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The client provider satisfaction survey was conducted by IMCC in Sissala East District in collaboration with three local NGOs and initiated by the regional health administration. The clients and the health workers find positive and negative aspects of the health services offered in the district. Many of the raised problems like bad staff attitude, discriminating waiting time, lack of information and so on are issues that can be addressed with little extra funding.
This project was carried out with financial support from IMCC and TDH
March, 2010
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Table of Contents
CLIENT SATISFACTION SURVEY IN THE SISSALA EAST DISTRICT . . . . . . . . . . . . . . . . 1
Table of Contents . . . . . . . . . . . . . .. 2
Executive summary . . . . . . . . . . .. . . . 5
Motivation and Problem statement . . 5
Approach . . . . . . . . . . . . . . . . . . 5
Results and recommendations . . . . . . . 5
Conclusion . . . . . . . . . . . . . . .. . . . . . . 7
Acronyms . . . . . . . . . . . . . . . . . . . . . 8
Chapter 1: Introduction . . . . . . . . . 9
Background . . . . . . . . . . .. . . . . 9
District Profile . . . . . . . . . . . 10
Health infrastructure . . . .. . . . 11
Problem Statement . . . . . . . . . . . 12
Justification for the Study . . . . . .. . 12
Aim and Objectives of the Study . . . . . . 13
Aim . . . . . . . . . . . . . . . . . 13
Specific Objectives . . . . . . . . . 13
Chapter 2: Literature Review . . . . . . . . 14
Chapter 3: Methodology . . . . . . . .. 15
Study Design . . . . . . . . . . . .. . 15
Sampling . . . . . . . . . . . . . . . 15
Training of Data Collectors and Pretesting .. 16
Data Management and analysis . . . . . . . 17
Collecting of data . . . . . . . . . . . 17
Transcription, coding and statistical analysis . . 17
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Quality Assurance . . . . . . . . 17
Ethics and Communication . . 18
Findings and recommendations . .. . . 18
Dissemination . . . . . . . . . . . . 18
Chapter 4: Results and findings . .. 20
Results from clients . . . . . . 20
Background information . . . . 20
Client satisfaction . . . . . .. . 21
Staff attitude . . . . . . . . . 23
Waiting time . . . . . . . . . .. . 25
Vital Signs . . . . . . . . . . .. . . 26
Information and communication . . . .. . 27
Prescription and dispensing of drugs . . 29
Cleanliness at the OPD and the washroom . 29
Privacy . . . . . . . . . . . . . . . . . . 30
Infrastructure/transportation . . . 31
Community involvement . . . . . . . . 31
National health insurance scheme . . . . . . 32
Clients' perception on quality of care and suggestions for improvements . . . . 32
Results from providers . . . 34
Background information . . .. 34
Provider satisfaction . . . . 35
Organizational culture . . . 35
Social and physical working environment . 35
Workload . . . . . . . .. 36
Information, professional support and management . 37
Conditions of service and motivation . . 38
Salary and promotion . . . . . . . 38
Motivational aspects . . . . .. 38
Image of organization . . . . 39
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Constraints and suggestions . . . . . 40
General staff satisfaction . . . . . 41
Chapter 5: Discussions . . . . .. . . 42
Chapter 6: Recommendations . . . .. 45
Chapter 7: Conclusion . . . . . . . 47
Thanks . . . . . . . . . .. 49
References . . . . . . 49
Appendix . . . . . . 50
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Executive summary
Motivation and Problem statement
The Sissala East District have experienced an increased disease burden and
problems in achieving the Millennium Development Goals 4 and 5. The District
Health Management Team have increased their efforts in promoting health and
made special initiatives to increase the access to health services in the district. In
spite of these efforts there is still no significant change. Both the District Director
of Health Services and the Medical Director of Tumu District Hospital have
expressed their concerns and the need for a survey that can provide more
information on the clients perception of the health services offered. It is our hope
that this survey can produce useful information and recommendations that can
help achieving the Millennium development Goals 4 and 5 and to reduce the
general disease burden.
Approach
The survey is a cross-sectional descriptive type and both quantitative and
qualitative data collection methods have been used. In total 164 clients and 33
health staffs have been interviewed. Respondents were sampled both from the
health centers and the district hospital. In addition 4 Focus Group Discussions
have been conducted. The data has been analyzed by the research team and
key findings were presented and discussed at a workshop with a broad spectra
of stakeholders. The ideas from the workshop have been used by the research
team for the final recommendations.
Results and recommendations
The clients are in generally satisfied with many of the health services offered, but
do also mention some problems. Many mention issues like poor infrastructure
and lack of health staff as problems. When it comes to the direct services offered,
33.5% of the clients told that they were not examined at all, as well 40.2% did not
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feel that their privacy was respected by the health providers. Many of the clients
also mention the importance of a good client-provider relationship. According to
the questionnaire most of the clients find the attitude of the health staff good and
feel that they were received cordially. When discussing staff attitude in the focus
group discussions the view is not that positive and some mention the behavior of
some of the health staff as being embarrassing. A need for the health staff to be
educated on how to relate well with clients is expressed by both clients and
providers.
When it comes to the providers job satisfaction it seems as the health staff are
satisfied with their job. 64% of the health staff talked to are happy or very happy
with their work. In spite of this more than half of the respondents would like to go
on a transfer. Some of the concerns and problems raised by the providers are the
uncertainty in salary, whether their salary is right or not and how and where to
redress their concerns. Many also mention long working hours and inflexible
working schedules ans being problematic. Lack of supervisory support,
colleagues, enough working space, functional lights etc. were also mentioned as
problems.
Many good recommendations came through the workshop. Concerning the client
provider relations more staff education on the code of ethics and the patient
charter is suggested, as well is better information about services provided, so the
clients will not have unrealistic expectations (e.g. concerning the use of
injections).
The importance of the staffs well-being is also mentioned as an relevant factor to
make the staff attitude better. If the health staff are satisfied with their work it will
possibly have a positive effect on their attitude towards the clients. An effective
duty roster and regulation of the leave system is mentioned as solutions to
improve the situation with non flexible working hours. More supervisory support
visits is also recommended, and it is recommended that data concerning salary
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for all the health workers is collected and compiled in a report that can be
brought to higher levels of Ghana Health Service.
Conclusion
The clients and the health workers find positive and negative aspects of the
health services offered in the district. Many of the raised problems like bad staff
attitude, discriminating waiting time, lack of information and so on are issues that
can be addressed with little extra funding. Solutions include clear information
procedures, more relevant trainings, collective and systematic salary review and
better planning and routines of the daily work. This will as well have a positive
effect on the providers working conditions.
Innovative and creative solutions (like community-based ambulance systems,
and rearranging of furniture, stores and rooms at the health centers) might as
well help in solving problems like poor infrastructure, and problems concerning
the physical working environment like no light, and not enough space.
If some of the recommendations are to be implemented it could improve both the
access to the health services offered, as well as making it more enjoyable for the
health staff to provide quality health care. Some of these recommendations are
already mentioned in the general health plans from GHS. As these are specific
for Sissala East it is recommended that they are highlighted and incorporated in
a specific health plan for the district. This will help achieving Millennium
development Goals 4 and 5 as well as improving the general health status of the
people in the district.
