ISSUES IN HEALTH PLANNING & MANAGEMENT IN NIGERIA

VOL-1

ISBN 978-34330-1-6 1998

A publication of NATIONAL COLLABORATING CENTRE FOR EDUCATION AND TRAINING IN HEALTH PLANNING AND MANAGEMENT University of llorin, llorin, Nigeria. Printed Offset and Produced by: NATHADEX PRINTING A PUBLISHING ENT. Opp. Doctor's Quarters, Odo-Okun, Sawmill, llorin,

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FOREWORD
It is an opportunity to be invited to write a foreword to a Book of Readings in Health Planning and Management. The book written by a group of researchers and practitioners mainly at the University of llorin, llorin, Nigeria, and edited by somebody who is not only involved in research in Health Planning and Management, but has been involved in training health practitioners at all levels of practices in the West African Subregion, will certainly add to the emerging literature in Nigeria on such a vital subject -HEALTH. Good health is basic to human life. Good health is a vital instrument for socioeconomic development. The issue of planning for and providing good health for the citizen of the world has been demonstrated by WHO to be something beyond the confines of any one profession. Thus a multi-disciplinary approach as demonstrated by the authors, and titles of articles in this book could only be an added effort to providing the people of the world better health even at this turn of the century. Focusing on a wide area that emphasizes investment in health and economic development, the book highlights information support for provision of primary health care, the need for population data in health planning in Nigeria, understanding factors of health and illness in health planning, enhancing patients satisfaction through adequate medical care, and evolving a control structure for health technology management in Nigeria. Certainly, the need for healthy living as a basis for planning and management for efficiency and effectiveness in the health sector deserves attention as has been given, and this adds to the robustness of this book.

This unique addition to existing literature in health planning and management in Nigeria will provide useful guide to health professionals and non-professionals. It is expected to open the window for more discussions on the various issues addressed. I hereby commend the book to all those who desire good health for themselves and others.

Professor I. I. Ihimodu,
Dean, Faculty of Business & Soc. Sciences, University of Ilorin, Ilorin, Nigeria. January, 1998.

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DEDICATION
This book of Readings in Health Planning and Management is our modest contribution in honour of Professor Eyitayo Lambo (Fellow of Operation Research), a pioneer Head of Department of Business Administration, University of Ilorin, Ilorin, Nigeria. As one of the pioneer researchers and teachers in Health Economics, Planning and Management in Nigeria, Professor Eyitayo Lambo's contribution to emerging literature in these areas is well acknowledged. After retirement from University teaching in 1992, Professor Eyitayo Lambo continues to contribute to better health for the people of the world by sending as Health Economist with the African Regional Office, World Health Organization. We wish him a healthy life in retirement. Editor, Amos O. PETU, Ph.D.

TABLE OF CONTENTS
Foreword........................................................................................................ Dedication...................................................................................................... Table of Contents........................................................................................... Economic Development and Health Policy in Nigeria Dr. K. T. Okorosobo and C. F. Okorosobo (Mrs.) ........................................ Sustainable Development, Public Health and the Imperative of Paradigm Shift Remi Medupin................................................................................................ The Spectrum of Modern Health Care System in Nigeria A. O.Petu....................................................................................................... Enhancing patient Satisfaction through Adequate Medical Care J. O, Olujide and A. L. Badmus .................................................................... Information Support for Primary Health Care T. M. Akande ................................................................................................. The Effect of Stress on Entrepreneurial Work S. L. Adeyemi (Mrs.) ...................................................................................... Healthy Living and Increased Labour Productivity in Nigeria Ilesanmi Oladele Ayodeji .............................................................................. iii v vi 1

23 43 64 85 98 119

vi
Social Life Events and Personal Homeostasis as Factor of Health and Illness J. O. Fayeye................................................................................................... Exercise Therapy a Neglected Aspect of Health Care Management in Nigeria Talabi, A. E. .................................................................................................. Planning for Health and Socio-Economic: What Benefits from Water and Environmental Sanitation Programmes J. A. Bamiduro............................................................................................... The Need for Population Data in Health Care Planning in Nigeria J. Funso Olorunfemi......................................................................................

