District in 2012 and established as a municipality by Legislative Instrument (LI) 2025. Rationale of its establishment was to facilitate government’s decentralization programs and local governance system. The people of the municipality are mainly Guans, with other settlers of different ethnic backgrounds; these include the Gas, Akans, Ewes, Walas/Dagartis, Moshies, Basares and other numerous smaller tribes. The main languages spoken are Akan and English. Kasosa is said to be one of the fastest growing communities in West Africa. 3.9.3 Geographical Location and Size of Awutu Senya East Municipal Assembly Awutu Senya East Municipal Assembly is located in the eastern part of central region within latitudes 5̊45 south and 6̊ 00 north and from longitude 0̊20 west to 0̊35 east. It shares common boundaries with Ga South Municipal Assembly (in Greater Accra Region) at the east, Awutu Senya District at the north and Gomoa East District at the west and south respectively. University of Ghana http://ugspace.ug.edu.gh 39 The municipality covers a total land area of about 180 sq km about 18% of the total area of the Central Region. Kasoa, the municipal capital is located at the south-eastern part, about 31km off the Accra-capital. Other major settlements are Opeikuma, Adam Nana, Kpormertey, Ofankor, Akweley, Walantu and Zongo. Figure 3.1: Map of Zonal Councils in Awutu Senya East Municipality Source: Planning Department, Awutu Senya East Municipal Assembly, 2013 University of Ghana http://ugspace.ug.edu.gh 40 Table 3.1: ZONAL COUNCILS, TOWNS AND COMMUNITIES IN AWUTU SENYA EAST MUNICIPAL ASSEMBLY ZONAL COUNCIL TOWNS COMMUNITIES (AREAS) KASOA ZONAL COUNCIL Iron City New Town Kasoa Zongo Iron City Dokustekope Banat Prince Derrick Maame Osofo KPORMETEY ZONAL COUNCIL Adam Nana Joe Mends Amuzukope Semenshia Lamptey Mills Bigman Town Kingdom Town Infrgate Area Mount Zion Area Freetown Adam Nana Christian Hill Ghana Flag Songai Joe Mends Zone 6 Asempa Ghana Flag OFAAKOR ZONAL COUNCIL Otamens Otamens City Rock City Gada Kope Alic Andam/Larbi Town Awushie Tetteh/Kaneshie Bentum Queen City Okwampi Ofaakor Newtown Kovor kope OPEIKUMA ZONAL COUNCIL American Town American Town Adakope Ayigbe Town Diamond City Opeikuma Krispol City Asamoah Town Adom City Doctor Jesus Estate Down Anigyekrom AKWELEY ZONAL COUNCIL Kaemebre Down Town Ash Town Kaemebre Akweley Township WALANTU ZONAL COUNCIL CP Windy Hills Biakoye Walantu Top Hill Blue Rose Estate Chief Imam Mosque CP Abease CP Last Stop CP Poultry Farm CP Evelip Farm CP Holly Valley CP Roman Down CP Winga Town CP Step to Christ Agenkwa CP Tipa Junction Little Rock Area Walantu Junction University of Ghana http://ugspace.ug.edu.gh 41 3.9.4 Topography and Drainage The topography of the municipality is characterized by isolated undulating highlands located around the Ofankor and Akweley area. The nature of the topography is directly related to the soil type. The highland and lowland area have loamy soils and clay soils respectively. The drainage in the high areas is not intensive as compared to the lowland areas. The major river, namely, Okrudu, drain into the sea and cause flooding during the rainy season. 3.9.5 Climate and Vegetation The municipal assembly forms part of the south-west plains of Ghana which is one of the hottest parts of the country. Temperatures are high throughout the year and range between 23̊C-28̊C; a maximum of 33̊C is attainable during the hot season. Rainfalls are heavy during the major season between March and September. The average rainfall is about 750mm. The municipality is underlain by Birrimain rocks, which consist of granites and phyllites. The area us basically low-lying with protruding granite rocks in some areas. In the semi-deciduous forest zones, the soil type is mostly loamy soils which supports many plants and therefore suitable for arable farming. These crops include pineapple, cassava, plantain, yam, maize, cola-nuts, citrus and pawpaw. University of Ghana http://ugspace.ug.edu.gh 42 3.9.6 Population The population of the municipality is currently estimated at 270,000 (projected from the 2000 populated and Housing Census). The average growth rate of the municipal is 3.0%. The ratio of male to female is 1 to 1.06 and the population is basically youthful. The number of houses within the assembly is 37,000 with an average household size of the municipal being five (5). This shows that there has been a significant reduction in the household size indicating an improvement over the 1984 due to the robust sensitization on family planning services in communities and at health and school facilities. Total number of households (HH) is 26,325 with 62.3% constituting male and 37.7% constituting female (ASEMA profile, 2013). 