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Acronyms
ANC Antenatal care
CHPS Community-based Health Planning and Services
DA District Assembly
DDHS District director of health Services
DHA District health administration
DHMT District Health Management Team
EPI Expanded Programme on Immunisation
GHS Ghana Health Service
HEW Health Extension Worker
HIV/AIDS Human Immunodeficiency Virus / Acquired
Immunodeficiency Syndrome
IMCC International Medical Cooperation Committee
IMCI Integrated Management of Childhood Illnesses
MDTDH Medical Director of Tumu District Hospital
MICS Multiple Indicator Cluster Survey
M&S - visits Monitoring and Support visits
NGO Non-Governmental Organisation
NHIS National Health Insurance Scheme
OPD Out Patient Department
TB Tuberculosis
TDH Tumu District Hospital
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Chapter 1: Introduction
The District Director of Health Services and the Medical Director of the Tumu
District Hospital in Sissala East District have independently expressed the need
for a survey to find out the client's perception of the services provided. Both the
District Director of Health Services and the Medical Director of the Tumu District
Hospital asked in the late spring 2009 the IMCC if they could partake in
conducting a "Client and Provider Satisfaction Survey" in the district. The IMCC
in collaboration with the Regional Health Research Office in Wa conducted the
survey between June and October 2009. The survey was sponsored by the
IMCC and TDH.
Background
Low patronage of orthodox health services in all districts in the Upper West
Region has increasingly become a worry to all stakeholders in health at the
regional, district and community level. As presented in the district profile, only
67% of the population of Sissala East District sought care at health facilities in
2006. In particular, outpatient attendance and skilled deliveries were the worse
affected. Although factors such as poor geographic and financial access served
to explain the low utilisation of services, it was also crucial to look beyond access
factors to issues of the quality of care rendered by facilities in the district.
Investigating the low patronage of health services had even become more
imperative given the fact that the Millennium Development Goals 4 & 5 enjoined
all stakeholders to reduce under five mortality by 2/3 and maternal mortality by
3/4 by the year 2015. And yet the Under-five mortality in the Upper West Region
remained at an unacceptably high rate of 113/1000 live births (2007 MICS). The
quality of care in health facilities should to be satisfactory to clients so as to
encourage them to seek care from qualified health personnel in order to avoid
needless deaths.
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District Profile
The Sissala East District is one of the eight districts in the Upper West Region.
The district was carved out of the old Sissala district in 2005 by the government
for effective governance and decentralisation system. The district is bounded to
the East by the Upper -East Region, South by Wa East, Manprusi district and
Nadowli districts, West by Sissala West district and to the North by the Republic
of Burkina Faso.
Tumu which was the capital of the Sissala District is still maintained as the capital
of the Sissala East District. The Sissala East District has a population of 51,718
(projected from the 2000 census figure) people living in 59 communities. Most of
them belong to the Sissala tribe. Dargaare, Kasenas, Twi, Hausa and English are
spoken amongst some populations in the district. The district covers an area of
approximately 4.600 km2 and has a rather low population density of about
12/km2. All roads are in a deplorable state.
The main occupation of the people in the Sissala East District is agriculture and
trading. About 68% of the population are subsistence farmers; livestock and
poultry are reared in small scale but the interest for cash crops is rising. Despite
rearing of the livestock and poultry, the people do not consume much of these,
but rather transport them to the south to sell for money to enable them buy food
stuffs for their family upkeep.
Moslem, Christian and traditional African religion are practised in the district.
However, the effects of religion on the people's health are rather mixed since it
has undermined the acceptance of some health messages.
The literacy level is low in the district, but is higher among males than females.
As a result of a high illiteracy rate local strategies for health promotion and
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education were developed to enable the District Health Administration to inform
and improve on the health of the people.
The water situation is very critical in some parts of the district because of the
poor rain fall pattern with only one short rainy season. The main safe water
supply system in the district is from underground water sources. These are bore
holes and hand dug wells. Other sources of water are small- scale dams, dug
outs and seasonal streams. Though there have been major improvements over
time, water supply is still inadequate. Even though the district has these
problems, it does not have indigenous guinea worm cases, but the situation is
often associated with diarrhoeal and typhoid diseases.
Health infrastructure
At the time of data collection the formal health system in the Sissala East District
consisted of 1 district hospital, 6 Health Centres (HC), 2 functional CHPS zones,
1 Mother/Child Health and Family Planning Clinic and 10 Community Nutrition
Centres. In total approximately 100 persons are employed as technical and nontechnical
health staff. The district has one permanently employed Ghanaian
doctor (who is currently on study leave) and two Cuban doctors which is woefully
inadequate giving a numeration calculation of a doctor-patient-ratio of 1-3:92,000
people. The figure 92,000 includes Sissala West since the District Hospital still
covers the two districts. The non-formal health sector plays a large role in the
villages, and there is some kind of cooperation with the formal health system
which can still be improved upon.
Three of the sub districts face water problems as a result of breakdown of their
bore holes. This has been reported to the Estate Unit of the Region Health
Administration, but by June 2009 no action had yet been taken. As well most of
the health facilities are without electricity and are using solar systems.
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Problem Statement
In spite of increased efforts by the District Health Management Team (DHMT)
through the intensification of health promotion/education activities, outreach
services, and special initiatives to increase access to health care services, such
as the implementation of CHPS and health insurance, the district continues to
experience an increased disease burden primarily emanating from preventable
causes. Coupled with this, in spite of efforts to improve on Reproductive and
Child Health services, through the conduct of safe motherhood trainings and the
vigorous provision of Expanded Programme on Immunisation(EPI) services
among others, the district still continued to record a number of maternal and
child/infant deaths.
More regrettably the district also continues to experience declining utilisation of
health services particularly in the area of institutional deliveries and OPD
attendance. Financial and geographical access problems have partly accounted
for this phenomenon.
Justification for the Study
It has been widely agreed upon by scholars and practitioners in the health care
arena that client assessments, when used in concert with other effectiveness and
efficiency measures, could provide a more comprehensive consideration for
organisational strategy options and policies aimed at improving service quality.
Although a number of fora have examined the issue of client assessment of
satisfaction with care at both regional and district level, clients' assessment of the
quality of health services in this district and for that matter the factors responsible
for the low utilisation of services in the district still remain unclear.
Hence, this study is not only relevant but also timely as it has provided useful
information for addressing clients' concerns about the quality of care in health
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facilities in the district. After all, a reversal of the current declining patronage of
orthodox health care services is not only a prerequisite for improving the overall
health status of the district population, but is also imperative if the Millennium
Development Goals 4 & 5 are to be achieved.
Aim and Objectives of the Study
Aim
The aim of the study is to conduct a client and provider satisfaction survey to
ascertain whether or not clients are satisfied with the services provided by health
facilities in the Sissala East District and also assess the satisfaction of providers
regarding their working conditions and the general environment within which they
work.
Specific Objectives
The specific objectives of the study include;
Assessing the clients' perception of quality of care
Assessing the views of clients on the quality of services they received at
health facilities in the district
Ascertaining the extent of community involvement in health programme
planning and implementation at the community level for ensuring
programme acceptance and sustainability
Assessing the providers view of their working conditions and the adequacy
of the general environment within which they work
Making recommendations for improving on the quality of health services
and the utilisation of health services in the district
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Chapter 2: Literature Review
Client assessment of health care is more comprehensive than assessment of
medical care. It encompasses medical, social, cognitive and emotional
components (Deen, 1999).
According to Linder-Pelz's patient satisfaction theory, patient satisfaction with
health care as an attitude, is based on the summation of the very subjective
assessments of the dimensions of the care experienced (Linder-Pelz, 1982).
These dimensions can include interactions with providers, the ease of access,
the burden of costs and the environmental issues such as cleanliness of the
health facility.
Thus, Jessie L.T and Shiela R.A (2001) has stated that understanding of how
clients' evaluate their health care is critical to the development of sound initiatives
aimed at maintaining and improving these evaluations and ultimately health care
delivery improvement.
Hence, as a critical aspect of health care marketing, managing clients'
assessments of their care is of increasing importance due to heightened
competition, the decreasing asymmetry of information between providers and
their clients and the new wave of legislative reactions such as the passing of the
National Health Insurance Law (Act 650). The health care environment has
therefore become more challenging with increasingly vocal demands of clients.