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156 169

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ENHANCING PATIENT SATISFACTION THROUGH ADEQUATE MEDICAL CARE

BY DR.J.O.OLUJIDE Department of Business Administration, University of Ilorin, Ilorin.

AND MR. A. L. BADMUS Department of Business Administration University of Ilorin, Ilorin. INTRODUCTION The concept of consumer satisfaction occupies a key position in marketing thought and practice. Satisfaction represents the major plank of marketing activity and invariably serves to connect decision process culminating in actual purchase and consumption with post-purchase and brand loyalty. The centrality of the concept is reflected by its inclusion in the marketing concept- that profits are generated through the satisfaction of consumer needs and wants (Churchill and Supprenant, 1982).

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The idea of satisfaction is fundamental to the delivery of the service. The goal of business is to serve the customer in some way and to fill some need, which is precisely the prescription of the marketing concept. Liechty and Churchill (1979) assert that the marketing concept as a measure of consumer satisfaction appears particularly appropriate in terms of satisfying the existence of the service business. Unfortunately, majority of government-owned service institutions sidetrack the centrality of marketing concept and are neither customer focused nor market-driven. Consumer opinion is yet to locate its rightful place in the formulation of health care and social policies. Linder-Pelz (1982) defines patient satisfaction as positive evaluation of distinct dimensions of the health care. The care being evaluated might be a single clinic unit, treatment throughout an illness episode, a particular health care setting or the health care system in general. Satisfaction with medical care is a relevant factor determining whether a person seeks medical services, complies with treatment and maintains a continuing relationship with a physician (Larson and Rootman, 1976). OBIECTIVES OF THE STUDY The adequacy of health provision represents the most important concern of any government the world over since the development and growth of any economy hinges on the healthiness of its citizenry. Enhancing patient satisfaction through adequate medical care is a sine qua non for achieving this developmental objectives. Consequently, patient satisfaction represents a relevant parameter in the utilization of health care services in any nation. And considering the global strategic plans -of "health for all by the year 2000", it becomes imperative to actually ascertain whether or not the people feel adequately served by our public and private health institutions. Therefore, the objectives are as follows:

66 a) b) c)

Patient Satisfaction and Medical Care To find out patients' assessment of the medical care provided in the government owned health institutions in Ilorin; To identify the basic elements of the service which patients complain about, are satisfied or dissatisfied with or which otherwise affect their utilization of or response to health care and; to recommend some ideas to providers of care-health planners, administrators and policy makers on how to modify their provision of care in order to make their patients relatively more satisfied.

METHODOLOGICAL ISSUES IN SOCIOLOGICAL STUDIES OF CONSUMER SATISFACTION WITH MEDICAL CARE The concept of satisfaction with medical care up till now is marooned in ambivalence and mired in controversies with some researchers considering satisfaction as antecedents to utilization. Korsch (1954) treats satisfaction as an outcome measure and inherent in this view is an interest in the interactions of provider and patient stressing instrumental and expressive aspect - a clear distinction by identifying a provider and by stressing cost convenience and perceived competence. Alternative conceptualization of satisfaction views it as an important input variable. Scuhmall (1964) and Anderson (1966, 1973) perceive satisfaction with trust and confidence in 'doctor' as a predisposing variable. Similarly, the prevailing conceptualization of utilization of preventive care measures. Afferata (1978) notes that the two conceptualizations are not necessarily incongruent with each other but complement each other. He further contends that low relationships between health beliefs and utilization may be the result of cancellation effect if no control for provider is introduced and that relationship between demographic variables and utilization may be due to the different experiences of clinic populations and private practice users. The unending shift in the burden of disease from acute to chronic

