PATIENT SATISFACTION WITH HEALTH SERVICES AT THE
OUTPATIENT DEPARTMENT OF INDIRA GANDHI MEMORIAL
HOSPITAL, MALE’ MALDIVES.
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF PRIMARY HEALTH CARE MANAGEMENT
FACULTY OF GRADUATE STUDIES
COPYRIGHT OF MAHIDOL UNIVERSITY
This thesis would not have been possible without the help and support of
I express my deep sincere of gratitude to Associated Professor Jiraporn
Chompikul, my major advisor, who offers me her endless support and remarkable
kindness from the beginning until the completion of my thesis. I also would like to
express my sincere thanks to my co-advisor, Associated Professor Sirikul Isaranurug,
for her constructive comments and suggestions.
I would like to acknowledge and pay my special thanks to Ministry of Health
Maldives for offering me this scholarship.
My special thanks go to my sponsor, World Health Organization (WHO) for
giving me this great opportunity to achieve my goals from this MPHM course and
gain precious experience from here. I would never forget endless support given by
MPHM staffs working in this institute, especially Ms. Sirilak Leyeskul and her
I eager to say “Thank you very much” to my all classmates who always inspire
me, especially Dr In Sokhanya and Dr. Kazi Asadur Rahman. Without your help I
might not be successful to achieve this.
I would also like to express my thanks to three Senior Staff Nurses who
participated in the process of data collection and give their valuable time to complete
the process with limited time. I thank to all my friends in Indira Gandhi Memorial
Hospital (IGMH) for encouraging me during data collection.
Lastly of all, I would like to thanks to my devoted husband and beloved
mother, brothers and sisters for their encouragement and support to make this
Fac. of Grad. Studies, Mahidol Univ. Thesis / iv
PATIENT SATISFACTION WITH HEALTH SERVICES AT THE OUTPATIENT
DEPARTMENT OF INDIRA GANDHI MEMEORIAL HOSPITAL, MALE’
ASMA IBRAHIM 5037998 ADPM/M
M.P.H.M (PRIMARY HEALTH CARE MANGEMENT)
THESIS ADVISORS: JIRAPORN CHOMPIKUL, Ph.D., SIRIKUL ISARANURUG,
M.D., Dip. Thai Board of Pediatrics
A cross-sectional study was conducted on patient satisfaction with health
services at the outpatient department of Indira Gandhi Memorial Hospital, Male’
Maldives, with the aim determining the relationship between satisfaction and
explanatory factors. Suggestions and comments from the patients were also revealed
in this study.
Using a structured questionnaire, data were derived from 251 patients using
the OPD services. Descriptive statistics were used to describe satisfaction level and
independent variables while the relationships between these factors were determined
by Chi-square test.
The average score of patient satisfaction was 3.5 and 10.4% of the patients
were highly satisfied with health services. Patients were highly satisfied with courtesy
(45.8%), quality of care (44.2%), physical environment (41.8%), convenience
(24.7%), and out of pocket cost (23.5%). Regarding predisposing factors, attitude
were significantly associated with level of satisfaction (p=0.002). The majority of the
patients was concerned about waiting time to seek a doctor’s service and counter
services are being delayed due to not enough staff being available.
Strategies emphasizing improving the image of the hospital should be
continuously implemented while the attitude of the patients could change with good
reputation of hospital. Patient satisfaction surveys can be conducted in each unit to get
the real picture for further strategies.
KEY WORDS: PATIENT SATISFACTION / OUTPATINET DEPARTEMNT /
LIST OF TABLES.................................................................................................. vii
LIST OF FIGURES................................................................................................ viii
LIST OF ABBREVIATIONS................................................................................ ix
1.1 Rationale and Justification....................................................................... 1
1.2 Research Questions.................................................................................. 4
1.3 Research Objectives…………………………………………................ 4
1.4 Conceptual framework............................................................................ 5
1.5 Operational definition of study variables................................................ 7
1.6 Limitation of the study............................................................................. 10
2 LITERATURE REVIEW
2.1 Patient satisfaction …………………………………………................. 11
2.2 Theoretical model................................................................................... 14
2.3 Factors related to satisfaction................................................................ 17
2.4 Health services in the Maldives............................................................ 18
3 RESEARCH METHODOLOGY
3.1 Research design..................................................................................... 22
3.2 Study site............................................................................................... 22
3.3 Study population................................................................................... 22
3.4 Sample size determination.................................................................... 23
3.5 Sampling technique.............................................................................. 24
3.6 Data collection tools............................................................................. 25
3.7 Pre-test................................................................................................. 29
3.8 Data collection procedure.................................................................... 30
3.9 Data analysis ....................................................................................... 30
3.10 Ethical consideration........................................................................... 31
4.1 Socio-demographic characteristics of the patients............................... 32
4.2 Expectation towards health services at OPD....................................... 36
4.3 Patient attitude towards health services at the OPD............................ 36
4.4 Patient satisfaction towards health services at OPD............................ 37
4.5 Association between independent and dependent variables................ 39
4.6 Patient’s comments and suggestion...................................................... 43
5.1 Methodological concern....................................................................... 45
5.2 Patient satisfaction towards health services of IGMH
5.3 Socio-demographical factors……………………………................... 48
5.4 Patient attitude towards health services of IGM hospital ................... 50
5.5 Patient expectation towards health services of IGMH
hospital ……………………………………………….....….............. 51
5.6 Comments and suggestions from the patients…………….................. 51
6 CONCLUSION AND RECOMMENDATION
6.1 Conclusion............................................................................................ 54
6.2 Recommendations............................................................................... 56
LIST OF TABLES
1 Total number of patients per day in each unit…………………………………… 24
2 Measurement and classification of variables …………………………………… 28
3 Socio-demographic characteristic of the patients ………………………………. 34
4 Overall expectation of patient towards health services at the OPD
of IGM hospital ………………………………………………………………… 36
5 Overall attitudes of the patients towards health services at the IGM hospital…... 37
6 Number and percentage of patients by overall satisfaction for each component... 38
7 Overall satisfactions towards health services at OPD…………………………... 39
8 Association between attitude and satisfaction …………………………………. 40
9 Association between expectation and satisfaction …………………………….. 40
10 Association between satisfaction and socio-demographic factors …………….. 42
11 Patient’s comments and suggestion for improving the quality of health
services at the OPD of IGM hospital..................................................................... 44
12 Frequency and percentage of patient’s attitude towards health services at OPD of
IGM hospital by item of question…………………………………………….…. 70
13 Frequency and percentage of the patients expectation towards health services at
OPD of IGM hospital ………………………………………………………..…. 71
14 Frequency and percentage of the patients satisfaction towards health services at
OPD of IGM hospital ………………………………………………………….. 72
15 Frequency and percentage of overall patient’s satisfaction with 75 cut-off
LIST OF FIGURES
1 Conceptual framework................................................................................. 6
2 Andersen’s behavioral model...................................................................... 16
3 Service system of OPD............................................................................... 21
LIST OF ABBREVIATIONS
ANC : Antenatal Care
CI : Class interval
ENT : Ear Nose and Throat
ICCU : Intensive Coronary Care Unit
IGMH : Indira Gandhi Memorial Hospital.
NTC : National Thalassemia Center.
OPD : Out Patient Department.
PNC : Postnatal Care
STO : State Trading Organization
TBA : Traditional Birth Attendance.
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 1
1.1 Rationale and justification
For every hospital, patients are the main users. The primary function of the
hospital is patient care. It is one of the yardsticks to measure the success of services
that it produces. Effectiveness of the hospital relates to provision of good patient care
as intended. According to Swamy (1975) patient satisfaction is the real testimony to
the efficiency of hospital administration. As the hospital serves all the members of the
society, the expectations of the users differ from one individual to another individual
because everyone carries a particular set of thoughts, feelings and needs. Hence
determination of patient’s real feelings is very difficult. It is the responsibility of the
administrator team. "Put yourself in your patient's shoes," was a proverb that explains
how to proceed with a patient (1).