Moreover, with the increased emphasis on cost containment and competition
amongst the public and private care providers, it has become more important
than ever for health care organisations and managers to have an accurate
representation of clients' perceptions of care (Jessie L.T & Shiela R.A 2001).
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Chapter 3: Methodology
Study Design
The study is a cross-sectional descriptive type and both quantitative and
qualitative data collection methods have been used. The quantitative data was
collected using a questionnaire to conduct client exit interviews among a sample
of clients who attended the health facilities on a specific day of the study. In
addition, staff at the health centres and District Hospital was also interviewed.
Four Focus Group Discussions were conducted. Two at the hospital and two in
two randomly selected sub districts. There were two focus groups with male
adults and two with female adults.
Sampling
The sampling frame included public not-for-profit health facilities providing
primary and secondary level care in the district. All health centres in the district
(besides Tumu where the data collectors met no clients), and the District Hospital
were selected.
In addition the average daily OPD attendance was determined for each facility.
The statistical facility of Epi2000 version 3.4.3 was used to compute the
appropriate sample size based on resources available. At 50% expected OPD
attendance for each facility within +-5% worst acceptable results, the sample size
was then computed at 95% confidence level as shown below:
Table 1: Sample Size determination:
Factor Attendance
/day
Per 2 days Per 3
days
Population size (OPD attendance) 103 205 308
Expected frequency/attendance 50% 50% 50%
Worst Acceptable margin +-5 (45% -
55%)
Same Same
Confidence level
80% 63 91 107
90% 75 117 144
95% 81 134 171
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99% 89 151 210
The attendance per day was obtained by dividing the total OPD attendance by
the number of days in the month/period.
Table 2: Sample Size:
Facility May, 2009
OPD
attendance
Average attendance Sample size
Per
1 day
Per
2 days
Per
3 days
Per
1 day
Per
2 days
Kulfuo 117 4 8 11 3 5
Kunchogu 72 2 5 7 2 3
Nabugubelle 110 4 7 11 3 5
Nabulo 93 3 6 9 2 4
Wellembelle 277 9 18 27 7 12
Tumu Hospital 2244 72 145 217 57 95
Total
2,913 94 189 282 74 124
The May, 2009 reported total of OPD attendance was used for the sampling for
all the facilities except Tumu Hospital. Tumu Hospital did not report for May,
2009, hence, January 2009 reported OPD attendance was used. The sampling
did not consider clients who accessed other services except for OPD services.
In total 164 clients and 33 health staff were interviewed during the survey.
Training of Data Collectors and Pretesting
To minimize the cost of the study 5 people, both male and female, from three of
the local NGOs were asked to help conduct the client interviews. They are all
familiar with the culture in the district and speak the local languages. A half-day
training session was organised for them before they did the data collection. The
training content included an overview of the research protocol, aim and
objectives, interviewing skills both for the exit interviews and the FGDs. The
questionnaires had been pretested and refined during other "Client and Provider
Satisfaction Surveys" in the region.
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Data Management and analysis
Collecting of data
The five data collectors conducted the client exit interviews at all the health
centres (they did not meet clients at Tumu Sub) and the hospital. They
administered the questionnaire in the local languages, but wrote the results and
the answers they received in English. IMCC staff was available at all time as
supervisors during the process.
The IMCC staff interviewed the health staff both in the health centres and the
hospital, since those interviews could be conducted in English.
Transcription, coding and statistical analysis
The focus group discussions were tape-recorded and notes were taken during
the discussions. The data collectors which conducted the interviews transcribed
them afterwards. Then the transcriptions were analysed manually and a coding
manual was developed.
All the closed-ended questions in the questionnaire were pre-coded whilst the
open-ended questions were coded after reviewing the responses and developing
a coding manual. The Epi Info version 6.04b was used for the statistical analysis.
Frequency and cross-tabulations were carried out and the results presented in
tables and graphs.
Quality Assurance
The following measures were adopted to ensure quality assurance:
A pre-test of the questionnaires and the manuals for the focus
group discussions had been done in other districts and relevant
amendments had been made to them before this data collection.
The data collectors were fluent in English, Dagaari and Sissali.
They were also trained prior to the field work.
The IMCC staff supervised the field work.
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In transcribing the focus group discussions, attention was paid to
detail and contextual relevance, whilst double entry of the
quantitative data was carried out.
Analysis and editing of the data was done in collaboration between
the Regional Health Research and Statistical Health Office in Wa
and the IMCC.
Ethics and Communication
The study was approved by the Regional Health and District Health
Administrations. The health centres and the hospital which were involved in the
study were informed about the survey in advance.
The participants were informed that participation was voluntary with no
inducements, and that they had the right to withdraw from the study at any time,
and that refusal to participate in the study would not in any way affect them. They
were also assured that any information obtained from them would be kept strictly
confidential. Verbal consent was obtained from the participants.
Findings and recommendations
In order to make feasible and relevant recommendations, management and in
charges from TDH, DHA and the health centres were brought together for a
participatory session. Key findings were selected by the research team and
presented. The findings were discussed in groups and recommendations and
action plans were drafted in plenary. With inspiration from these drafts, the final
recommendations of the study were made.
Dissemination
The final report with all findings and recommendations from the study will be
disseminated to all stakeholders, including all the health facilities who
participated in the study, District Assembly and Non-Governmental Organisations
operating in the district. It will as well be available at the districts health library
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and published on the Sissala Research Committee's web-page
www.src.imcculand.dk.
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Chapter 4: Results and findings
The results and findings of the study were written based on the background
information of the respondents and the key elements in the questionnaire and
focus group discussions. These include assessment of: client-provider
relationship and staff attitude, waiting time, quality of care, information,
organisation and working conditions. The results also considered infrastructure
and community involvement as well as the general overall satisfaction with
services. These elements were also tailored to reflect the objectives of the study.
Results from clients
Background information
Data collection for the client satisfaction survey was conducted in the Sissala
East in June, 2009 for all health facilities in the district except the two functioning
CHPS compounds and Tumu health centre. In all, 121 clients were interviewed
from the District hospital while 43 clients were interviewed from the other five
health centres.
The background information of the clients interviewed included age, sex, marital
status, occupation and the community or section address. Out of the 164 clients
interviewed, 104 representing 63.4% were females while 60 representing 36.6%
of them were males.
More than one third of the interviewed clients were within the age group of 20 to
29. Quite a number of mothers mentioned the ages of their children that was
rendered services but were too young to talk.
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Figure1: Age group distribution of clients:
14
20
61
28
19
9
13
0
10
20
30
40
50
60
70
Less than
10
10-19 20-29 30-39 40-49 50-59 60+
Age group
No. of clients
Indeed, the most predominant occupation of the clients interviewed was farming.
Farmers are representing 43.9% while only 10.3% were in the formal sector. The
remaining percentage was either traders or was engaged in other minor forms of
business.
60.4% are married and a minority of them (5.5%) out of the 164 clients were
widowed, with the rest of the clients being single. The predominant religion (2/3)
of clients was Islam while Christians were making up almost one third.
There was a high level of illiteracy among the clients interviewed since almost
half of the clients did not have any form of education at all. Seventy-four of them
representing 45.1% attested to this fact with only 13,4% of them attaining
university education. The remaining 41,5% of them had attained primary, junior,
senior secondary school as well as technical or vocational trainings.
Client satisfaction
Generally, this section deals with the relationship that exist between clients and
the service providers during the interaction period. This relationship was
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examined right from reception through to the exit of the client. Client-Provider
relationship was measured in terms of staff attitude, waiting time, the manner in
which clients were received and information given to clients. General cleanliness,
transportation and NHIS are also touched upon. During the focus group
discussions the issues were discussed in-depth.