3.9.7 Religion Various types of religions in the Awutu Senya East Assembly are positioned into five categories, respectively; Christianity comprises 54% of the total population (26.2% male, 28.7% female), followed by Islam with a total percentage of 32.5% (17.6%male, 14.9% female). The traditional religion covers 2.2% of the total population (1.9% male, 0.3% female). Population with no religion stands at 8.1% of the total population (5.7% male, 2.4% female), and other religions covers 2.3% (1.2% male, 1.1% female) pf the total population (ASEMA Profile, 2013). 3.9.8 Economic Activities Trading mainly in wholesale and retail, agro-processing, informal sector service and commerce are considered to be the main economic functions of the municipality. Trading and its related activities are the leading economic ventures and employ about 60% of the working population in the municipality. Livestock is also practiced but on a smaller scale. University of Ghana http://ugspace.ug.edu.gh 43 The private informal sector contributes enormously to the Awutu Senya East Municipal economy with the employment of about 21% of the working population in the baking and service sectors that need to be integrated with the formal sector. Other economic activities include service (banking and internet) and agro-processing (cassava dough, Gari and Corn dough). Figure 3.2: Local Economy Distribution Source: (ASEMA Profile, 2013) 3.9.0 Education The Awutu Senya East Municipal Assembly has the following public institutions: 16 Pre-schools, 21 Primary Schools and 17 Junior High Schools. In the private institutions, there are 46 pre- schools, 44 Primary Schools, 22 Junior High Schools, 5 Senior High Schools and 2 Technical Vocational Institutes. The breakdown of public schools enrollment in 2009 is made up of 4,325 pupils in Public Kindergartens, 15,118 in Primary Schools, 5,863 in Junior High Schools and 1,973 in Senior High Schools. Almost in all cases a higher proportion are boys. Trading 60%Farming 13% Services 21% Agro- Processing 5% AWUTU SENYA EAST LOCAL ECONOMY University of Ghana http://ugspace.ug.edu.gh 44 The case is different in the kindergarten category where there are more girls than boys in 2009. This data on educational institutions and enrollment currently serves as a base line data due to the further decentralized and the division of the Agona District into Agona West and Agona East. The most visible and critical issue affecting education is the poor nature of school infrastructure on the municipality which needs to be tackled immediately in order to improve the performance of education in the municipality. 3.9.11 Health There are fifteen (15) private facilities within the district, one (1) Polyclinic, one (1) Health Center and two (2) Community Health Posts (CHPS) compounds. Malaria is recorded as the highest case in every year followed by diseases like acute respiratory infections, skin diseases, anemia, diarrhea, among others. The highest level of health delivery system in the municipality is the private facilities. University of Ghana http://ugspace.ug.edu.gh 45 CHAPTER FOUR PRESENTATION OF DATA AND DISCUSSION OF FINDINGS 4.1 Introduction This chapter of the work presents the findings of the survey conducted at Kasoa Polyclinic using a structured questionnaire. The questionnaire was designed to elicit information from clients on their satisfaction of the services rendered by Kasoa Polyclinic using SERVQUAL indicators. For the purpose of clarity, descriptive statistical tools such as tables, frequencies and charts were used in the presentation of the findings. Relevant literature was also used to support the study as a way of discussing the findings. The chapter covers findings on the characteristics of the clients and their satisfaction of services rendered at the Kasoa Polyclinic. 4.2 Demographic Characteristics of respondents 4.2.1 Sex and Age of respondents The total number of respondents was 80. Out of this number, 35% of the respondents were males and 65% were females. The findings in Table 4.1 also show that the majority of the respondents were between the age’s brackets of 26 – 35 years. Thus, 53.8% of respondents were between the ages of 26 – 35 years. From the total respondents 25% were also between the ages of 18 – 25 years. A 12.5% constitutes the age range of 36 – 45 years and 8.8% out of the total respondents were 46 years and above. University of Ghana http://ugspace.ug.edu.gh 46 This shows that majority of the respondents who participated in the survey were within the youthful age category. Table 4.1: Age and Sex of respondents Sex Age Total 18-25 26-35 36-45 46-Above Male 4 14 5 5 28 5.0% 17.5% 6.2% 6.2% 35.0% Female 16 29 5 2 52 20.0% 36.2% 6.2% 2.5% 65.0% Total 20 43 10 7 80 25.0% 53.8% 12.5% 8.8% 100.0% Source: Field data, 2014 4.2.2 Marital status of respondents Table 4.2 below shows that majority of the respondents were married. Only a few were either single, widow, divorced or separated. 