Consumer satisfaction is generally defined as the consumer’s view of services
received and the results of the treatment. It has been used by program evaluators to
enhance health care providers’ ability to render services that meet consumers need
(2). Society now acknowledges the importance of the views of users in developing
services, and the healthcare sector has used a range of methods to identify the views
of patients and the public (3). Dansky and Miles (1997) state that from a management
perspective, client satisfaction with health care is important for various reasons. First,
satisfied patients are more likely to maintain a consistent relationship with a specific
provider. Second, by identifying sources of patient satisfaction, an organization can
address system weakness, thus improving its risk management. Third, satisfied
patients are more likely to follow specific medical regimens and treatment plans.
Finally, patient satisfaction measurement adds important information on system
performance, thus contributing to the organization’s total quality management (4).
Asma Ibrahim Introduction / 2
Research on patient satisfaction with medical care can be traced back to the
late 1960s. Over 40 years, an overwhelming number of publications on the topic have
appeared. At first, research focused on patient satisfaction as a condition to be
satisfied in order to reach desirable clinical outcomes, such as appointment keeping or
compliance with recommended treatment. Gradually, interest shifted to patient
satisfaction as a dependent variable. Nowadays, hardly any hospital will fail to
incorporate in-patient satisfaction rating into their evaluation of care (5).
According to the South African Black Population study 76% rely on public
hospitals and the facilities are overcrowded, understaffed and under resourced,
contributing to waiting time of more than 1 hour to see a health provider (6). Thomas
et al investigated patient satisfaction in a oncology outpatient clinic in Middlesex
University in Enfield UK and reported that out of 252 patients 92% were "always" or
"usually" reassured as a consequence of their visit. This study also confirmed the fact
that clinical staffs are one of the most important sources of satisfaction. Similar Italian
and British studies also reported strong and weak points of their services that were
brought out by patient satisfaction surveys and took measures to rectify the problem
areas. The health care system is basically a service based industry and customer
satisfaction is of utmost importance just as in other service-oriented sectors (7).
Maldives is a developing country and most efforts in health services seek to
provide basic health care needs to all citizens adequately and equally. There was a
paucity of reliable and valid satisfaction measures. In addition, no studies have
investigated the relationship between the component of patient satisfaction and health
status. The Indira Gandhi Memorial Hospital serves as the major tertiary referral
hospital. It also serves as the focal point for entry to health service for the people of
the whole country. This hospital is situated in Male, the capital of Maldives. The
hospital, with its wide ranging departments and modern diagnostic facilities, are
manned by qualified and experienced medical personnel. The IGMH policy is to
deliver an affordable and wide-ranging health care service to Maldivians. To achieve
this IGMH has been conducting several methods to enhance their services; however
they need to go through a long path to reach the goal. The customer image of the
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 3
hospital still desired better quality of services appropriately throughout whole
country. OPD problems like overcrowding, delay in consultation, lack of proper
guidance and many others lead to patient dissatisfaction. Some departments had
conducted client satisfaction and comments surveys. According to the statistics of
Maldives, no standard survey has been conducted in IGMH in terms of patient
satisfaction. The reason to choose OPD for this study was that IGMH provides
services to the whole country. It is often called shop window that leads to glide in
both new and old patient, which hold back the long run sustainability of any hospital.
The government considers that the enjoyment of the highest attainable level of
health is a basic right of every citizen. The mission is to protect the health of the
people and supportive environment for health and provide preventive, curative and
rehabilitative services through an affordable and accessible health system. Health
care has been changing over the years. The objectives of health care changed with the
requirements of society and the availability of resources and technology. The WHO
Alma Ata conference on supporting Health for All, held in 1990, defined future
development in health to be human centered (8).
It is now a global trend in healthcare development toward integrating
subjective user satisfaction into the evaluation of medical service quality (9). Most
countries are focusing their attention on the cost and access to health care because it
needs to be distributed appropriately and equitably (10). Consumer expectations have
grown proportionately with the rising wealth of the population, resulting in strong
societal pressure to adopt policies on satisfying consumer expectations (11). Medical
care aims not only to improve health status but also to respond to patient needs and
wishes and to ensure their satisfaction with care (12). Patient satisfaction surveys are
an instrument in monitoring hospital’s quality of care relation to cost and services. It
is a significant indictor of quality of care. To evaluate and improve the quality of care
provided, it is of vital importance to investigate the quality of care in the context of
health care. Satisfaction might be influenced by socio-economic factors, accessibility
to the services and the experience towards the health services (13).
Asma Ibrahim Introduction / 4
IGMH is a government hospital which covers total male population in the
nearby islands and referrals throughout the country. Out of a total 156 doctors
throughout the country, 89 are specialists. There are 442 nurses who include ward,
staff, specialized and assistant nurses. The IGMH capacity is 236 beds with one
Operation Theater, one Intensive Coronary Care Unit (ICCU), one labor room, one
scan room, one X-ray department and CT scan room. In- patients are admitted in 5
main wards namely, Gynecological, medical, surgical, ENT (Ear, Nose & Throat),
Eye & Orthopedic in one ward, pediatric ward and also 5 private wards. There are 9
rooms in each private ward.
In this patient satisfaction study the researcher aimed to determine the patient
satisfaction with OPD services at IGMH. Patient satisfaction included 5 subscales:
convenience, courtesy, quality of care, out of pocket cost and physical environment.
They are indicators of how the patients are satisfied with services. Other than this,
independent variables such as predisposing factors (age, sex, marital status, education
level, occupation and attitude) enabling factors (family income and health insurance)
and need factors (health problems and expectation) were determined for their
relationship to satisfaction with health care. In addition patient opinions and
suggestion on improvement from patients were analyzed thoroughly.
1.2 Research questions
1. What is the level of patient satisfaction towards health services at the
outpatient department of IGMH?
2. What are the factors related to patient satisfaction with health care
1.3 Research objectives
1.3.1 General objectives
To assess the satisfaction of patients who have utilized the OPD
services provided by IGMH and to identify factors related to patient’s satisfaction.
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 5
1.3.2 Specific objectives.
1. To assess the level of satisfaction with the services provided by the
2. To determine the relationship between socio-demographic factors
and the level of satisfaction.
3. To identify the relationship between patient’s attitude and the level
4. To find out the relationship between enabling factors and the
5. To determine the relationship between need factors towards the
services and the satisfaction level.
6. To describe the patients opinions and suggestion on improving the
services in the outpatient department at Indira Gandhi Memorial Hospital.
1.4 Conceptual framework
For this study, the conceptual framework was derived from Ronald M.
Andersen Behavioral Model. Andersen’s behavioral model organized an array of
correlates of health and health care behavior from the different literature in sociology,
psychology, economics and medicine into predisposing, enabling and need predictors
of families’ use of physician and hospital services. According to Andersen (1968) the
amount of health services used by a family will be a function of the predisposing and
enabling characteristics of the family and its need for medical care (14). These three
factors mentioned in Andersen’s model were used to plan the conceptual framework
for this research. (Details in chapter 2)
Asma Ibrahim Introduction / 6
Independent variables Dependent variable
- Marital status
- Education level
- Number of visits to hospital
Patient Satisfaction towards
health services at OPD
Enabling factors - Courtesy
- Family income - Quality of care
- Type of payment
- Out of pocket cost
- Physical environment
- Health problems
Figure 1 Conceptual framework
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 7
1.5 Operational definition of study variables
It refers to the patients’ value judgments and succeeding reactions to the
stimuli they perceive in the health environment just before, during, and after the
course of their clinical visit. The indicator for client’s satisfaction in this study
consists of convenience, courtesy, out of pocket cost, quality of care and physical
Convenience refers to the availability of health care provider and receiving the
services as wanted and willingness of providers.