General satisfaction of the clients with the services offered is a measure of the
effectiveness and efficiency of a health care system. One hundred and four
representing a greater percentage of 63.5 respondents said they were satisfied
with the services they received. Out of those who were not satisfied, all of them
said they were not properly attended to.
Figure 2: Reasons for clients' satisfaction
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Staff attitude
The study asked respondents about the attitude of staff in most of the units in the
hospital and in the health centre setting.
Table 3: Staff attitude:
Unit Very good
(%)
Good (%) Fair (%) Poor (%) NA
(No.)
Records 26% (42) 62% (99) 8% (13) 4% (6) (1)
Consulting room 43% (67) 41%(64) 12%(18) 4%(7) (6)
Injection room 26% (8) 52%(16) 19% (6) 3% (1) (133)
Dressing room 29% (4) 57% (8) 7% (1) 7% (1) (148)
ANC 11% (1) 56% (5) 11% (1) 22% (2) (153)
Dispensary 24% (35) 64% (94) 11% (16) 2% (3) (12)
Labour room 29% (2) 29% (2) 29% (2) 14% (1) (157)
The attitude of health service staff is one of the potent ways their efficiency is
measured by clients. Results from the individual interviews showed that staff
attitude was good. However during the focus group discussions that allowed
more time for answers and comments, the picture was quite different.
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According to the questionnaire most of the clients found the attitude of the staff
they met in the different units as being good or very good. When investigating the
issue in focus group discussions, both the male and the female groups made it
clear that a good client/provider relationship is very important. One of the females
who had attended TDH said: "The behavior of some of the health staff can also
determine whether a facility is good or not". The respondents thought there
should be mutual respect and said that the clients should be treated with care
and sympathy by the health professionals. Responding to the question about
suggestions to improve health services, one of the male respondents, from the
hospital said that: "The nurses should avoid insulting and mishandling patients"
and another one said: "Discrimination at the hospital should be avoided." The
research did not investigate whether or not discrimination is actually occurring in
the hospital, but the fact that the clients feel that there is discrimination is enough
for the subject to be looked into.
Some of the women also mentioned that the female providers do not treat fellow
women properly and thus prefer men which they find more caring and
sympathetic. With regards to the gender issue there is a risk that the results are
biased as most nurses are female and most medical assistant and doctors are
men. The preference for male health providers might actually be the preference
for the higher educated health providers rather than a gender issue. We cannot
determine this from the present data, so further investigation will be needed to
elaborate on this issue.
Since the client-provider relationship is one of the most important issues for the
people participating in the focus group discussions, some of their responses are
quoted here:
"In my opinion it does not really matter who attends to me. Preferably the one
who behaves well towards me is the best."
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"I prefer the men because they are more caring than the women. This is because
the women in the health facility underrate their fellow women who they think they
are better than."
"Generally the behavior of some of the nurses is very embarrassing. The Doctor
should really educate the nurses on how they should relate with clients."
The focus group discussions with respondents sampled from the health centers
have a more positive view on the client/provider relationship than those sampled
from the hospital. None of the people in the discussions at the health centers
expressed any bad experiences concerning relationships, but one of the men
mentioned as an important parameter for quality health care: "There should be
mutual respect between the health personnel and the clients. If mutual respect
does not exist, some clients will be scared of visiting the health facility because
they think that they will be disregarded when they go there".
The information from the focus group discussions show that staff attitude and
client/provider relations remains an issue which needs major improvement. In
actual fact, clients expect to be received cordially at all levels. In spite of the
issues mentioned in the focus group discussions, an overwhelming number of
clients who answered the questionnaire, 152(92.7%) said they were received
cordially with only 12(7.3%) of them described the reception as cold-heartedly by
the staff at the hospital. This is an odd contradiction and might be caused
because people are speaking more freely when they are discussing these kinds
of issues in a group than when they are being asked about them individually.
Waiting time
In Ghana, health care services at the facility level commence with the issuance of
the OPD card. The OPD cards are kept and managed at the records unit of the
OPD. The survey revealed that clients did not have to wait for so long to receive
their already existing cards in order to access health services in the health
facility. Almost half of the clients admitted that they waited for less than 30
minutes to receive their cards which represented 76(46.3%) out of 164 clients.
25
Again, 21.3% of the clients waited between 30 min. to 1 hour and the remaining
32.3% waited for more than an hour to receive their cards. This can be described
as being average because these units mostly operate manually warranting a
certain level of delay not forgetting the large numbers of people who seek health
services daily.
Half of the respondents 83(50.6%) described their waiting period as pleasant and
21(12.8%) thought it was very pleasant. Nonetheless, some of the clients
60(36.6%) described their waiting times as being unpleasant.
Another point of call of this survey was at the dispensary to see how services
there were provided to clients. Some clients numbering 76(46.3%) had to wait for
more than 1 hour to receive their prescribed drugs. Other clients 40(24,4%)
waited more than 30 minutes and 48(29.3%) had to wait for 15 to 30 minutes and
to receive their prescribed drugs.
Usually, the queuing model applied in our health facilities is First-Come, First
Served and services based on the urgency of the condition, but when the matter
of waiting time was discussed in the focus groups, some of the men participating
in the discussion at the hospital also wondered whether the clinicians treat
people they know before others who are waiting, because they have experienced
so much waiting time. The men also mentioned that the hospital is always
crowded because there are a lot of communities with no clinics, and then those
people go to the hospital instead.
At the focus group discussions with the males from the Health center, some
express a concern about coming to the district hospital, because of the long
waiting time and risk of having to spend the night in Tumu while they are waiting.
At the Health Centers, waiting time is not mentioned as a problem.
Vital Signs
It is mandatory that the vital signs of all clients are taken before the
commencement of their case management. In this regard, the study asked
clients whether their vital signs such as Blood Pressure, Temperature, and
Weight amongst others were taken prior to the initiation of treatment.
26
Figure 3: Number of clients whose vital signs were taken.
In terms of the vital signs taken, an impressing majority of clients had blood
pressure, temperature and weight measured. It was evident though that 7.3% of
the clients had no vital sign taken prior to the management of their condition.
Table 4: Summary of vital signs indicators.
Indicator Percentage (%)
Proportion of clients who had their weight taken 92.4
Proportion of clients who had their temperature taken 88.4
Proportion of clients who had their blood pressure taken 77.4
Proportion of clients who had their respiration taken 12.2
Proportion of clients who had none of their vital signs taken 7.3
Proportion of clients who had their height taken 3.6
Proportion of clients who had their pulse taken 3
Information and communication
The client-provider communication usually commences at the facility gate where
staff are expected to provide clients with assistance to locate service points
easily. Besides the gate, the next point of call is the medical records unit where
effective communication is needed. The Information often given at the OPD is
perceived as the first most important information a client usually need in every
27
health facility. Hence, there is the need for such information to be clear and
useful to the client.
Generally, clients expect the history of their condition to be taken thoroughly to
help the clinician in the management of the case. The study revealed that a
majority 148 (90.1%) of them were given the opportunity to tell the clinicians the
nature of their condition. Similarly, the results indicated that 106 (66.5%) of them
were examined adequately by the clinicians primarily through touching. Fiftyeight
of them, 33.5% said they were not examined whatsoever.
As much as clients treated wants to know what is wrong with them, it has
become uncommon for clients to be provided with adequate information about
their condition. It was therefore not surprising when this client satisfaction survey
revealed that out of the 164 clients, 99 representing a percentage of 60.4
attested to this painful truth that is fast crippling the efficiency of health service.
