Patients’ level of satisfaction on quality of health care at Mwananyamala hospital in Dar es Salaam, Tanzania

Quality of health care is defined as a degree of performance in relation to a defined standard of interventions known to be safe and have the capacity to improve health within available resources [1].

The patient satisfaction perspective of hospital care had gained more attention in recent years and studies have shown that patients are most satisfied with interpersonal interactions, such as staff-patient relationships [2]. A study done in South Africa concluded that patient satisfaction is a fundamental indicator of equitable quality of care [3]. Another study on patients’ satisfaction at a referral hospital in Tanzania observed a high level of satisfaction among respondents, mainly because of the hierarchical health care delivery system, whereby the referral hospital is at the apex with super-specialty services. However, a small proportion of patients were dissatisfied with long waiting time, high cost of treatment, and investigation charges [4]. It is well documented that if patients’ level of satisfaction on quality of care does not meet their standard, they may decide to seek for treatment somewhere else [5‐7].

In fact, satisfied patients are likely to exhibit favorable behavioral intentions, which are beneficial to the healthcare provider’s long-term success. However, one of the major barriers to better health care for much of the population in developing countries, including Tanzania, is lack of access to even basic health services [8]. In Tanzania, despite efforts by the Government, through the Ministry of Health and Social Welfare (MoHSW), to improve the quality of care through different approaches such as Health Quality Improvement Framework, still health service provision is constrained by a number of factors in terms of poor infrastructure, unavailability of drugs and/or medical equipments and limited human resource for health [9, 10]. For example, in 2006 the national average population/doctor ratio was 138,000 persons per doctor, while the national average population/nurse ratio was 5,000 persons per nurse [11].

In Tanzania, 80% of all patients attending health facilities are attended at out-patient-department (OPD), hence making OPD a key area to assess quality of care [9‐11]. To understand patients’ level of satisfaction it was imperative to conduct this study to determine patients’ level of satisfaction on the quality of health care delivered at the OPD in Mwananyamala hospital in Dar es Salaam, Tanzania.

This study used the Donabedian model [12] to determine patients’ level of satisfaction on quality of care at the study setting. According to the Donabedian model, three key domains, namely structure, process and outcome are interrelated in the context of quality of care. Donabedian posit that a good structure increases the likelihood of good process, which increases the likelihood of good outcome, such as patients’ satisfaction [12]. The Donabedian model was adopted in this study because it has received substantial empirical support for its ability to generate information from which inferences can be drawn on quality of care [12].

However, there is dearth of empirical evidence on the use of Donabedian model to assess patients’ satisfaction on quality of care provided at different health care facilities in Tanzania. This study therefore aims to determine patients’ level of satisfaction in an urban health care facility. Findings from this study will add knowledge to the literature by assessing how Donabedian model might explain patients’ level of satisfaction on quality of care and provide evidence for improvement of quality of care in the study setting.

A total of 422 study participants were included with a response rate of 100%. Mean age of participants was 36.8 ± 11.9. Almost half, (n = 191, 45.3%) were aged 34 years or less, most, 52.8% were female, 55% were Christians and 84.6% were either employed or self-employed. Table 1 below summarize socio-demographic characteristics of all study participants.

The study findings indicate that the overall patients’ level of satisfaction on the quality of care at the OPD in Mwananyamala hospital was relatively low. This is in line with findings of patients’ satisfaction studies elsewhere [20, 21]. However, this is contrary to a study done in Muhimbili National Hospital in Dar es Salaam, whereby a high proportion of patients were satisfied with quality of care [22]. In fact, it is not generally proven that patients’ satisfaction is related to quality as reported by Leonard (2008) in a study done in Arusha Tanzania. In this study Leonard showed that, in the Tanzanian context, satisfaction is not directly associated with quality, but changes in quality do lead to changes in satisfaction, as patients notice improvements [5]. Of all five dimensions used to assess patient’s level of satisfaction, respondents were least satisfied with the assurance dimension, followed by reliability, tangibles, empathy, and responsiveness. According to Donabedian model [12] there is a strong relationship between all three domains of structure, process and outcome, which exist in the context of quality of care. Based on the Donabedian model assurance dimension was used to assess the structure category. Of all items used to assess assurance dimension, respondents were least satisfied with OPD staff adherence to confidentiality of patient’s information. The observed dissatisfaction of patients’ on providers’ lack of adherence to confidentiality of patient’s information underline the importance for the hospital management to strengthen adherence skills among OPD staff on confidentiality of patient’s information. It is well documented that patients who perceive lack of confidentiality on their medical information tend to seek care somewhere else [5‐7, 23, 24].

In this study reliability dimension was ranked second by respondents. Reliability dimension was used to assess the process domain according to the Donabedian model. In the reliability dimension, respondents were least satisfied with proper prescription of medications. The observed level of dissatisfaction of respondents on proper prescription of medications at the OPD may raise concern regarding clinician’s ability to make proper diagnosis and treatment of common diseases [23‐25].

Tangibles dimension, which was used to assess the structure domain was ranked third by respondents. Respondents were dissatisfied with clinician’s ability to prescribe good drugs. This observation substantiates respondent’s dissatisfaction on proper prescription of medication mentioned in reliability dimension above. In this study, empathy was used to assess the process domain. Respondents were dissatisfied with lack of compassion by the OPD staff. Provider’s behavior towards patients, such as politeness is an important predictor for patient satisfaction [4, 5, 26]. This observation, which is reported to be common in most public health facilities, force patients who can afford to pay for services to choose to go to private health facilities instead of seeking care at public health facilities [26‐29]. It is important for the hospital management at Mwananyamala to encourage the health personnel to embrace staff-patient relationship, whereby the patient is viewed as a customer in order to improve the quality of care in this setting.

Responsiveness was used to assess the process domain as well. Respondents were least satisfied with OPD staff respect towards patients. It is well documented that patient’s perception of health care provider’s behaviour, such as respect influence their view’s towards quality of care [4‐6].

From the Principal Component Analysis (PCA), six items (3 empathy items versus 3 tangibles items) explained 53 percent of the patient’s satisfaction scores on quality of care. Empathy items which explained most of the dissatisfaction on quality of care were failure to show compassion, lack of politeness and inadequate listening by OPD staff. Tangibles items which explained most of the dissatisfaction on quality of care were lack of essential drugs, poor prescription of drugs by clinicians and insufficient seats and toilets at OPD. Apart from perceived poor prescription by clinicians at OPD, the perceived lack of essential drugs observed by respondents is crucial, because availability of essential drugs is an important factor influencing patients’ level of satisfaction observed in several studies in other settings [21‐25].

According to the Donabedian model, all three domains, structure, process, and outcome are interrelated and in order to improve quality of care, all must function well to achieve the expected outcome, such as patients’ satisfaction [12]. However, it is important to note that a multitude of factors influence patients’ level of satisfaction and quality of care hence caution should be taken into consideration while making conclusions regarding quality of care [5, 8, 29‐34].

In conclusion, respondents in this study perceived low quality of care provided at the OPD in Mwananyamala hospital. Key areas of concern includes: improvement on communication skills in showing compassion, politeness and active listening, availability of essential drugs, and improvement on clinicians’ prescription skills. If policy can improve the reality on the ground, patients will notice, and hence indirectly improve their satisfaction.