Courtesy refers to the way providers express their respect and politeness shown to the
patients (e.g. doctors, nurse and pharmacy assistance and other health care personnel).
Quality of care refers to the superiority of care that patients perceive from doctors in
terms of knowledge and skills to diagnose and treatment and quality of equipment.
Out of pocket cost refers to the amount of money spend out of pocket for
registration, investigation and medication.
Physical environment refers to the features of the setting in which the health services
are provided. This includes pleasantness of atmosphere, clear sign and direction,
enough toilet and clean drinking water.
The answer of each question is measured by using Likert scales. In the present
study the answers are ranked in 5 scales as;
Very satisfied = 5, satisfied = 4, neutral = 3, dissatisfied = 2 and very dissatisfied =1.
The scores are summed and then divided into two groups.
Asma Ibrahim Introduction / 8
High satisfaction considered above 80% of total score and for low satisfaction
considered as equal or below to 80% of total score.
Age: is a real age of respondent up to birthday at the time of study. The age range is
16 -65 years. At 16 years is the secondary school leaving age and 65 years is the
retirement age, at these category respondents able to answer questions independently.
Age group will be divided in to three categories by using class interval:
- 16- 32 years
- 33- 49 years
- 50- 66 years
Gender: refers to the characteristics of the respondent as male and female.
Gender will be divided into two categories:
Marital status refers to the respondent was single, married, divorce/separated and
widowed. Marital status will be divided in to four categories:
Educational level refers to the highest level of educational background of the
respondent. Educational level will be divided in to six categories:
- No education –no formal education
- Primary school – from grade 1 to 7
- Secondary school – from grade 8 to 10
- Higher secondary school– from grade 11 to 12
- Higher education- from a college or university
Occupation refers to the main job of respondent to earn for his living. It will be
divided in to six categories:
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 9
- Civil servants
- Private sectors
Number of visit to hospital during last 6 months refers to the total number of visits
to the hospital by the patient during last 6 months. The respondent for this study have
been utilized the services more than once before 6 months. Therefore it was divided
into two groups. The cut-off point as > median and < median score. Median score
used because the data was not normally distributed.
Attitude refers it is a hypothetical construct that represents an individual's like or
dislike for an item. In this attitude meant as cognitive perception of a patients towards
services that they get from hospital. To measure attitude of the respondents a set of 5
questions would be asked. Whether they agree or disagree with the statement, Likert
scale was used as above;
Strongly agree = 5
Agree = 4
Not sure = 3
Disagree = 2
Strongly disagree = 1
Total score was computed and categorized as good fair and poor attitude.
Since the data was not normally distributed, percentile was used as a cut-off point to
categorize into three groups; good, fair and poor.
Family income refers to the respondent’s family income earned per month. (Nuclear
family) It was an open-ended question.
It was divided into 3 groups for data analysis by using class interval:
- 1000 – 17333 RF
- 17334 – 33667 RF
- 33668 – 50001 RF
Asma Ibrahim Introduction / 10
Type of payment refers how patient would pay for the health services. It was divided
into four categories; private scheme, government scheme, insurance schema and
Health problems refer to the general condition of the patient.
It was assessed by asking an open-ended question and identifies the present health
problem of the patient.
Expectation refers to the state of expecting or looking forward to an event at the
hospital. He or she might expect to get treatment as soon as possible without delay.
Expectation would be measured in terms of waiting time, quality of care and
accessibility of services with multiple choice questions. To know expectation of
patient 5 questions were asked and got mean score for each respondent to calculate
descriptive statistics to find percentile to categorize into three groups; high, medium
and low expectation.
1.6 Limitations of the study.
The main constrain was due to limited time to complete required sample size.
Ethical committee review took about 2-3 weeks to get permission. The planned
duration for data collection was 18 days, but due to limited time it has been changed
to 10 days.
When study was conducted hospital launched new software for registration.
The system got delayed and was not able to consult the doctors on time. Therefore
some patients went back home due to inconvenience on the first day that changed to
new system. The patients were not happy with new system and patient had gone
through many problems during that time. Some patients hesitate to answer the
questionnaire. Due to this the researcher was not able to collect data through
interviewer. Some doctors gave pre information about the survey so the researcher
gains more co-operations from the patients.
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 11
The literature review included the following topics:
- Patient satisfaction
1) Meaning and scope of satisfaction
2) Benefits of patient satisfaction
3) Measurement of satisfaction
- Theoretical model
- Factors related to satisfaction
- Health services in the Maldives
2.1 Patient satisfaction
2.1.1 Meaning and scope of satisfaction
Patient satisfaction was initially perceived as being related to issues
around access to medical infrastructure and nursing care (15).Patient satisfaction is
generally defined as the consumer's view of services received and the results of the
treatment. The importance of patient satisfaction has had a long history of debate,
beginning over two millenniums ago in ancient Rome. Plato suggested in a statement
that since the doctor "cuts us up, and orders us to bring him money...as if he were
exacting tribute...he should be put under rigid control," and that this could be done by
calling an assembly of the people and inviting opinions about "disease and how drugs
and surgical instruments should be applied to patients" (2). To evaluate and improve
the quality of care provided, it is vitally important to investigate the quality of care in
the context of health care. Patient satisfaction is a significant indicator of the quality
of care. Consequently, quality work includes investigations that map out patient
satisfaction with nursing care. To improve quality of nursing care, the nurse needs to
Asma Ibrahim Literature Review / 12
know that factors influence patient satisfaction (16). Fitzpatrick (1991) states that
since 1984 the objectives of the Australian federal evaluation policy have emphasized
efficiency, effectiveness and accountability. Patient satisfaction has been used as an
indicator of accountability. Satisfaction was seen, therefore, as a surrogate indicator
justifying and validating health care initiatives (17). Health care organizations are
operating in an extremely competitive environment, and patient satisfaction has
become a key indicator, gaining and maintaining market share. Without acceptable
levels of patient satisfaction, health plans may not get full accreditation and will lack
the competitive edge enjoyed by fully accredited plans (8). According to Jones (1978)
satisfaction surveys are the main sources of feedback from patients about the health
care services and as such they inform purchasing decisions, stimulate proposals to
restructure service delivery and can be used to evaluate the effects of policy change
2.1.2 Benefits of patient satisfaction
Patient satisfaction is important to the process of health care for a
number of reasons. Patients who are dissatisfied with their health care change health
care providers or "doctor shop" more frequently,
- more frequently disenroll from prepaid health plans,
- adhere less well to medical regimens prescribed by their doctors,
- and willingness to seek malpractice litigation (19).
According to the Fitzpatrick, (1990) satisfied patients are more likely to follow
planned care and make better use of health services. Therefore patient satisfaction
was seen, as a substitute indicator justifying and validating health care initiatives. And
also it has been used to evaluate patient controlled analgesia (18).
In August 2003, Press Ganey reported on one study of nearly 2 million patient
surveys- the largest study of patient satisfaction ever conducted. He stated that "…the
Baby Boom generation…as a whole is less satisfied than patients in the adjacent age
groups. Members of the Baby Boom generation have been described as distrustful of
institutions, more informed than others, and harder to please because of their high
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 13
expectations”. In fact, studies show that is likely already happening. The upshot is that
healthcare is, or soon will be, facing a market that has increasing choice and very
demanding expectations. It will pay healthcare marketers to sharpen their pencils
when it comes to creating satisfaction (20).
2.1.3 Measurement of satisfaction
Measuring patient satisfaction are being used as surrogate expressions of
is users’ preferences about the range and type of health services they want, as a way
of quantifying the quality of medical and nursing care as patient focused outcome
measures (18). An increased focus on enhancing relationships with patients can result
in a reduction in medical errors (21).