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conditions and changes in the age structure of population of patients and individuals requiring long-term medical treatment and social care, underscores the growing importance of the studies of quality of medical care as a component of health care research. It has been realized that satisfaction with care is a relevant variable in deciding whether or not a person seeking medical advice complies with treatment and maintaining a continuing relationship with a practitioner. Also, the attitudes of the patients are of paramount importance with respect to long-term care, the quality of care can become synonymous with the quality of life and satisfactions with care collapses to an important component of life satisfaction. Care assess to be of high quality on the basis of clinical, economic or other provider defined criteria will be far from ideal if as a result of the care, the patient is dissatisfied. There is then a sound rationale for making the organization and delivery of health care more responsive to the patient needs. Tester and Mechanic (1975) compared consumer satisfaction with prepaid group practice and fee for service and Hulka et al (1971) developed a sophisticated method of measuring attitudes towards electors based on the Thurtine equal appearing interval techniques modified to a Likert format. Korsch et al (1976) employed relatively complex techniques to study parental evaluations of pediatric care. Their hypothesis was that a causal relationship existed between the nature of the verbal communication between doctor and patient and the outcome in terms of patient satisfaction. Studies of hospital care have been reported by McGhee (1966) and Cartwright (1967). McGhee found that the greatest single defect in hospital care was the barrier to easy exchange of information. In Cartwright study (1967), patients were asked to identify what struck them most about their experience in hospital? 40% were entirely enthusiastic in their replies, the staff being the most frequent subject for praise. The food, the physical surrounding and the medical treatment also received favourable comments. Just under 20 percent were mainly critical; the

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Patient Satisfaction and Medical Care

staff, the food, the physical conditions and the hospital routines being the most frequent sources of unfavourable comments. When asked directly, 61% of the patients reported some difficulty in getting information, 21% being unable to find out what they wanted to know about their conditions and treatment; 40% indicating a variety of other difficulties regarding information. Cartwright saw this as part of a general failure to recognize the social and psychological requirements of patients. Scott and Gilmore (1966) interviewed a sample of patients attending outpatient clinics. 20 percent complained about the lack of primacy but other than this, there was little evidence of dissatisfaction. In general, majority of patients stated that they were very satisfied with their care when asked to give an overall assessment, though the communication of information about illness and treatment appeared to be the most source of dissatisfaction. There are many other methodological issues which need to be considered. One is the way in which patient satisfaction with a service or care environment may be rated. Where comparisons are to be made between two service units, it is necessary to devise some measure of customer satisfaction so that relevant comparison can be drawn. There are three approaches that can be employed to get a scale of satisfaction. Firstly, there is global evaluation which is inadequate measure of consumer opinion since the majority studies indicate that the level of satisfaction expressed varies with different aspects of medical care. Results of Henley and Davis studies (1967) support a multidimensional conceptualization of patient satisfaction. They also indicate that the level of satisfaction expressed varies with different aspects of medical care. Global evaluations which ask respondents how satisfied they are in general tend to mask these differentials and for the fact that they do not take cognizance of such specific instances of dissatisfaction, global evaluations tend to be biased toward the satisfaction end of the scale. The two alternatives to global evaluations are variations of the