When this practice is not critically reviewed, you will have Doctors treating the
same illness all the time because they fail to tell their client their illness, which
would help the patient to practice some preventive measures.
Around 80% of the clients who visited medical records unit, nurses at the vital
signs section, clinicians during consultation and the pharmacy unit attested to the
fact that they often received beneficial information.
The study conducted showed that 44(26.8%) clients considered the information
they received from the OPD as very clear and 72(43.9%) said information given
was clear to them as against 48(29.3%) who said the information was either not
clear or completely absent.
It also seems that there is a lack of information concerning why a certain
treatment is chosen or not. According to one man at the focus group discussions
at one of the sub clinics, the hospital and clinics should continue to give
injections. He said: "Psychologically, when your mind is set for injections and you
28
are denied, you will not feel better despite the numerous medicines you might be
given. The clinic no longer gets patients because they do not give injections.
There is a self owned clinic at Bugubelle and every market day people go there
for injections." This statement tells us indirectly, that the clients are not being
explained properly why they do not give injections at the GHS facilities and thus it
comes back to communication and client/provider relations.
Prescription and dispensing of drugs
It is important that all prescribed drugs will be served to clients. The survey
revealed that 107(65.2%) of the clients received all their prescribed drugs which
is very encouraging. Only three (1.8%) of the clients did not receive any of their
prescribed drugs and 32.9% of the clients received some of their drugs at the
dispensary. Not only were the prescribed drugs dispensed, dosage instructions
as to how to administer the drugs were also given to the clients. One hundred
and fifty representing 91.4% said they received helpful instructions with only
8.5% saying they did not receive any instruction pertaining to the right dosage of
their drugs.
Some of the clients were able to give the dosage, 134 (81.7%) of them said they
were told to administer their drugs on a daily base while 27 (16.5%) of them
could not remember the exact dosage. These numbers tell us, that information is
given, but not always adequately.
Cleanliness at the OPD and the washroom
Since the OPD is the first point of call for clients any time they visit the hospital,
there is the need for an optimal level of hygiene to be observed to prevent
spreading of diseases and to serve as an example for clients to keep their homes
clean. It was therefore heart-warming to have 108(65.9%) of the clients admitting
that the various OPDs they have visited were clean with an accompanied number
of 43(26.2%) describing them as very clean. Nevertheless, 13(7.9%) described
the OPD as not clean and recommends hospital management to take a second
look at the OPD.
29
Table 5: Cleanliness at the OPD and wash room:
Service area Very clean (%) Clean (%) Not clean (%)
OPD 43 (26.2) 108 (65.9) 13 (7.3)
Wash room 7 (4.3) 113 (75.00) 34 (20.7)
This survey also sought to know about the cleanliness of the Patients Wash
rooms. Out of 164 clients interviewed, only 34 of them had used the wash rooms
during their visit. For those who used the wash rooms, 26 (76%) agreed that the
wash rooms were very clean/clean. Nevertheless, there is still room for
improvement since 8 of them constituting 24% said the wash rooms were not
clean.
Privacy
In terms of privacy, a considerable number of the clients interviewed, 98 (59.7%)
said they were accorded privacy while 66 (40.2%) thought their privacy was not
respected by the clinicians or health service providers. Of those who were not
accorded privacy, several reasons accounted for that. Some apparently said they
were not given privacy at all while others felt disturbed by more than one
consultant in the consulting room. The patients' charter stipulates that each
patient should be treated with respect and more particular to ensure the patients'
right and accord them with the necessary privacy they deserve. Indeed, 56 (84%)
of those whose privacy was compromised claimed that there were several other
patients in the consulting room, while 11(16%) mentioned the fact that there were
more than one consultant in the consulting rooms. It is therefore ethical that
clients are kept informed about such arrangements for instance if the clinician
does not understand the local dialect and constantly have a third person present
for interpretation.
30
Infrastructure/transportation
All of the respondents, both men and women and from both the focus group
discussions at the hospital and the health center consider means of
transportation to the hospital or health centers as a problem. They mention that
an ambulance service exists at the hospital, but that it is too expensive for people
to use. They explain that patients and their families often try to find other ways of
transportation like loan of private cars or taking the motorbike. They are not
satisfied with the situation as it is today. One of the male respondents from the
focus group discussion at the health center pointed out: "The only common
means of transport that we use to transport patients is our motorbikes which are
not very safe. Last my sick daughter was picked on a motorbike and on the way
to Tumu, they had an accident and she got injured in addition." Another person
mentioned the bicycles that are given to the health-volunteers at the communities
as a solution for bettering the transportation problems. He thinks they should be
provided with some carriers, so they could be used for transportation of patients
to the health centers. Some of the respondents also talk about the bad roads in
the district as being a problem, because it is hard to reach the health centers or
the hospital.
Community involvement
The focus group discussions showed that civil society and the communities in the
district have a certain interest in health implementation and planning. Many of the
respondents said, that they help clean and weed the health premises. Both the
women and the men also mentioned the existence of a health committee and
health volunteers in the communities. They mentioned that the volunteers and
the committee arrange meetings for the people in the communities where health
issues can be discussed, and if there are concerns, the volunteers will forward it
to the DHA.
The respondents also mentioned that the people in the communities are aware of
the health talks and sensitizations given to them, and try to live up to the
31
recommendations the health staff give them. Keeping their surroundings clean,
produce vegetable for their children, and sleeping under treated mosquito nets
are some of the examples given.
National health insurance scheme
Since the introduction of the National Health Insurance scheme, most clients
have registered with the scheme to help reduce the cost of health service at the
health facilities. Those clients who were interviewed had a greater number of
them saying they had valid NHIS cards thus 145(88.4%) while 18(11%) said they
did not have valid NHIS cards. Of the number insured with valid insurance cards,
38(26%) of them had to pay for some of their medicines. Some of the drugs
prescribed were not covered by the scheme and for some clients their NHIS
cards were expired before they went for the drugs.
In the group discussions respondents were also talking about problems
concerning the NHIS. They confirm that they often have to pay a lot for medicine,
because the hospital or the clinics drugstores do not have it, or because the
medicine is not a part of the schemes coverage.
Clients' perception on quality of care and suggestions for improvements
Generally, the study revealed that 49% of the clients were satisfied and 13%
were very satisfied with the services offered. In the contrary, 1% and 5%
respectively were very disappointed and disappointed respectively.
Table 6: General Satisfaction with service:
Level of satisfaction No. of clients Percentage
Very disappointed 1 1
Disappointed 8 5
Cannot Tell 52 32
Satisfied 81 49
Very satisfied 22 13
Total 164 100
Table 7: Reasons for uncomfortable practices:
32
Response Frequency Percentage
The service point was overcrowded 8 35
Joining long queues for drugs 2 9
The practising of favouritism at the facility 4 17
We are not told the particular sickness worrying
us
1 4
Emergency cases are not treated as such 6 26
Some people smoke at the facility 1 4
Unstable lighting system 1 4
Total 23 100
Table 7: Suggestion for service improvements:
Suggestion No. of
clients Percent
Employment of more and qualified health personnel 31 18.9
Expansion of health infrastructure 27 16.5
Adequate drugs should be provided in the hospital and clinics 24 14.6
Provision of adequate amenities like toilets/urinals/electricity/water 12 7.3
Health workers should be polite 10 6.1
Provision of more facilities in the hospitals 8 4.9
Appropriate drugs should be prescribed for patients 8 4.9
Provision of more ambulatory services 7 4.3
Upgrading some of the clinics 5 3
Provision of adequate equipment 5 3
The use of improved technology , e.g. computer 4 2.4
Organized open days for public discussion 3 1.8
Patients should be treated equally 3 1.8
Intensive supervision of workers 3 1.8
The cost of drugs should be reduced for people who are not
covered by NHIS 3 1.8
Health workers should be motivated 2 1.2
People should be advised to register with NHIS 2 1.2
No suggestion 7 4.3
Total 164 100
Table 8: Recommendations by clients
33
Response No. of
clients Percent
Enough medical and health personnel
62 37.8
Improve on infrastructure, logistics and equipment eg., ambulance
24 14.6
Good working behavior of health workers
17 10.4
Enough and adequate drugs at dispensary
13 7.9
No recommendation
12 7.3
Cordial relation between health staff and patients
11 6.7
Intensive health talk to patients
5 3
More training workshops organization
5 3
Improving coverage/outreach communities
4 2.4
Improve on motivation packages
3 1.8
NHIS should be well equipped and functioning
3 1.8
Provision of adequate seats for patients
2 1.2
Good records keeping
2 1.2
Renovation and provision of adequate bungalows
1 0.6
Total
164 100
Results from providers
Background information
In total 33 health providers were interviewed, 18 from the 6 Health Centres and
15 staff members from the district hospital. Their ages ranged from 21 to 56
years, with an average of 33 years. In terms of sex composition, there is a
slightly larger amount of woman represented (58%). The health providers have
been in the service for periods ranging from less than a year to 30 years.