Lebow (1983) consider that all inquiries into both the felt adequacy of
treatment and of surrounding setting are specific aspects that may include reactions to
the quality of care, to its helpfulness, its cost and continuity, the availability and
accessibility of the practitioner, and the reaction to supporting services (17).
Rubin (1993) and Drain (2001) both concluded that patient satisfaction studies enable
patients to select health care clinicians, facilities or insurance plans: less satisfied
patients are more likely to seek health care elsewhere (18).
If receipt of care, guidance and support were to help patients make genuinely
informed choices about interventions, it would be likely to impact on operational
delivery of services. A study by James (1992) describes a nurse who worked
previously in an acute hospital setting and then moved to another job in hospice. Soon
after starting work in that hospital, the nurse described that she left her old job due to
busy routines which can get in the way of and undermine effective communication.
Hospitals were established in response to an identified need for environments better
suited for terminally ill patients, for whom palliative care rather than curative
treatment was appropriate (22). Communication between patients and practioner is a
central part of health care. Effective communication is essential, for practioners to
Asma Ibrahim Literature Review / 14
understand the nature of the disease and the way patient thinks about the illness.
Failure to communicate effectively leads to numerous adverse effects; including
patient not understand the test result and fails to reassurance (23).
- Quality of care
Hospitals are emphasizing enhanced quality of care along with the improvement
of technology. Researchers explained the quality of health services in seven factors.
They are efficiency, effectiveness, efficacy, optimality, legitimacy and equity.
Therefore adaptation of modern quality service from manufacturing and other
servicing industry has changed the situation of quality of care. The combination of
conventional and modern health care techniques had lead to the modern era of quality
health care management (24).Perhaps the most important lesson for physicians was to
take the time and effort to draw patients’ expectations. Stimson and Webb (1975)
suggest that satisfaction is related to the perception of the benefits of care and the
extent to which these are the patient’s expectations (25). When physicians recognize
and address patient expectations, satisfaction is higher not only for the physician; it
may help to remember that patients often show up at a visit desiring information more
than they desire a specific action (26).
- Out of pocket cost
The survey of seven countries conducted by the commonwealth fund shows
that Americans have the highest out-of-pocket coats and the most difficulty paying
medical bills. Even though they have the most expensive health-care system, they are
more likely to skip care because of cost and experience with medical errors. Patients
in Canada, the Netherlands, and the United Kingdom rarely reported not getting
needed medical care because of costs (27).
2.2 Theoretical model
In this study a theoretical framework for viewing health services utilization is
presented, emphasizing the importance of the:
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 15
- Characteristics of health services delivery system
- Changes in medical technology and social norms, treatment and illness
- Individual determinants of utilization.
These three factors are specified within the framework of impact on health care
Andersen’s behavioral model was used for the construction of the conceptual
framework for present study. The model has been used to display and test complex
causal models of health care-seeking behavior and to simply order any array the
relevant predictors and indicators of utilization.
Predisposing variables include those that describe the propensity of family members
to use services- including family composition such as age, gender and marital status.
Social structure includes education, employment, social class and ethnicity. Health
beliefs are attitudes, values, and knowledge that people have about health and health
services that might influence their succeeding perceptions of needs and use of health
resources. People who believe strongly in the value of health care or physicians might
be more likely to seek care than those who do not have these beliefs.
The enabling factors describe the means individuals have available to them for the
use of services.
- Resources specific- income, savings and health insurance.
- Community attributes- physician and hospital bad ratio, geographic location
and community attitude towards medical care.
Need factors to determine health status or cause of illness are the most immediate and
important causes of health use.
Among the predisposing characteristics, age and gender represents biological
imperatives suggesting the likelihood that people will need health care.
Asma Ibrahim Literature Review / 16
Social structures that determine the status of a person in the community, his or
her ability to cope with problem, (marital status education and occupation) included
only in the study.
Health beliefs are values of health services, physician and good health. They
provide one means of explaining how social structure might influence enabling
resources, perceived need, and subsequent use.
In enabling factors community resources are not included in this study because
it is not suitable for this setting.
Health problems and expectations will be measured by need factors. The need
for care may be based on the illness and response to seeing doctor or on regular
ANDERSEN’S BEHAVIORAL MODEL
PREDISPPOSING ENABLING NEED USE
Family composition Family resources Illness
Social structure Community resources Response
Figure 2 Andersen’s behavioral model (29).
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 17
2.3 Factors related to satisfaction
Aday and Anderson (1974) have suggested that perceptions of satisfaction are
the result of individual patient characteristics and of the medical care systems they
enter. Often service recipient characteristics have been studied such as age, race, and
education (16). The ability to cope with presenting problems and commanding
resources to deal with the problems, social structures were measured by a broad range
of factors that determine the status of a person in the community. In these measures,
used to assess the social structure include education, occupation, ethnicity, social
network, social interaction, and culture (30).
Age- the most consistent finding has been related to age. Older patients tend to be
more satisfied with their health services.
Gender- studies on the effect of gender are contradictory, with some studies showing
that women tend to be less satisfied and other studies showing opposite.
Socio- economic status- most studies have found that individuals of lower socio-
economic status and less educated tends to be less satisfied with their health.
Health problem- results from previous studies on the relationship between health
status and patient satisfaction have found that patients in better health tend to report
greater satisfaction with health care than patients in poor health (31).
Socio-demographic variables are related to all kinds of health care experiences
that patients have, and the way they understand them. Those people who are educated
will be involved in their treatment and diagnosis more than less educated people who
will remain less satisfied with the services. Therefore sometimes it is difficult to
interpret findings of relationship between socio-demographic and satisfaction (32).
An essential element of any policy aimed at encouraging choice is the provision of
help with transport and travel costs. Adequate transport represents an essential and
fundamental element of improving access to health services. Ware (1978) mentioned
that dimensions of patient satisfaction include art of care; technical quality of care,
accessibility, finances, physical environment, availability, continuity, and
efficacy/outcomes of care (33). A study in Scotland investigates the patient
Asma Ibrahim Literature Review / 18
satisfaction of pharmacy services provided to oncology outpatients. Issues identified
from the interviews included frustration with waiting time for medicines,
communication and information needs. The perception of waiting for medicine was
a source of dissatisfaction (16).
2.4 Health services in the Maldives
The Republic of Maldives is an archipelagos nation situated on the equator at
approximately 7° North 0° South latitudes and between 72° to 73° Eastern longitudes.
It consists of 1,190 low lying garland islands naturally divided into 26 atolls that
stretch 820 kilometers from north to south and 120 kilometers from east to west.
Although the country has a large number of islands, only 194 are inhabited and are
divided into 20 administrative Atolls, each locally administering a group of islands.
The total population of Maldives was 298,968 with 151,459 males and 147,509
females in 2006. Male’, has a population of 103,693 with 51,992 males and 51,701
females. They are served by IGMH and referrals from around the country. The Male’
was divided in to 4 wards: Maafannu, Henveyru, Galolhu and Machangoalhi.
Organization of the health system
Health services in Maldives are organized into a four-tiered system comprising
central, regional, atoll and island levels. However, with the expansion of health
services, atoll hospitals are being established, beginning in 2001, changing the system
to a 5-tier system. At the top of this pyramid is the Ministry Of Health, under which
are the Department of Public Health, IGMH, National Thalassaemia Centre (NTC),
Maldives Water and Sanitation Authority, Department of Medical Services, Maldives
Food and Drugs Authority and Atoll Hospitals. At the regional level are 5 regional
hospitals, each catering to 2-5 atolls. At the Atoll level are the atoll health centers
staffed by doctors and community health workers. Some of these Atoll Hospitals have
recently been upgraded as atoll hospitals in order to provide emergency Surgical and
Obstratic facilities. An upgrading program is currently underway to provide inpatient
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 19
and enhanced maternal health care services. At island level, health services are
provided by family health workers and Traditional Birth Attendance (TBAs).