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same approach. Both distinguish separate facets of a service, one treating them as discrete items while the other composting individual items to arrive at an overall score of satisfaction. Each of them has its merits and demerits bit both can provide sensitive measures of consumer opinion and can give indications of how a care situation would have to be changed in order to enhance patient satisfaction. Within the three types of approaches mentioned, studies can be differentiated according to whether they only measure the extent of satisfaction - dissatisfaction or whether they measure the range as well. The former makes use of respondents who are satisfied or dissatisfied while the latter makes use of a multidimensional scale and gives an indication of the relative intensity of satisfaction and dissatisfaction and is the most sensitive measure of consumer opinion. Locker and Dunt (1978) contends that any measure of consumer satisfaction needs to take account of differential satisfaction with individual aspects of services, to employ a multidimensional scale for rating the consumers response and to base responses on actual experiences of care. A further issue is the extent to which respondents' reports reflect their time feelings about the service they received. This can be tackled if questions are used which differentiate between a service and the individual providing it. Another important issue is the nature of consumer assessment of care. Also, one needs to know the basis of expressions of satisfaction and dissatisfaction. Stimson and Webb (1975) have suggested that satisfaction is related to perception of the outcome of care and the extent to which it meets patient's expectations. This is supported by Larsen and Rootman (1976) who demonstrated that a relationship between satisfaction and expectation is not necessarily direct but contend that, it then seems reasonable to suggest that expression of satisfaction are the end-product of a process of evaluation in which expectations figure to some extent (Locker and Dunt, 1978). With respect to the various services provided by the government-

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Patient Satisfaction and Medical Care

owned institutions, many people hold what Friedson (1972) calls practical expectations anticipated outcomes which derive from an individual's own experience, the reported experience of others or a knowledge from other sources or what has been described as the minimum tolerable or the least acceptable level. This offering might not be the only alternative but it is better than nothing. Friedson defines the ideal expectation as preferred outcomes deriving from a patient's evaluation of his problem and goals in seeking medical care. The practical and ideal expectations may not coincide thereby giving rise to a situation in which the patients are satisfied because their practical expectations have been met although the care they receive does not meet their goals. Other supports for patient's expectation can also be found in the data provided by Cartwright (1967) and in the association found by Mechanic and Tessler (1975) between expressed satisfaction, skepticism towards medical care, faith in doctors and readiness to seek health care. Korsch et al (1968) found that satisfaction was lower when patients' expectations that physicians would be communicative and friendly were not met. ACCESS DEFINITIONS AND RELATIONSHIP TO CONSUMER The definition of access in medical care has generated a lot of controversy with different scholars giving their own view of what the concept means. Some authors likened access with entry or use of the system while others use it to mean such terms as accessible. Though access a times is used to characterize factors which influence entry or use, there is still differing opinions concerning the range of factors included within access and whether it characterises the range of factors include within access and whether it characterises the resource or client. A second dissatisfying factor is the extent of patient care which include coping with patients who have self-destructive diseases, dealing with angry or disrespectful patients and making decision beyond competence.

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IMPACT OF DOCTOR-PATIENT COMMUNICATION ON SATISFACTION AND OUTCOME Given that the basic technical care has been made and the appropriate treatment prescribed in any given health care system, one would expect that the positive application of certain psychosocial variables would usually lead to a positive outcome and this outcome in turn, would lead to a satisfied patient. The psychosocial variables embrace the patient and his expectations, the physician communication with his patients and the patient's motivation and ability to carry out the physician instructions. This leads us to view effective primary-care delivery as being a product of a long and complex causal chain whose links include the psychosocial components. Owing to the difficulty of testing the entire long chain as a total visit, several variables were employed. Francis (1969) and Korsch (1968) demonstrated relationship between patient expectation and compliance and between compliance and satisfaction. Other studies too have shown the link between compliance and outcome (Wilson 1973, Feintein, 1959). Berdict and Williamson (1973) studies focus on two variables -satisfaction with the health care process, satisfaction with care process and satisfaction with care response to the process of medical intervention while the latter focuses on the results of the intervention. Result from the studies point to the fact that d-p communications do appear to affect patient's expectations and outcome does seem to affect patient satisfaction. However, it was noted that communication did not appear to influence compliance and neither communication nor compliance affect outcome. METHODOLOGY The survey population consisted of a random sample of one hundred and eighty people who attended any of the public hospitals/clinics in Ilorin. These hospitals and clinics are primary health