63.8% of respondents were married and 33.8% were single. Widow represented 1.2% and divorced or separated also represented 1.2%. The proportion of males who were single was more than females who were single and in the same way; the proportion of females who were married was more than the male proportion. University of Ghana http://ugspace.ug.edu.gh 47 Table 4.2: Marital Status by Gender Sex Single Married widow Divorced/ separated Total Male 13 15 0 0 28 46.4% 53.6% .0% .0% 100.0% Female 14 36 1 1 52 26.9% 69.2% 1.9% 1.9% 100.0% Total 27 51 1 1 80 33.8% 63.8% 1.2% 1.2% 100.0% Source: Field data, 2014 University of Ghana http://ugspace.ug.edu.gh 48 4.2.3 Religious Affiliation Majority of the respondents were Christians while a few were Muslims, and only 1.25% belonged to other religion. Thus, 75% of the respondents were Christians and 23.75% were Muslims. Figure 4.1: Religious Affiliation Source: Field data, 2014 4.2.3 Educational Level of respondents The results in Table 4.3 depict the highest educational level attained by the clients. The results indicate that generally, majority of the respondents had attained secondary education. Only a few of the respondents have a higher education. Of the total respondents 48.75% have secondary education, 30% also had attained tertiary education, 15% of the respondents had literate primary education and 3.8% had no education and 2.40% had higher education. 0 10 20 30 40 50 60 Christian Muslim Other 75% 23.75% 1.25% Religious affiliation Christian Muslim Other University of Ghana http://ugspace.ug.edu.gh 49 It can also be realized that majority of males and females both have attained secondary education. Interestingly, one each of male and females has attained higher education. But the proportion of females with tertiary education is higher than that of males. Thus, whiles 11.2% of males have higher education, 18.8% of females have tertiary education. On the average, the literacy level of females was higher than males. Table 4.3: Education by Gender Highest Education Gender Total Male Female No education Count 0 3 3 % of Total .0% 3.8% 3.8% Literate Primary Count 4 8 12 % of Total 5.0% 10.0% 15.0% Secondary Count 14 25 39 % of Total 17.5% 31.2% 48.8% Tertiary Count 9 15 24 % of Total 11.2% 18.8% 30.0% Higher Education Count 1 1 2 % of Total 1.2% 1.2% 2.4% Total Count 28 52 80 % of Total 35.0% 65.0% 100.0% Source: Field data, 2014 University of Ghana http://ugspace.ug.edu.gh 50 4.2.4 Occupation of the respondents The general results from the work the respondents do show that preponderance of the respondents is engaged more in the informal sector than in the private sector. This is even evident in the gender analysis where the majority of males and females are self-employed. Those working in the private sector were only 15.0%. The self-employed workers, who can broadly be considered as working in the informal sector, were 52.5% of the total respondents. Students were 20% of the respondents. Civil servants, who can be considered as formal sector workers were represents 7.5%. But the proportion of females was higher than the males. Engaged in other work were 1.2% males. University of Ghana http://ugspace.ug.edu.gh 51 Table 4.4: Occupation by gender Occupation Gender Total Male Female Private sector Count 6 6 12 % of Total 7.5% 7.5% 15.0% Self-Employed Count 12 30 42 % of Total 15.0% 37.5% 52.5% Unemployed Count 1 2 3 % of Total 1.2% 2.5% 3.8% Student Count 7 9 16 % of Total 8.8% 11.2% 20.0% Civil Servant Count 1 5 6 % of Total 1.2% 6.2% 7.5% Other Count 1 0 1 % of Total 1.2% .0% 1.2% Total Count 28 52 80 % of Total 35.0% 65.0% 100.0% Source: Field data, 2014 University of Ghana http://ugspace.ug.edu.gh 52 4.2.5 Level of Income of Clients The study also examines the income range of the clients who visit the Kasoa polyclinic. Analysis of the results as captured in Table 4.5 below indicates that majority of the respondents earn a relatively low income. Only a few earn an average to higher income in a month. For instance, as