In Male’ other than IGMH there is one private hospital and a few private
clinics. ADK Hospital is one of the largest private healthcare organizations in the
Maldives. It's a fifty (50) bed private tertiary acute care hospital, providing a wide
range of medical and surgical services for the total management of patients located in
Male'. In addition to the hospitals in Male', there are four regional hospitals located in
the north, south and the central regions of the country. These hospitals play a major
role in extending the quality of health services to the rural population. The four
regional hospitals are in Addu Atoll – Hithadhoo (southern atolls), Haa Dhaalu
Kulhuduffushi, Raa Atoll Ungoofaaru (northern atolls) and Meemu Atoll Muli
(central atolls). The regional hospitals provide secondary health services as well as
some specialist care. By the end of 1996, the four hospitals had a total bed capacity of
125 and have 34 doctors and 107 nurses.
Tertiary level curative services are provided by the IGMH, established in
1995. It is a 236-bed tertiary care general and specialty hospital. It is the highest
referral center in the country, providing the necessary services to the people as well as
providing to the needs of the rest of the health facilities including the Regional and
Atoll Health Centers. The outpatient department is the most important department
which deals with day to day patients, most of whom do not required admission for
treatment. The OPD is normally open from 09:00am to 6:00pm on all days except
Friday and public holidays. Whenever a holiday extends more than 2 days, then the
OPD services are provided on the third day.
Health education information is provided and the close circuit television
provides updated hospital information, health massages and entertainment. The heart
of the OPD is the reception and the cash counter that makes consultation memos for
appointments provides information and direct enquires. Patients can make an
appointment for the desired doctor two days in advance.
Asma Ibrahim Literature Review / 20
At present the IGMH OPD provides care for the following areas: Internal
Medicine, Surgery, Gynecology, Ear-Nose-Throat, Dermatology, Ophthalmology,
Orthopedics, Urology, Neurology, Pediatrics, Psychiatry, Gastroentrolology, Diabetic
clinic, Dental, Nutrition and Dietary and Antenatal and Postnatal care.
Casualty department is a special clinic which provides health care to patient
who needs both urgent and immediate medical attention. Medical staff are supported
by an observation room, a Blood bank and Labour Room provides 24-hours service.
The STO, (State Trading Organization) pharmacy within the hospital provides 24
hours service. Other than STO pharmacy one more pharmacy provides services during
official hours in OPD.
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 21
Service System at Outpatient Department in IGMH.
Cardiology Pediatrics Dermatology Neurology Psychiatry
OPD OPD OPD OPD OPD
Medical COUNTER OPD
Ophthalmology Nutrition and Orthopedic
OPD Dietary OPD OPD
Tablet Pharmacy STO pharmacy
Patients go home
Figure 3 Service system of OPD
Asma Ibrahim Methodology / 22
3.1 Research design
This study was a cross sectional study.
3.2 Study site
Indira Gandhi Memorial Hospital was selected as the study site. It was the
main hospital in the Maldives. The study was based on the patient who utilizing the
general services at OPD.
3.3 Study population
The study population consisted of patients aged from 16 - 65 years who got
services at the general OPD section in IGMH, from 21st to 31st of January in 2008.
3.3.1 Inclusion criteria
1. The OPD patients of the general OPD, and age from 16 to 65 years.
2. Willing to provide the answer to study interviewers.
3. Patients who have made at least 1 visit (including the present visit)
3.3.2 Exclusion criteria
1. Patients cannot speak (mute) or listen (deaf).
2. Patients were in the serious condition.
3. Patients have a mental health problem
4. Patients from Pediatric, Psychiatric, Dental, Antenatal care (ANC)
& postnatal care (PNC) units were not included in this study. The
location and service system are different from other units in OPD.
Even though registration are done by same counter with other units.
Pediatric unit were not included, because the age range is from 16 -
Fac. of Grad. Studies Mahidol Univ. M.P.H.M. (PHC Management) / 23
65 years and are not able to answer questionnaire
independently.Psychiatry unit was not included because they were
also not able to answer questionnaire due to suffering from mental
disorders. Dental department was separately provided services as
different department in the hospital. ANC & PNC clinic are also
separately giving services especially for antenatal and post
antenatal patients only.
3.4 Sample size determination
Sample size of the patients was determined by using the following statistical
Z 2 PQ
Where, n = estimated sample size
Z = z – score, z =1.96 at 95% confidence interval.
P = Proportion in the population possessing the characteristics of interest,
which is the satisfaction with health services. Since there was no previous
study the researcher used P= 0.5 to gain maximum sample size.
Q = 1-P (1- 0.5 = 0.5)
d = degree of accuracy desired setting at 0.065
(1.96) 2 (0.5)(0.5)
So, n= = 228
The sample required for this study was at least 228. When 10% for missing
was taken into consideration, the required sample for this study was 251 patients.
Asma Ibrahim Methodology / 24
3.5 Sampling Technique
Stratified sampling was applied to draw the patients in order to get information
about the OPD units mentioned in this study. In this type of sampling technique the
researcher identifies the relevant stratums and their actual representation in the
population. Random sampling was then used to select a sufficient number of subjects
from each unit (stratum). Population was stratified into 10 units of services as shown
in Table 1. Then Random sampling was used to select the sufficient number from
each stratum to determine the actual number of the samples per day.
Proportionate size was applied to represent the patients from each unit.
Table 1 Total number of patients per day in each unit (10 days planned for data
UNITS Total no. of Average no. of Estimate no. of Proportionate Average no. of
tokens/ consultation / consultation size/ unit patient/day/
day/unit day/ unit (10 days) unit
Internal medicine 180 68 680 36 4
Surgery 75 57 570 30 3
Gynecology 132 39 390 21 3
Ear-Nose-Throat 75 75 750 39 4
Dermatology 90 70 700 37 4
Ophthalmology 70 40 400 21 3
Orthopedics 102 71 710 37 4
Urology 50 49 490 26 3
Neurology 20 6 60 3 1
Nutrition /Dietary 10 2 20 1 1
TOTAL 804 477 4230 251
Source: Indira Gandhi Memorial Hospital, Male, Rep of Maldives.
*Data collection planned for two weeks excluding Fridays. Therefore data will be
collected over a period of 10 days.
*Appointment made one day prior to consultation. List of names of all patients would
get before in hand.
Fac. of Grad. Studies Mahidol Univ. M.P.H.M. (PHC Management) / 25
3.6 Data collection tools
The research instrument planned for this study was a structured questionnaire.
The questionnaire was divided in to five parts;
I – Socio-demographic factors
II – Expectation towards services
III – Attitude towards services
IV – Patient satisfaction towards health services at OPD.
V – Suggestion and comments from the respondent regarding
the services of IGMH.
Part I. Socio-demographic factors
This part describes about the age, gender, education, occupation, monthly
family income (immediate), number of visit to hospital, type of payment for this visit
and the present health problem. The age has been categorized in to three groups (16-
32, 33-49, and 50-66). The marital status has been categorized in to four groups
(single, divorced/separated, married and widowed). The education level has been
categorized into seven groups (no education, literate, primary school, secondary
school, higher secondary school, higher education (diploma and degree) and others.
The occupation has been categorized into six groups (civil servants, private sectors,
self-employed, unemployed, student and others (religious schools and classes). The
family income has been categorized into three groups (1000 – 17,333), (17,334 –
33,667) and (33,668 – 50,001). The number of visits during last six month was
categorized into two groups by using median score. (≤median and > median) The type
of payment for this visit has been categorized in to four groups (private scheme,
government scheme, insurance scheme and others).
Health problem was an open ended question, and classified into 15 sub groups
to analyze the health problems.