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Patient Satisfaction and Medical Care

care centres. The sample was restricted to those who have made at least one out-patient clinic visit in 1995 to ensure that they qualify as consumers of health care and that the information given relates to current experience. PROCEDURE FOR DATA COLLECTION The data used for the study was gathered from a survey conducted in 1995 in Ilorin town. The data was collected by means of a 32-item questionnaire in which respondents were asked specific questions relating to various aspects of medical care received from the public hospitals. Respondents were also asked to list and comment on those aspects that mostly caused satisfaction or dissatisfaction with the services received. The questionnaire was administered to assess the respondents' attitude towards the physicians, the nurses, the pharmacy services, the empathy, courtesy and professional interest of the contact staff, adequacy of information given and received, access mechanisms and convenience of the facilities of the public hospitals and clinics. Only the pharmacy service was investigated among auxiliary and support services because it, is the only one that was common to al the health centres considered and with which majority of the people had contact with. Out of the 180 questionnaires administered, 175 were highly completed and returned unable giving a satisfactory response rate of 97.2%. SCALE OF MEASUREMENT The survey scale of instrument was a comprehensive patient satisfaction questionnaire including items that assess attitudes towards all aspects of care relevant to the study. A multi-item measure of each dimension as well as an overall index that aggregate across dimensions was developed because levels of satisfaction may differ depending on the dimension of care under consideration. This was done by considering some of the ideas on patient satisfaction questionnaire suggested by Mangelsdorff (1979).

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These ideas together with those gathered through informal discussions with people who are in the public hospitals as their sources of medical care led to the identification of. four aspects of care on which satisfaction items were formulated. The aspects of patient satisfaction considered include: (a) Physician interaction aspect which was made up of seven items relating to the conduct humanness of the doctors. (b) Nurse interaction aspect which was made up of four items that relates to the empathy and courtesy of the nurses as well as the adequacy of the information given by the nurses. (c) Pharmacy services which was composed of four items relating to information, financial aspects and drug availability. (d) There was also a global evaluation item that asked for the overall assessment of the medical care received from the public hospitals and clinics. All these gave a total of 25 scored satisfaction items. The response format employed a five-point Likert scale as follows: Point 1 completely satisfied Point 2 satisfied Point 3 no opinion Point 4 dissatisfied Point 5 completely dissatisfied The Likert scale format allowed for greater discrimination of the intensity of a respondent's belief regarding an issue. Besides they were four questions that tried to investigate the personal experiences of respondents at the public hospitals/clinics. Three of these items were scored on a nominal scale (Yes and No) while the fourth item was open-ended and solicited opinions or attitudes but reports of actual experience. There were also three other open-ended questions and two of these asked the respondents to list and comment on the aspects of medical care that they were most satisfied/dissatisfied with while the last item requested respondents to give suggestions as to how improve the

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medical care in the public hospitals/clinics. The result was a 32 item satisfaction questionnaire and demographic information regarding sex, age and educational background were also asked for. TECHNIQUE OF DATA ANALYSIS To analyze the data collected, statistical analysis was employed. The statistical techniques employed include: (1) Frequency distribution analysis (FDA): The FDA was used to determine the proportion of satisfied to dissatisfied respondents with the various aspects of care considered. This will in turn help to identify those aspects of care which patients complain about, are satisfied or dissatisfied with and which will otherwise affect their utilization of health services. (2) Cross Tabulation Analysis (Chi-squared-test of Significance): This was used to determine whether the observed variations in the respondents degree of satisfaction were due to difference in sex,, age, educational background or whether they were due to other factors different from the ones considered in the study.