34
Provider satisfaction
This section deals with the providers' working conditions and their satisfaction.
This was examined through the questionnaire which also considered several
open ended questions. The providers' satisfaction and their views upon services
offered were measured in terms of organizational culture, working environment
and professional support as well as motivation and their image of the
organization.
Organizational culture
None of the respondents were able to fully state the mission/vision of their
working place (health center or hospital). 73% were able to state it partially. They
could not express it line by line, but they mentioned things like: taking good care
of the patients, not discriminating among people, showing empathy and
promoting community health.
Many of the respondents had difficulties in identifying whether or not they had a
formalized job-description. 85% of the respondents state that they have a job
description. 82% of those with a job-description were satisfied with it and 18%
were not satisfied with their job-description. When asked why they were not
satisfied, one said "I also do a lot of other things, which is not in the description,
and which I am not trained for." Among those respondents who are satisfied with
their job-description they explain that they are satisfied because they are doing
what they have learned and are trained for.
The providers' insight into the organization seems to be limited. Many are not
able to express their specific role in how to fulfil the vision/mission of Ghana
Health Service. A part of the reason may be that the formalized job-description
does not cover all the tasks that the providers are faced with during their work.
Social and physical working environment
It appears that all the respondents have a good social working environment.
Everybody answer that they have a cordial relationship with their supervisor and
that they relate well with their colleges. Some of their comments are: "We all eat
35
together", "we communicate about how to see the clients and how to run the
clinic" and "We share ideas and interact".
Almost everybody feel that their supervisor appreciates their work. Only one
respondent (3%) feels otherwise. These are comments from 2 respondents in
different positions at the health center:
"Because whenever they [DHMT] come, they say, they appreciate our effort and
that they know we do not have enough staff. They say, they are trying to do
something about it, but it is hard, because people are not coming [when posted
to the district]".
"Sometimes the in-charge say that [the work is appreciated], or we sit together,
laugh and have fun, but she do not give anything, just with words".
When asked about their satisfaction concerning their physical working
environment only 39% of the respondents were completely satisfied. Some of the
complaints that were repeated by different responders were: no light, no
functional bathrooms and toilets. Others are also concerned about lack of space
and rooms. As one health provider said: "the place is too small. We cannot
provide privacy for the clients".
Workload
A number of the respondents regard their working day to be 24 hours as they will
always be on duty. When asked how many hours they will actually spend in the
health centre the answer ranges from 7 - 11 hours with an average of 8 hours
and 42 minutes. An impressive 94% are willing to work extra, if there are patients
who will need their attention. Most of the respondents are already doing this.
Some also note that extra pay should follow extra hours.
When prompted to answer whether they fell overworked or under-worked, 64%
think they are overworked, and only 6% think they are under-worked. 30% are
satisfied with the present workload.
One respondent said: "We are overworked because we are on duty 24 hours a
day" and another say: "No over- or under-work, but it is inconvenient because
36
you cannot move, you have to be here if there comes patients. So sometimes
you are overworked and sometimes you are under-worked"
Information, professional support and management
On information flow, most respondents say that they receive the information from
the DHMT/management, either at trainings or through letters. Mostly, this
information goes to the in-charges at the health centre or hospital ward. Then the
in-charge share the information through staff meetings. A few complain with a
comment like this "We do not get much information. I only get information from
private books and internet". One from a health centre tells that it can be hard to
live up to the expectations given in the job-description, because of a
communication gap: "No, I am not empowered enough to do what is expected of
me. It is difficult to get information from higher levels. There is a communication
gap, especially about funding. You make your action plans, but there are no
funds to carry out the activities."
For complaints going up the system, everybody say, that they will contact their
immediate supervisor either to redress or to forward to higher levels.
In general it seems that there are clear channels for information flow, but the
system is not used/managed optimally.
The providers are in general satisfied with the management, 12% think it is
excellent, 64% find it very good and 24% think that it is fair. A majority (85%) of
the respondents also say that they receive supervisory support from higher levels
(the DHMT or the hospital/region). When asked how many visits they have
received for the last three months, 72% are able to answer and of those, 83% of
them have experienced 1-3 visits. 17% have not had visits for the last three
months.
37
Conditions of service and motivation
Salary and promotion
Salary seems to be a major problem for many of the employees. One third of the
respondents say that they are on their right salary. For the remaining two thirds
(66%), some do not know whether or not their salary is right, and some know
positively, that their salary is wrong.
One complains "I'm not on salary yet. I have to get money for food - for
everything, from my family" and another one "I do not think so. Most juniors
receive more than me. I do not understand it. I do not know what to do about it.
When I said it to the region, they said, I should take care, that I would not be set
off the list, or else I could go to Accra - But I cannot go to Accra".
Many respondents compare their salary to that of their colleagues, and find that
they are underpaid. Many also complain that rise in salary does not follow official
promotion.
When it comes to allowances, most of the respondents do not know of it. It
seems as it is not a standard for the regular health worker. Only 12% answered,
that they receive allowances, and most of these, are those who are not yet on
salary.
Most respondent are not due or do not know whether they are due for promotion
and 18% say that their promotion has delayed. The duration of delays varies
from a few months to years.
As for both salary and promotion it seems as if many of the respondents know
little about the official conditions of their employment. This makes it difficult for
the staff to claim what is rightfully due to them, and even those who are on the
right salary may doubt whether they get their share.
Motivational aspects
61% of the respondents do not get uniform supply regularly. Some receive it
once a year and some have not received it for the last couple of years or since
they graduated or started working.
38
Many of the respondents (85%) do not think that their facility reward staff for
outstanding performance. Most of those say like this respondent "I have never
seen something like that". When the respondents are asked "What in your
opinion constitutes motivation?" the answer is often in the category of money
(e.g. token, gifts, cash). What is possibly more surprising is that most
respondents say that verbal appreciation is an important motivational factor. Also
the satisfaction of the clients is motivating "I'm motivated, when I attend to a
client successfully".
And another one say "Motivation is more than money. The way you are talked to
by the district can motivate or de-motivate you."
Two thirds of the respondents are officially accommodated. Most of the remaining
third are from the Tumu Township, and for them, accommodation is a serious
problem.
Many of the respondents (82%) have attended in service training during the last
three years. The areas of training are many ex IMCI, TB, HIV/AIDS, malaria,
family planning and abortion care. All of these are clinical issues, which seems to
be very relevant the respondents daily work. A few of the HEWs mention that
they never go for trainings. One say "Training at the DHA is only the in charge
nurse and field technician, never us [HEWs]."