Asma Ibrahim Methodology / 26
Part II. Expectation towards health services
In this expectation parts oriented by questions on total cost out of pocket
(payment for registration, laboratory and medication). The option given for this
question has been the cost out of pocket might not be affordable as “1” and the cost
out of pocket might be affordable as “2” , cost out of pocket might be enough to
cover for this visit as “3” and last option were don’t have expectation as missing
value. Patients who did not have any expectation were not included in the analysis for
that question of expectation variable. (Entered * for Minitab software)
Next question was about expectation towards the quality of care (quality of
instrument and service providers), the option given for this part was quality of care
will not be good as “1” ,quality of care will be acceptable as “2” and quality of care
will be excellent “3”, and last were don’t have any expectation as missing value.
Then about waiting time the option was waiting time will be long “1” and
waiting time will be acceptable “2”, and waiting time will be short “3”, and missing
value as don’t have any expectation.
Then about hospital environment (cleanliness, ventilation and health
messages), the option was surrounding will not be good “1”, surrounding might be
acceptable “2” and surrounding might be excellent “3” and missing value as don’t
have any expectation.
In the last expectation question were asked about information acquired from
doctors concerning illness. The option given for this was that any useful information
might not be obtained “1”, that some of useful information might be obtained as “2”
and that lots of useful information might be obtained as “3” and missing value as
don’t have any expectation.
The total score was 15 for 5 questions. The mean score was calculated for
each respondent since the number of answers varies according to the type of
questions. Then the quartile was used as a cut-off point. The expectation part was
classified into three levels: high, moderate and low. The high level was considered as
Fac. of Grad. Studies Mahidol Univ. M.P.H.M. (PHC Management) / 27
higher than the third quartile; the medium level was between the first quartile and the
third quartile; and the low level was less than first quartile.
Part III. Attitude towards health services
For attitude part of the questionnaire, five-point Likert ranking scale was used.
Since there was no negative question the ranking was given as answered by patient,
from 1-5. Then median, quartile deviation, maximum score and minimum score was
calculated after summing up the total score. The data was not normally distributed so
percentile was used as a cut-off point. The results for overall attitude were classified
into three levels; good, fair and poor. The high level was considered as higher than the
third quartile; the fair level was between the first quartile and the third quartile; and
the poor level was less than first quartile.
Part IV. Patient satisfaction towards health services at OPD
In satisfaction part, five-point Likert ranking scale was used for all the
questions. Then median, standard deviation, maximum score and minimum score was
calculated after summing up the total score. Higher score was considered as 80-100
and low 79 -20. Since there was no standard score for IGM hospital, therefore used
Thailand standard score 80% as cut-off point for this study. The result for overall
satisfaction was classified into two levels (high and low).
Part V. Suggestion and comments from the respondents regarding the services
In suggestion and comments sum up all the comments and suggestion get the
percentage and frequency and discuss the points and recommend on it.
Asma Ibrahim Methodology / 28
Table 2 Measurement and classification of variables.
Variables Measurement and classification
Age In years 16 – 65 years
Sex Female, male
Education No education
Higher secondary school
Higher education (diploma and bachelors)
Occupation Civil servants
Others( fishing and agriculture)
Family income 1000 – 17,333RF Low
17,334 – 33,667RF Moderate
33.668 – 50,001RF High
Class interval (CI) = Max.Score – Min.Score
level of income
< minimum + CI :Low income
(min +CI) to (min + CI +CI ) :Moderate income
> minimum + CI +CI :High income
Number of health visits. ≤ median
(during last six months) ≥ median
Fac. of Grad. Studies Mahidol Univ. M.P.H.M. (PHC Management) / 29
Table 2 Measurement and classification of variables. (cont.)
Variables Measurement and classification
Health problem Medical problems
ENT/ Eye problems
Gastro Intestinal problem
Urinary Tract Infection problem
Gynecology and Obstetrics problem
Type of payment Private scheme
Expectation High expectation :(>Q3)
Medium expectation :(Q1 – Q3)
Low expectation :(<Q1)
Attitude Good attitude :(>Q3)
Fair attitude :(Q1 – Q3)
Poor attitude :(<Q1)
Satisfaction High satisfaction :(>80% of total score)
Low satisfaction :(≤ 80% of total score)
3.7 Pre- test
For the validity and reliability of the questionnaire, pre-test on the
questionnaire was conducted with 30 patients in Maldives which was my study site.
The cronbach’s Alpha was adopted for reliability analysis of each part of
questionnaire as follows:
Asma Ibrahim Methodology / 30
Expectation of patients -------------------------------------- Cronbach's Alpha = 0.72
Attitude of patients ------------------------------------------ Cronbach’s Alpha = 0.76
Satisfaction of patients -------------------------------------- Cronbach’s Alpha = 0.67
According to these results, some questions for satisfaction parts were unclear
and some statements have been changed under the guidance of advisors.
3.8 Data collection procedure
Data collection was carried out by the researcher and with help of 3 trained
interviewers. The data were collected when patients were waiting for consultation at
OPD. It would be difficult to collect data after consultation because there were two
pharmacies inside hospital and payment are done separately from each pharmacy.
Prepare the data collection team by providing training to the 3 nurses on:
- How to select the patients,
- How to interview the patients,
- How to check, verify the questionnaires on the spot after
completing by the interviewers.
3.9 Data analysis
3.9.1 Data entry and editing:
After the collection was completed, it was entered by using EpiData
3.0 program. Steps are to be as the following:
- Each item will be coded and checked consistency of coding in all
- Entering data; and
- Check and edit consistency of data in all variables.
Fac. of Grad. Studies Mahidol Univ. M.P.H.M. (PHC Management) / 31
3.9.2 Data analysis
Minitab 14 program was used to analyze the data. Frequency and
percentage were calculated for predisposing factors (sex, age, marital status,
education attainment, occupation and attitude) for enabling factors (family income
and type of payment) and need factors (health problem and expectation) were
analyzed. For the level of patient satisfaction in each class of age, education,
occupation, marital status, income, health insurance, health problem; Mean, median
standard deviation, maximum and minimum were calculated for quantitative data’s.
Quartile deviations, maximum and minimum were calculated for patient
satisfaction, attitude and expectation since the data being rated in scale. Chi-square
test were performed to determine the relationship between the satisfaction level and
age, sex, marital status, education, occupation, income, expectation, attitude, health
insurance and health problem of patients. Significant level was set at 0.05.
3.10 Ethical consideration
Official letters were issued from Mahidol University to get the permission
from ethical committee from the ministry of health and the director of the Indira
Gandhi Memorial Hospital, a written consent for observation and interview from
patients. Pre permission was taken by the patients before answering the questionnaire.
Asma Ibrahim Results / 32
This cross-sectional study was conducted to determine the patient satisfaction
with health services at the out-patient department (OPD) of Indira Gandhi Memorial
Hospital (IGMH) in Male’ of Maldives.
Two hundred and fifty one patients were interviewed at the out-patient
department. The data were collected from 21st January to 31st January 2008, per day
25 patients was selected randomly. Structured questionnaires were facilitated by three
Senior Staff Nurses, for data collection. The results were presented in tables and as
well as descriptive form. The results for patient satisfaction towards general outpatient
department are presented as follows:
1. Socio-demographic characteristics.
2. Enabling factors towards health services at the OPD of IGMH.
3. Need factors towards health services of the IGMH.
4. Patient satisfaction towards health services of the IGMH.
5. Association between dependent and independent variables.
6. Suggestion and comments from the respondent regarding the health
services of IGMH.
4.1 Socio-demographic characteristics of the patients.
For this study, socio-demographic characteristics were gender, age, marital
status, education, occupation average family income (immediate family considered),
present health problem and way of payment were explains in accordingly.
The results in Table 3 show that majority of the patients were females (69.3%)
from overall respondents while male patients were only (30.7%).