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Table 1: Summary of the distribution of responses to the satisfaction items relating to the conduct/humanness of the doctors: Frequency distribution Item Item content % % % No Satisfied No Opinion Dissatisfied 5 Spends enough time in treatment 73.7 6.3 20.0 6 Show interest/ concern 72.0 10.9 17.1 7 Willing to listen 84.0 4.6 11.4 8 Allows one to ask questions 66.9 6.3 26.8 9 Adequacy of information given by doctor 60.5 11.4 28.1 10 Careful daring treatment 77.7 9.1 13.2 11 Outcome/efficacy of care 81.7 6.3 12.0 Table 1 above shows the frequency distribution of the response to the various aspects of medical care answered and because of the low frequencies of completely satisfied and completely dissatisfied, these were collapsed to form the satisfied and dissatisfied columns respectively. The above results show that majority of the respondents are satisfied with the conduct/humanness in the public hospitals/clinics in Ilorin Town with as high as 84% being satisfied with the doctors willingness to listen to patient's complaints. Although all of these assessments (with respect to the physician interaction aspect) are predominantly favourable, they do indicate that about 10 to 30% of the respondents arc dissatisfied with the various items relating to the

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conduct/humanness of the doctors. When these responses were subjected to further analysis (cross tabulation and significant test), the results indicate that the observed variations in all the responses with respect to sex and educational background were however not statistically significant. In other words, the observed variations in the respondents' degree of satisfaction with the conduct/humanness of the doctors were not due to differences in sex or educational background. This was also found to be true for the responses to five of the items with respect to age. the exceptions were the two items relating to information; the extent to which you can ask the doctor questions about your health and the amount of information given to you by the doctor concerning your medical problems. The observed variations to these two items with respect to age were found to be statistically significant at P = 0.05. The data in table 2 below strongly indicate that the majority of the respondents are dissatisfied with the behaviour of the nurses in the public hospitals/clinics with as high as 70% expressing dissatisfaction with the courteous treatment by the nurses. The data is also supported by the fact that this aspect of medical care attracted the most unfavourable comments where the respondents were specifically asked to report on any bad experience or where they were asked to list and comment on the aspect of care they were most dissatisfied with. Many of the respondents complained about rudeness and/or uncaring attitude of the nurses. Further analysis (cross tabulation and significance test) of the responses showed that the observed variations in the degree of satisfaction were not due to differences in sex, age or educational background of the respondents but may be due to other variables not considered in the study.

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Table 2 SUMMARY OF THE DISTRIBUTION OF RESPONSES TO THE ITEMS RELATING TO COURTESY, EMPATHY AND ADEQUACY OF INFORMATION GIVEN BY THE NURSES Item No 13. 4. 12. 21. 22. 23. Item content Amount of courtesy shown by the nurses Length of waiting time for doctor Continuity of care Length of waiting time for drugs Comfort of the waiting rooms Other patients seen at the hospital/clinic general cleanness of hospital/clinics Frequency Distribution (%) satisfied No Opinion 21.7 15.4 21.1 31.4 30.9 8.0 4.0 13.7 7.4 11.4 Dissatisfied 70.3 80.6 65.2 61.2 57.7

51.4

8.6

40.0

Source: Questionnaire As can be seen from the table, an overwhelming 80% of the respondents expressed dissatisfaction with the length of waiting time for doctor. Other items where majority of the respondents expressed dissatisfaction include continuity of care i.e. the fact that one has to see a completely different doctor with each visit (65.2%), length of waiting time I for drugs (57.7%) and ability to get medical care in emergency (55.4%). Even with the other items, the proportion of dissatisfaction range from 23% for convenience of operating hours to 40% for cleanliness of care

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Patient Satisfaction and Medical Care