Image of organization
Most respondents are convinced that the image of the public about the services
offered, is good or at least okay. Although some respondents from the busy
places like TDH say that they often receive complaints about too much waiting
time. Some also note that the clients sometimes think that they do not get the
right treatment, because they want injections which they often do not get, since it
is not always the standard treatment for their condition.
39
One respondent from a sub-clinic tells "...when you tell them to go to hospital
they do not feel fine, but they appreciate the little we are doing. The way we
approach them they like that."
And one from TDH "We always try to satisfy the clients that are coming, and I
think they are satisfied."
The respondents have been asked whether there were certain things that made
them proud or embarrassed them. It seems as they are concerned about the
quality of care offered, since most of them (88% and 85%) could mention both
something that made them proud and something embarrassing about the quality.
Many of the mentioned areas are the same, ranging from family planning, ANC
and delivery to surgery and serving of drugs. There exists some degree of
inconsistency which could suggest that the standards for treatment are not the
same at the different units, or that the staffs' expectations to standards are
different. One person also mentioned client-provider relationship as a concern:
"They [some of the colleagues] do not know how to relate well/talk nicely to the
clients and staff."
Constraints and suggestions
Every respondent were asked to list the three most critical constraints of service
delivery. Most mentioned lack of staff and particularly lack of skilled midwives and
consultants/doctors. Many also mentioned transport difficulties i.e. weak
motorbikes, fuel shortage and bad roads. For the health centres the poor
electrical supply is also one of the commonly mentioned constraints. Other points
that have been mentioned by several respondents are staff motivation/attitude
and difficulties getting the right supply from the district store.
As for suggestions on how to improve the service in the district, most
respondents mention the usual issues of more funds, more staff, more fuel etc.
As for the more achievable suggestions some respondents talk about human
resource management, provider-client relations and regularity of M&S visits.
Some of their suggestions are as follows:
40
"If staff attitude towards the work changes, it will improve the service."
"Better information to the patients"
"There should be motivation and there should be regular support visits from the
district"
General staff satisfaction
Overall it seems like the health staffs are satisfied with their work. When asked
how happy they were with their job, 64% of the respondents were happy or very
happy. One said: "I am happy because I am a nurse, and I am able to save
peoples life". 15% of the respondents answered that they are okay with their
work, and 3% were not happy. Some of the negative comments mentioned were
delay in payment, lack of equipment and too heavy workload. One said: "...I am
not satisfied because of the delay in salary, and no promotion." One person also
said: "You have to say you are pleased, because you cannot do anything about
it, it is just the way it is." A sentence like this might indicate lack of involvement in
the decision making processes concerning their work.
More than half of the respondents (58%) would like to go on transfer. Through
the questionnaire some open ended questions revealed what was important for
where people would like to work. Some of the things mentioned were that they
want to stay close to their family, that there are learning possibilities and that
there is a good working environment.
41
Chapter 5: Discussions
In general a good relationship between clients and providers is important for
everyone to obtain quality health care. As mentioned in the results there exists an
odd contradiction concerning the client-provider relations among the results from
the questionnaire and the focus groups discussions. The focus group discussions
point out the fact that some clients experience the health personnel, especially at
the hospital as being impolite or rude. This seems as a general reflection, going
through the focus group discussions. On the other hand most of the clients
answer that the staffs' attitude is good or very good. In addition 92.7% of the
clients felt that they were received cordially by the staff at the hospital or clinic.
What causes this contradiction is hard to tell and there might be more than one
reason. It might be because people tend to think the same and agree with each
other when discussing in a group, and then even a few bad experiences can
have a major effect on the image of the health service. It could also influence the
answers that the clients at the exit interviews felt it was wrong to say anything
negative about the staff that just treated them.
Nevertheless since some of the clients are bringing it up, it needs to be looked
into. When the clients get a chance to make recommendations good working
behaviour of health workers and cordial relationship between health staff and
patients are rated as respectively 3rd and 6th most important. The fact that some of
the providers also state staff attitude as being problematic makes it a strong
case.
Another concern by the clients at the focus group discussions were the long
waiting time at the hospital. This might be right, even though the questionnaire
shows the waiting time as being average. However some of the providers also
mention that the clients sometimes complain about too much waiting. In some
situations especially at the hospital, being a busy facility, this might be the case.
Information and communication are serious issues. The fact that only 39.6%
were informed about their diagnosis shows that major improvements are needed.
42
Not only is it the client's right to be informed about her or his illness, it is also
important to prevent diseases in reappearing.
The results also show that some of the health education given to patients either
is simply lacking or not good enough, since many clients cannot understand why
they do not get injections. The clients actually go to private for profit clinics to
receive these. In general it is important that information concerning the clients'
health as well as general health education is exposed in a suitable way for
illiterates since the illiteracy level in the district is high.
When it comes to the providers the results give us the impression that there is a
lack of involvement or partaking in the decision making processes concerning
their work. It seems as if many do not know how to take part in these processes,
and even though they all know where to go or who to forward their problems to, it
seems impossible for them to act upon their concerns. Weather this is caused by
lack of involvement or lack of opportunities is hard to tell, but it might be
something that needs to be looked into, also because more than half of the staff
talked to give the impression that they would like to go on a transfer.
None of the respondents talked to were able to state the mission/vision of the
Ghana Health Service and in addition many were not fully aware of their job
description. This could indicate lack of involvement by the employees or
problems in leadership by the management, but it also raises the question
whether the mission/vision is a practical tool for the daily work.
Some of the concerns raised by the staff as affecting their satisfaction with work
were wrong salary, inflexible working hours and problems with their physical
working environment. In contrast to this all providers talked to feel they have a
good relationship with their colleagues as well as their supervisors. Supervision
is mentioned as a motivational factor by the providers and it is something that
could be improved upon so everyone receives it.
43
When asked how happy the health providers are with their job, a majority are
happy or very happy with their job. This tells us that it is good to be a health
worker even though there are many serious issues to look at.
44
Chapter 6: Recommendations
Over all, the clients and providers who contributed to the study have a good idea
of what constitutes quality health care. In addition it seems as if the providers
have a clear idea about what constitutes a satisfying working environment.
However both clients and providers point out things that need improvement to
make the quality of health care even better and more satisfying.
As described in the methodology section a workshop was arranged for all
relevant stakeholders. Findings from the study were revealed and five key issues
had been identified for further discussion and group work. The issues were as
follow: client provider relations, salary irregularities, 24 hours duty,
communication & information and supervisory support.
The participants in the workshop were active, critical and constructive. The
issues were discussed and recommendations were drafted. With inspiration from
these the research team have made the recommendations. Some of the
recommendations will be cited here.
With regard to the client provider relations, which both clients and providers
mention as being problematic, many recommendations are brought up.
According to client's expectations, e.g. their desire for injections, it is
recommended that the health staff should try to educate the clients, both when
they are attending the OPD as well at community level durbars. If the clients are
aware of the side effects of injections or other issues like mechanisms of drugs,
then they know what to expect and will not get disappointed when they attend to
the services. Some clients complained about the staff attitude, to improve on this
orientation and education for staff on the GHS code of ethics and the patient
charter was suggested. A suggestion box, where the clients can address their
problems and concerns, was also suggested. It is also important to have a look
at the staffs well-being and satisfaction, if improvements on the staff attitude are
to be expected. When the staff are satisfied it is likely that they are more
motivated to provide a proper attitude towards their clients. Adequate working
45
equipment, staff motivation, accommodation and regular supervisory support are
recommended to enable better staff satisfaction.
A majority of the health workers interviewed, say that they are happy to work in
Sissala East. In the light of the many complaints this is a little surprising but none
the less positive. This fact can be useful as a way of attracting more manpower
to the district and to keep those employees who are already here.