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 33
Out of 251 patients the youngest patient was 16 years and oldest was 65 years
old. The median score was 31.00 years and quartile deviation was 7.7. Patients were
distributed in three categories as shown in Table 3
Most of the patients were married (67.7%) one-fourth was of single (25.90%),
divorced/separated were only 2.8% and widows were 3.59%.
Most patients (36.3%) had primary level of education. The second most
(29.9%) had secondary level of education. Very few had higher education and only
1.2% had no education.
Related to occupation, most of the patients were unemployed (32.7%) and the
second most were civil servants (29.1%). The others groups were agriculture and
With regard to the average family income per month in Ruffiya, the lowest
amount that earns were 1000 RF and highest amount that earns were 50,000 RF. The
median of family income was 8000 and a quartile deviation was 16,333. The patients
with low income were 79.7%, moderate income was 17.1% and high incomes were
The present health problems of the patients, was classified into 10 groups as
follows: Medical problem, ENT/ Eye problem, Skin problem, , Gastro Intestinal
problem, Surgical problem, Urinary tract infection, Gynecology &obstetric problem,
orthopedic problem, Neurology problem and follow-up. The top three of health
problems were ENT/Eye problems (23.1%), Medical problems (15.6%) and skin
Most of the patients used private scheme or self financing (64.9%) for
payment. The second commonest scheme was government insurance scheme (30.7%).
Asma Ibrahim Results / 34
Table 3 Socio-Demographic Characteristics of The Patients.
Socio-demographic factors Frequency Percent
Female 174 69.3
Male 77 30.7
16-32 133 52.9
33-49 69 27.3
50-66 49 19.5
Median=31.0 QD=7.7 Max=65.0 Min=16.0
Single 65 25.9
Married 170 67.7
Divorced/separated 7 2.8
Widowed 9 3.6
No education 29 11.6
Primary school 91 36.3
Secondary school 75 29.9
Higher secondary school 38 15.1
Higher education 11 4.4
Others 7 2.8
Civil servants 73 29.1
Private sector 27 10.8
Self-employed 27 10.8
Unemployed 82 32.7
Student 27 10.8
Others 15 6.0
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 35
Table 3 Socio-Demographic Characteristics of The Patients (cont.)
Socio-demographic factors Frequency Percent
Average monthly income (RF)
1000 - 17,333RF 200 79.7
17,334 - 33667RF 43 17.1
33668 - 50001RF 8 3.2
Median= 8000 QD= 16,333 Max= Min= 1000
Number of visit for last 6 months
≤ median 126 50.2
≥ median 125 49.8
Median = 3 Minimum = 1 Maximum = 30
Medical problems 39 15.6
ENT/Eye problems 58 23.1
Skin problems 34 13.6
Gastro intestinal problem 7 2.8
Surgical problem 23 9.2
Urinary tract infection 15 6.0
Gynecology and obstetric 16 6.4
Orthopedic problem 33 13.2
Neurology problem 5 2.0
Follow-up 21 8.4
Type of payment
Private scheme 163 64.9
Government scheme 77 30.7
Insurance scheme 9 3.6
Others 2 0.8
Asma Ibrahim Results / 36
4.2 Patient’s attitude towards health services at the OPD of IGM hospital.
The percentage distributions of attitude by each question were shown in Table
12 in Appendix B. Highest percentage (69.7%) of the patients agreed that medical
staff treats in a friendly and courteous manner. Percentile or quartile was used as a
cut-off point to divide attitude into three groups because the data was not normally
distributed. The total score of attitude was equal to 30. Table 4 shows that more than
half 59.0%of the patients’ had fair attitude towards hospital while the good and poor
attitude were almost same, 20.7% and 20.3% respectively.
Table 4 Overall Attitudes of the Patients Towards Health Services at the IGM
Attitude level Frequency Percent (%)
Good attitude (>23.0) 52 20.7
Fair attitude (18-23.0) 148 59.0
Poor attitude (<17.99) 51 20.3
Median=21.00 QD= 1.67 Max= 30 Min= 6
4.3 Expectation towards health services at OPD
The patients were asked about their expectation towards health services
provided by the IGM hospital. There were five questions in this section, including
cost of services, quality of services, waiting time, physical environment and
information exchange. The percentage distribution of each question was shown in
Table13 in Appendix B. To get the overall expectation, sum the total score for each
respondent and then calculate the mean score for each respondent. Since the data were
not normally distributed (p-value <0.05) so percentile was used as a cut-off point to
categorized into high, medium and low expectation. The entire patients answered all 5
questions except patients who got financial support by government and insurance
scheme. Table 5 shows the overall expectation towards the hospital, 20.7% of the
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 37
patients were highly gratitude their expectation towards services and 58.2% patient’s
had moderate expectation, while 21.1% had low expectation.
Table 5 Overall Expectation of Patients Towards Health Services at the OPD of
Expectation Frequency Percent (%)
High expectation (>2.61) 52 20.7
Moderate expectation (2.2-2.6) 146 58.2
Low expectation (<2.19) 53 21.1
Median=2.50 QD=0.2 Max=3.00 Min=1.25
4.4 Patient satisfaction towards health services at OPD in IGM hospital.
The percentage distribution of each question of satisfaction is presented in
Table 14 in Appendix B. The highest percentage (23.1%) was the feeling very
dissatisfied with cleanliness and tidiness of the OPD atmosphere. The patients were
most felt (15.1%) very satisfied with the good ventilation inside the hospital. The
median, quartile deviation, maximum and minimum score were calculated after
summing up total score for each component separately and calculated 80% and above
as high and 79 and below as low satisfaction.
The convenience part had 5 questions asking about simplicity and trouble
free of service system, availability of instruments, cooling arrangement, availability of
doctors and nurses/clinical assistance for consultation. Frequency and percentage
were presented as on Table 6. Most patients were not (75.3%) satisfied with the
The courtesy part had 4 questions about friendliness of doctors and nurses,
their attentiveness, appropriate time spent for medical examination and privacy
maintenance while examining patient. The patients had high and low satisfaction
45.8% and 54.2% respectively.
Asma Ibrahim Results / 38
The quality of care patients were asked about competency of doctors, quality
of instrument, examination of patients and the way pharmacists dispensed drugs. The
result showed that, 44.2% of patients were highly satisfied and 55.8% of patients were
not happy with quality of care provided by IGM hospital.
Two questions were asked for out of pocket cost for medical expense,
affordable and any protection financially against medical problems. Most patients
were not satisfied (76.5%) and 23.51% were happy with the cost out of pocket they
spent for medical services.
The last part of satisfaction was asked about physical environment of IGM
hospital. It included clean and tidy, enough sitting chairs available in waiting area,
availability of drinking water and clean toilets, clear signs and direction, and
ventilation. The overall scores shows that 41.8% of patients were highly satisfied and
(58.2%) had low satisfaction towards environment.
Table 6 Numbers and Percentage of Patients by Overall Satisfaction for each
Level of Satisfaction
Variables N (%) N (%)
Convenience 62(24.7) 198(75.3)
Courtesy 115(45.8) 136(54.2)
Quality of care 111(44.22) 140(55.8)
Out of pocket cost 59(23.5) 192(76.5)
Physical environment 105(41.8) 146(58.2)
The median, quartile deviation, maximum and minimum score was calculated
after summing up total score for 20 questions; 80% and above considered as high
satisfaction rate and 79 and below as low satisfaction rate. Since Maldives did not
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 39
have a standard level for satisfaction, researcher used standard value used in Thailand
as a cut-off point.
The Table 7 shows overall satisfaction with health services of IGM hospital.
The results showed that three quarter of the patient were having low (89.7%)
satisfaction and only 10.4% were highly satisfied with services.
Table 7 Overall Satisfactions Towards Health Services at OPD.