environment and other people seen at the hospital/clinic. Further analysis of the responses showed that the observed variations in the degree of satisfaction were not die to differences in age, sex or educational background of the respondents. An exception was with the item on comfort of the waiting rooms where the observed variations in the responses with respect to sex was found to be statistically significant at P = 0.05. The frequency distribution analysis of the responses to the overall appraisal of medical care showed that 30.3% of the respondents were satisfied, 8.6% had no opinion while 61.1% of them were dissatisfied with the totality of the services. Of the latter group, 9.7% of them claimed to be completely dissatisfied. This result is consistent with the other findings relating to specific aspects of care. No significant difference could be found in the responses with respect to sex, age or educational background. Analysis of the result of the items that prove the respondents personal experiences at the public hospital/clinics revealed that 61.7% of the respondents felt that it was not easier to go to the drug store than to bother with a doctor while 38.3% of them felt that it was. This result is consistent with the earlier favourable assessment of doctors. 56% of the respondents felt that the doctors or the other people working, in the hospital did not care about them while 44% felt otherwise. This result is still consistent considering the highly unfavourable assessment of the nurses. A good majority i.e. 76% of the respondents felt that they would rather be attending private hospital/clinics if they had the money to pay the bills. It is interesting to note that: (1) Despite the amount of medical care in the public hospitals/clinics, as many as 24% still prefer their services. Reasons given by the respondents for this preference include the wider range of specialty and expertise possesses by the most of the public hospitals, the range of equipment/facilities available that makes for better quality of

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care especially in situations calling for specialised diagnosis treatment and follow-up and the fact that medical care is relatively care; (2) Of the 30% of the respondents who are satisfied with the overall services, only 24% of them would like to continue with their service if they had money. It does imply that the economic factor plays a very important role in the amount of patronage the public medical institution have at present. Some more support for the attitudes expressed in relation to the specific satisfaction items could be found in the comments made by the respondents in the openended section of the questionnaire. The doctors were constantly mentioned as one of the aspects of satisfaction and comments included their willingness to listen to patients, proper attention to patients, encouraging attitude of the doctors. . Other aspects of satisfaction mentioned by the respondents include the affordability of medical care and the operating hours of the hospitals/clinics. The nurses attracted the most unfavourable comments. Respondents described the general attitude of the nurses to patients as 'rude' unfriendly', uncaring, 'not kind' and use of abusive language on patients. Other items of dissatisfaction frequently mentioned by the respondents include general laxity of all health workers to emergencies causing unnecessary delays that sometimes result in loss of life; unavailability of drugs at the hospital pharmacy; too many patients to a doctor; length of waiting time for all the services and unclean environment of the places of care especially lack of good toilet facilities. DISCUSSION The findings contrast strongly with those of the satisfaction studies carried out in developed countries where the majority of consumers are usually satisfied with the quality of health cae and probably because of the number of dissatisfaction elements are minimal. They also contrast

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with studies which have suggested that other factors may not be as important as the why a patient feels about his doctor and the assertion that the degree to which a patient believes the doctor cares about him may well be the most important elements in determining compliance and satisfaction/Harper 1976). The findings are not however, surprising considering the deplorable state of health care delivery system in Kwara State in particular and Nigeria in general. Most of the areas causing dissatisfaction are in one way or the other related to the inadequacies of the health system. The length of waiting time for services for instance, is. directly related to the disproportionate number of patients, pharmacists and other health workers and the dissatisfaction with communication with the pharmacy staff could be related to the fact that the staff are forced to give less than adequate attention to each patient because by the great number of patients they have to attend to. We would like to quote some of the respondents to support these: "patients' time care being wasted at all the stages of treatment, hospital staff are not enough particularly the professionals'. There are not enough doctors to attend to patients. Many patients 'wait for long time before seeing a doctor. The dissatisfaction would be minimised if only the government can increase the number of staff especially the doctors in various department because of the number of some people'. Other inadequacies like the non-availability and prices of drugs and the comfort of the writing rooms also reflect the inadequate allocation of funds to the health care sector. The animosity against the behaviour of the nurses is so strong and we quote some of the respondents in this regard. It is no easy thing seeing the doctor but once he comes he gives you full attention, however the reception that one receives from the nurses and other para-medical staff are