In spite of the general job satisfaction, more than half of the providers would like
to go on transfer. It is recommended to make the transfer system more
transparent and include consideration to family location and a fair distribution of
staff to the most distant sub-districts.
Groups at the workshop were discussing both 24 hours duty, supervisory support
and salary irregularities. Regarding the long working hours and the non flexible
working schedule many different solutions came up. An effective duty roster that
ensures some to be on post while others are off, and regulation of the leave
system so that there will not be missing too many from the same unit at the same
time was recommended. So was equitable distribution of staff to the different
units in the district, and attractive packages for students who come and work in
vacations and other leave-periods. Health promotion and education for clients
and communities was also mentioned as a way to limit the no. of emergencies
and limit the workload of 24 hours duty. As mentioned 17% of the providers
talked to had not experienced any supervisory support visits for the last three
months. The supervision is appreciated and experienced as motivational by the
providers so it is recommended that all staff experience supervisory support from
management and colleagues. As well people are advised to contact their nearest
supervisor/ colleague for support if they need it. Through the workshop an action
plan was brought up to correct salary irregularities. It is recommended that data
on all effected health staff in the district is being collected and compiled in a
report that can be brought to higher levels of GHS.
The information the clients receive concerning their illness and dosage of
medication etc. is an issue that can still be further improved. 60.4 % of the clients
46
participating in the survey were not informed about their illness/diagnosis. This is
a shame because the client has a right to know and be explained what is wrong
with him or her, and because illnesses might be prevented if people are aware of
symptoms and preventive measures. Many of the clients who received drugs
were able to tell their dosage afterwards, but still 18% could not. This can be
problematic because wrong dosages or wrong use of medication can have fatal
consequences. It is recommended that all clients are told about their diagnosis
and educated about their condition and the treatment. Thus prevent reoccurrence
of the same condition and reduce worries and anxiety. Education
and information about right dosage and use of medication is recommended as
well. It is important that health staff knows what is the right treatment for every
individual case so this can be handed over to the client. It is also of great
importance that the health staff are sure that the clients understand the
information given to them. Just to list the medication for the client might not be
enough and the providers should be sure that the client has the right
understanding before he or she is leaving the health facility.
Chapter 7: Conclusion
The survey shows that the clients find both positive and negative aspects of the
health services offered in the district. The facilities are found to be clean and
many of the clients feel that the reception at the facility is cordial. The problems
raised by the clients vary between infrastructural problems to lack of privacy and
bad staff attitude. The staffs' working conditions is something that can be
addressed by more information, trainings and better planning and routines. This
could in turn help to solve many of the complaints raised by the clients, like
problems with staff attitude, waiting time, insufficient information/education about
their illness or dosage of medication.
The staffs who participated in the survey complain about their physical working
environment like no light, not enough space etc. In addition they mention issues
like wrong salary, not enough supervisory support visits, heavy work load and
47
inflexible working hours as issues that contribute to low staff satisfaction. Some
of these issues could be changed for the better. Better working schedules and
rotations, regular supervisory support and joined reporting on incorrect salary
could make the providers' work more satisfying for them. These changes could
have a positive effect on their attitude towards their clients and colleagues.
Problems raised by the clients and providers concerning transportation and lack
of staff are problems that are typical for a remote area like Sissala East District.
These issues are hard to immediately act upon and change for the better, but by
continuing cross sectoral cooperation and encouraging communities to find
collaborative solutions e.g. community ambulance systems, some of these
problems can be addressed as well.
If the recommendations are to be implemented it will have a positive effect on
many of the problems raised by both the clients and the health providers. Some
problems like lack of health staff (e.g. doctors and midwives) and the problems
concerning the bad roads to, from and around the district are undoubtedly issues
that are hard to deal with and immediately act upon. But if some of the other
problems are dealt with it can still have a positive effect. If the district have a
satisfied health staff and clients that are happy with the health services offered it
might attract more qualified staff. A strong voice from the whole district to the
region and national level might also have an effect on these hard to dealt with
problems.
If the district can make their clients and health providers satisfaction even better
it will hopefully have a positive effect on the overall health status of the district.
48
Thanks
We would like to thank everyone involved in this survey, all clients and staff
talked to, the DHMT, the TDH, the statistical office and research office in Wa.
A special thanks will go to the data collectors from the three local NGOs:
ASUDEV, YARO and PAWLA.
And last but not least a special thanks to everyone who participated in the
workshop where the recommendations were drafted.
References
Deen A.M., 1999, "The applicability of SERVQUAL in different health care
environments", Health Marketing Quarterly, Vo. 16 No. 3, pp. 1-21.
Ghana Statistical Service, 2009, "High Impact Rapid Delivery (HIRD)
Supplementary Survey, 2007 (District MICS) - Monitoring the situation of children
and women, Upper west Region". Ghana, June 2009.
Jessie L.T. and Shiela R.A., 2001, incorporating patients' assessment of
satisfaction and quality: an integrative model of patients' evaluations of their care.
MCB University Press, Texas, USA.
Linder-Pelz S., 1982, ‘Toward a theory of patient satisfaction", Social Science
and Medicine Vol. 16, pp. 577-82.
49
Appendix
Appendix 1: Summary of indicators
Category Indicator
Output/statistics
(%)
Waiting time
Proportion of clients who were delayed in
receiving their OPD cards 46.3
Proportion of clients who were delayed in
receiving their medications 29.3
Staff attitude
generally
considered to be
very good
Proportion of staff attitude at records unit 25.6
Proportion of staff attitude at consulting room 40.9
Proportion of staff attitude at injection room 4.9
Proportion of staff attitude at dressing 2.4
Proportion of staff attitude at dispensary 21
Proportion of staff attitude at antenatal unit 0.6
Proportion of staff attitude at labour room 1.2
Cleanliness
Proportion of clients who agreed that the OPD
was clean
26.2
Proportion of clients who agreed that the
wash rooms at ward was clean
4.3
Records of vital
signs
Proportion of clients who had their blood
pressure taken
77.4
Proportion of clients who had their
temperature taken
88.4
Proportion of clients who had their pulse
taken
3.0
Proportion of clients who had their height
taken
3.6
Proportion of clients who had their
respiration taken
12.2
Proportion of clients who had their weight
taken
92.4
Proportion of clients who had none of their
vital signs taken
7.3
NHIS
Proportion of clients who had valid NHIS
cards
87.4
Proportion of clients who had valid NHIS
cards but paid for some medicines
26
50
Satisfaction
Proportion of clients who were given all the
prescribed medicines
65.2
Proportion of clients who were given
adequate instruction on medicines
administration
91.4
Proportion of clients who were satisfied with
services at the medical records unit 81.7
Proportion of clients who were satisfied with
services by nurses during history taking 87.2
Proportion of clients who were satisfied with
information by clinician during consultation 89.6
Proportion of clients who were satisfied with
dispensing by pharmacy staff 86
Proportion of clients satisfaction with general
billing system 9.8
Proportion of clients satisfied overall 49.4
Proportion of clients who were comfortable at
the OPD 12.8
Proportion of clients who received clear
information at OPD 26.8
Proportion of clients who reported their
complaints to clinician 90.2
Proportion of clients who were physically
examined by clinician 66.5
Proportion of clients who were satisfied with
the clinicians examination 57.9
Others Proportion of clients who were told their
diagnosis 42
Proportion of clients who find cost of services
as cheap 0.6
Proportion of clients who paid for their
medicines 23.2
Proportion of Patient's who were accorded
privacy during consultation 59.7
Proportion of clients who received all the
prescribed medicines
65.2
51
Proportion of clients who experienced some
uncomfortable practices 14
52
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