high as 33.8% of respondents earn less than GH¢ 100 in a month and 28.8% also earn GH¢ 100 - GH¢ 300. Respondents representing 25% earn between GH¢ 400 - GH¢ 600. Only 12.5% earn GH¢ 700 and above. We can therefore say that many of the clients the polyclinic serves are mainly people within the lower income range. University of Ghana http://ugspace.ug.edu.gh 53 Table 4.5: Monthly Income level Income Gender Total Male Female Below 100 Count 9 18 27 % of Total 11.2% 22.5% 33.8% 400-600 Count 6 14 20 % of Total 7.5% 17.5% 25.0% 700 – above Count 3 7 10 % of Total 3.8% 8.8% 12.5% Total Count 28 52 80 % of Total 35.0% 65.0% 100.0% Source: Field data, 2014 The study also tried to assess how clients, with such income range pay their bills at the polyclinic. It was very interesting to note that more than half of the respondents patronize the government health insurance scheme (NHIS) to help cater for their bills. Only a few are not NHIS subscribers and therefore pay out of their pockets. As high as 68.8% of respondents pay their medical bills using the health insurance scheme, 28.8% pay out of pocket and only 2.5% use private insurance scheme to finance their hospital bills. This is not surprising because the number of NHIS subscribers in the country is increasing yearly and this shows that many Ghanaians are patronizing the insurance scheme to cater for their bills. University of Ghana http://ugspace.ug.edu.gh 54 Table 4.6: How clients pay their clinic bills Means of payment Gender Total Male Female Out of pocket Count 10 13 23 % of Total 12.5% 16.2% 28.8% Gov't Insurance Scheme Count 16 39 55 % of Total 20.0% 48.8% 68.8% Private Insurance Scheme Count 2 0 2 % of Total 2.5% .0% 2.5% Total Count 28 52 80 % of Total 35.0% 65.0% 100.0% Source: Field data, 2014 University of Ghana http://ugspace.ug.edu.gh 55 4.3 SERVQUAL DIMENSION IMPORTANCE SCORES The SERVQUAL customer perception tool that was administered to the clients of Kasoa Polyclinic included a section that asked the respondents to divide 100 points between the five dimensions based upon their perception of importance. The respondents were asked to assign the most points to the most important dimension and fewer points to the least important dimensions. The results captured in Figure 4.2 show that ‘tangibility’ (the appearance of Kasoa Polyclinic physical facilities, equipment, personnel, and communication materials) was the first most important aspect to them with an average 23.5 points. Thus, the clients consider the facilities, equipment, personnel and communication materials in a health facility to be of the greatest importance to their health care. The second most important dimension to them is ‘responsiveness’ (willingness to help patients and provide prompt service) with 20.3 points. The third important dimension to them is ‘reliability’ (ability to perform the promised service dependably and accurately) with 20.2 points. ‘Assurance’ (the knowledge and courtesy of Kasoa Polyclinic’s employees and their ability to convey trust and confidence) was the fourth important aspect with 18.7 points and ’empathy’ (the caring, individual attention Kasoa Polyclinic provides its patients) was the least important aspect with 17.3 points. University of Ghana http://ugspace.ug.edu.gh 56 Figure 4.2: Weight of SERVQUAL dimension Source: Field data, 2014 4.4 PERCEPTION SCORE AS A MEASURE OF SATISFACTION For the purpose of this study, the perception score of 5.6 out of 7 (80% of the maximum) is the minimum score needed to measure true satisfaction for the combined dimensions as well as each sub category of the dimensions. For example, a SERVQUAL respondent perception score of 5.6 in Responsiveness would indicate an acceptable level of satisfaction for that category. The same would be true for each of the sub category of that dimension as long as each achieved at least a 5.6 perception score. Conversely, a SERVQUAL respondent perception score of 5.5 in Tangibility would indicate a non-acceptable level of satisfaction for that category. The 80% perception threshold has been used in other customer service satisfaction assessments where SERVQUAL was used as the primary assessment tool. 0 5 10 15 20 25 Tangibility Responsiveness Reliability Assurance Empathy 23.5 20.3 20.2 18.7 17.3 Servqual weight University of Ghana http://ugspace.ug.edu.gh 57 As cited by Gibson (2009), the 80% perception threshold has been used in other customers’ service satisfaction assessment where SERVQUAL was used as the primary assessment tool. Azim Ferdous justified the 80% threshold in a customer service