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always terrible. The attitude of the nurses towards the patients are not encouraging because sympathy counts most with patients'... The attitude of the nurses are inexplicable and against their professional ethics especially considering the fact that the profession is known for empathy and companion for the sick. This non-professional attitude together with the uncaring attitude of all the health workers impacts significantly on patients' satisfaction and supports our earlier assertion that many of the government owned service institutions are not customerfocused. The number of dissatisfied respondents to emergency care is a strong indication that emergencies are not given the prompt attention they deserve. Some of the respondents' comments in this regard offer some insight into the reasons for the delays. 'Emergency cases, I strongly believe that anything emergency should be treated with quick and urgent action. In most cases, the doctors and nurses are too far to attend to all the cases'. .......in the case of emergency, they will ask you and as a result life may be lost' in case of emergency treatment like accident-victims, it is somehow delayed till the dying point of the patients unless the patients are part of the important or sick people in the state'. From the comments quoted above it can be deduced that the reasons why emergencies are not promptly attended to include: inadequate number of health personnel to attend to patients hospital/government policies regarding settlement of bills and accident victims. the social factor. The social status plays an important role in patients getting the prompt services they deserve. With regard to the cleanness of the care environment, respondents specifically reported lack of good toilet facilities for the patients. This reflects laxity on the part of the hospital workers and administration.

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CONCLUSION This research work has given us an insight into the operations of our public health institutions particularly those areas affecting utilization of health services, and the interaction between the health workers, the environment of service and the consumers of medical care. Results indicate that inspite of poor funding, inadequate infrastructure and overwork, the performance of the doctors in the public hospitals/clinics was satisfactory and confidence the consumers had in them was equally satisfactory. The attitude of nurses to work and the way they relate to patients have continued to agitate the minds of the users of our public health institutions. The results of this research have merely confirmed what people have been saying about the nonchalant and non-professional attitude of the nurses. Other areas of concern are the length of waiting time for services, the environment of health care delivery, the non-availability of drugs and their prices and the idea of seeing a completely different doctor on each visit. The above indicate that a lot of work has to be done by the government and related agencies to re-orientate the nurses, create a clean and conducive environment for servuction and made drugs available at affordable costs. All these will help to improve the image of our public health institutions and patients satisfaction.

J. O. Olujide Mr. A. L. Badmus 83 REFERENCES 1. Carstairs, V: 'Channels of Communication', Scottish Health Service Studies No. 11, 1972. 2. Cartwright, A: Human Relations and Hospital Care Rutledge and Kegan Paul, London 1964; Patients and Their Doctors, Routledge and kegan Faul, London, 1967. 3. Churchill, G.A. Jnr. and Supremant, C: An Investigation into the Determinants of Customer Satisfaction,' Journal of Marketing Research XIX, 491,1992. 4. Darby. M.R. and Karni, E.; Tree competition and the Optional Amount of Fraud', Journal of Law and Economics, 16, 67-86, 1973. 5. Eigher, F. and Langeard E: The Service Offering - Concepts and Decisions. 6. Friedson, E.: Patients Views of Medical Practice. The Modern Hospital, 89, 88, 1992. 7. Haynes, R.B.: A critical Review of the Determinants of Patient compliance with Thercepeutic Regimens (Edited by Sackett, D.L. and Haynes, R.B) F. 26. The John Hopkins, University Press Baltimore, 1976. 8. Hanley, B. and Davis, M.S., 'Satisfaction and Dissatisfaction": A study of the chronically Ill-aged Patients', J. Hilt. Sc. behaviour, 8,165,1967. 9. Hulka, B.J. Zyzansi, S.J., Cassell, J.C. and Thompson, S.J., Scale for the measurement of attitudes towards physicians and medical care, Med. Care 8,429,1970. 10.Satisfaction with medical Care in a low income population, Journal of Chronical Diseases, 24,661,1971. 11. Kinley, J. Bradshaw and Ley, F. Patients and Satisfaction and reported acceptance of advice in general practice. JOR, Coll. Gen. Practice 25,558,1975. 12. Korsch, B. Gozzi, E. and Francis. V. Gaps in doctor - Patient communication and patient satisfaction, Pediatrics 42,855,1968.

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