assessment of the Shahjalal Islami Bank Limited as follows: “Some researchers prefer to concentrate on the –top box responses- those scores of 4 or 5 out of 5- the excellent or very good ratings. It is argues that these are the scores that are requires to create genuine satisfaction and loyalty. In their book “The Service Profit Chain”, Heskett, Sasser and Schlesinger argue that a rating of 9 or 10 out of 10 is required on most of the key issues that drive the buying decision. If suppliers fail to achieve such high ratings, customers show indifference and will shop elsewhere. Capricious consumers are at risk of being wooed by competitors, readily switching suppliers in the search for higher standards. The concept of the zone of loyalty, zone of defection as suggested by the three Harvard professors is illustrated below in the diagram”. Figure 4.3: Illustration of zone of loyalty Zone of Loyalty Heskert, Sasser & Schlesinger, (1997) University of Ghana http://ugspace.ug.edu.gh 58 While it is true that the focused of that study was on a private banking sector provision of services, the concept of loyalty, keeping clients, and gaining new customers apply equally to the Kasoa Polyclinic. Clients receiving services at the bank who are dissatisfied will become less loyal and change their preference. Likewise, clients of the Kasoa Polyclinic who are not satisfied with services being rendered will simply give up and find alternative areas for services that will sooth their expectations. Therefore, the correlation between satisfaction and loyalty which led to Ferdous’s application of the 80% threshold applies to this study as well. University of Ghana http://ugspace.ug.edu.gh 59 4.5 SERVQUAL RESULTS BY DIMENSION 4.5.1 Tangibility The Tangibility dimension of the SERVQUAL customer perception tool is comprised of questions which assess Kasoa Polyclinic clients’ expectations and perceptions of the equipment, materials, physical appearance of facility and employees of the Kasoa Polyclinic. When considering each of the four factors making up the tangibility dimension of customer satisfaction in table 4.7, the clients’ perceptions of the polyclinic falls short of their expectations in the area of modern looking equipment (gap score – P-E = -1.94) and in visually appealing physical facilities (gap score – P-E = -2.33). This means that as a polyclinic, the clients who come there expect the clinic to be refurbished with modern amenities but such are not really seen. The facilities there are not modern looking in respect to the wide gap of the difference between their expectations and their perceptions. Similarly, the physical appearance of the hospital was assessed to be far below their expectation. According to some of the clients, they expected a well-structured polyclinic that is spacious enough to serve people. Even the consulting rooms are too small and in the midst of the small nature of the rooms, a room is shared by two doctors, which defiles the confidentiality policy of clients in the hospital. An observation at the hospital during the time of interview does support the assessment made by the clients with regards to the obsolete nature of some of the equipment as well as the non-spacious nature of the consulting rooms. University of Ghana http://ugspace.ug.edu.gh 60 Expectations exceed perception in the areas of the professional appearance of employees (gap score – P-E = -0.77) and the keeping of health education materials (gap score – P-E = -1.89). It is important to note that some of the clients believe that the dressing of some staff does not meet the modern way of dressing of health workers. In an interaction with one of the OPD patients, he noted that he was unable to differentiate the doctor from patients when he was met outside of the clinic earlier in the morning since the appearance of his attire showed no evidence as being a of such. The average unweighted gap score (P-E) for the tangibility dimension of customer satisfaction is -1.73. This therefore indicates that on the whole, perception of clients concerning the tangible services of the polyclinic is far below expectation. The average score of the tangibility dimension (5.51) also indicates that its satisfactory level is unacceptable as it is below the 5.6 SERVQUAL perception score of respondent for the above dimension. A summary of the result of tangibility dimension of client satisfaction is summarized in the table below. University of Ghana http://ugspace.ug.edu.gh 61 Table 4.7: Tangibility Dimension - SERVQUAL Results Tangibility Factor Dimensions