Variables Frequency Percent (%)
High satisfaction (>80) 26 10.4
Low satisfaction (≤ 80 ) 225 89.7
Median=71.00 QD=32.5 Max=91.0 Min=26.0
4.5 Association between independent and dependent variables.
The association between the predisposing characteristics, enabling resources
and need factors of the patients and the patients’ satisfaction were resoluted by using
Regarding predisposing factors, there was significant association only between
attitude and satisfaction (p value=0.002). In Table 8 shows patients’ attitude towards
health services reveals that patients with good level of attitude were 21.2% satisfied
with health services and 10.0% with fair attitude and low 0.0% showed with high
satisfaction. Majority of the patient had poor attitude with low satisfaction towards
services of IGM Hospital.
Asma Ibrahim Results / 40
Table 8 Association Between Attitude and Satisfactions.
Level of satisfaction χ2 P-value
Level of Attitude High N (%) Low N (%)
Good attitude 11(21.2) 41(78.9) 12.428 0.002*
Poor attitude 0(0.0) 51(100.0)
Median=21.0 QD=8 Max=30.0 Min=6.0
*statistically significant at p-value <0.05
For enabling and need factors, only expectation was not associated with
satisfaction (p- value = 0.056). According to results in Table 9, among the patients
with high expectation 15.4% had high satisfaction compared to the low expectation
Table 9 Association Between Expectation and Satisfactions.
Level of satisfaction χ2 P-value
Level of expectation High N (%) Low N (%)
High expectation 8(15.4) 44(84.6) 5.771 0.056
Moderate expectation 17(11.6) 129(88.4)
Low expectation 1(1.9) 52(98.1)
Median=2.5 QD=0.2 Max=3.00 Min=1.25
Table 10 shows predisposing factors, which did not have any significant
association with satisfactions. It was found that high proportion of both females and
males were lowly satisfied. Females with low satisfaction were 88.5% and males
The age group was classified into three groups by using equal class interval.
The percentage of high satisfaction (12%) was high in age group 16-32 years. All age
groups showed high percentage of low level of satisfaction. In age group 16-32 years,
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 41
88% of the patients had low satisfaction, age group 33-49 years were 93% and age
group 50-66 years were 90%.
Marital status was regrouped in to three groups, single, married and
divorce/separated /widowed. All categories of marital status showed high percentage
of low satisfaction. From three groups the high percentage of high satisfaction was in
divorce and widowed (12.5%).
In perspective of education of patients, it was regrouped into four groups; no
education, primary education, secondary education and higher secondary
school/higher education/others. The patients with various level of education had
almost same level of satisfaction. All the groups were having low satisfaction. The
patients with secondary level of education had higher percentage of high level of
satisfaction (14.7%) compared to other groups.
Regarding the occupation of the patients, it was regrouped for analysis. They
were civil Servants /private Sector, self-employed/ others and unemployed/s. Most of
the patients had low satisfaction. High percentage of high satisfaction was found in
unemployed/ others group.
The average family income earned per month was divided into three groups by
class interval as 1000 – 17,333 Ruffiya, 17334 –50001 Ruffiya. Both groups had the
same distribution of satisfaction.
The total number of visits during last six month was categorized in to two
groups. Statistical analysis showed no relationship between numbers of visits with
Payment for these visits was categorized into four groups; private scheme,
government scheme, insurance scheme and others (some private organizations). All
groups had high percentage of low satisfaction. The patients who paid by self or
Asma Ibrahim Results / 42
private scheme had high percentage of high satisfaction (11.7%) compared to other
Table 10 Association Between Socio-Demographic Factors and Satisfactions.
Level of satisfaction χ2 p-value
Socio-Demographic factors High (N %) Low (N %)
Female 20(11.5) 154(88.5) 0.79 0.38
Male 6(7.8) 71(92.2)
16-32 16(12.0) 117(88.0) 1.121 0.571
33-49 5(7.3) 64(92.8)
50-66 5(10.2) 44(89.8)
Single 5(7.7) 60(92.3) 0.982 0.612
Married 19(11.2) 151(88.8)
Divorced/separated +widowed 2(12.5) 14(87.5)
No education 1(3.5) 28(96.6) 3.653 0.301
Primary school 10(11.0) 81(89.0)
Secondary school 11(14.7) 64(85.3)
HSC/HE/others 4(7.1) 52(92.9)
Civil Servants / Private 9(9.0) 91(91.0) 0.519 0.771
Self-employed/ Others 4(9.5) 38(90.5)
Unemployed/ Student 13(12.0) 96(88.1)
Average monthly income (RF)
1000 – 17,333RF 20(10.0) 180(90.0) 0.136 0. 712
17,334 – 50,001RF 6(11.8) 45(88.2)
Number of visits last 6 months
≤ 3 visit 8(8.7) 94(91.3) 0.494 0.482
>3 visits 17(11.5) 131(88.5)
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 43
Table 10 Association Between Socio-Demographic Factors and Satisfactions (cont.)
Level of satisfaction χ2 P-value
Socio-Demographic factors High (N %) Low (N %)
Medical/gasto+surgical/uro 13(9.4) 125(90.6) 0.459 0.795
Ortho /neuro +gynae /follow-up 8(10.7) 67(89.3)
ENT/Eye +skin 5(13.2) 33(86.9)
Private scheme 19(11.7) 144(88.3) 0.861 0.650
Government scheme 6 (7.8) 71(92.2)
Insurance scheme/ Others 1(9.1) 10(91.0)
4.6 Patient’s comments and suggestion to improve the quality of health services
at the OPD of IGM hospital.
Out of 251 patients 72.9% of the patient provided comments and suggestions
to improve the quality of health services. Most of the patient expresses more than
three comments or suggestion to improve. The comments and suggestion are
summarized in frequency and percentage as shown in Table 11 below.
Most of the comments were related to conveniences which were negative
comments than positive. The complaints about inconvenience mostly stressed on long
waiting time to consult doctors and access to pharmacy services. Some patients
comment about cleanliness of the environment as a positive point but some patients
notice toilets to be cleaner than this and provide some kind of hand washing solution
According to the comments concerning courtesy of staffs, some patients
suggested staff should provide service in a friendly manner with a smile on face and
be more polite with them. As shown on Table 11 patients suggested on improving
punctuality and courtesy of doctors. The most important improvement was about staff
patient relation should be strengthen and guide the patients as much as possible.
Asma Ibrahim Results / 44
Table 11 Patient’s Comments and Suggestion for Improving Services at the OPD of
IGM Hospital. (Most of patient’s more than three comments or suggestion)
Comments and Suggestion Frequency Percent
Long waiting time for consultation 46 24.0
Counter services are being delayed/less staffs 22 11.5
Drinking water are not sufficient/no glass 6 3.1
Difficult to get appointment 19 9.9
Cancer treatment should be available 3 1.6
Increase number of specialists. 18 9.4
Free medical services in a near future 13 6.8
Availability of advanced procedures, MRI 6 3.1
Punctuality and friendliness of doctors/health care 13 6.8
providers. 10 5.2
Clinical assistance friendliness
Out of pocket cost
Laboratory investigations are costly 13 6.8
Toilets should be cleaner, availability of hand wash- 14 7.3
Update sign boards 9 4.7
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 45
Indira Gandhi Memorial Hospital is the only tertiary hospital in the Maldives,
which provides services to the people of Male’ and nearby islands and, referrals from
whole country. The main purpose of this study was to determine the patient’s
satisfaction towards the OPD services. Patient satisfaction was the outcome variable
which was an important component for program evaluation. Therefore this study
would benefit health managers for improving effectiveness and efficiency of the
hospital in future.
5.1 Methodological concerns
This study was conducted in the hospital during working hours and when the
hospital launched a new registration system. Most of the patients were in confusion
with the services and were reluctant to express their real feeling and opinion towards
health services that provided by OPD. The questionnaire was designed for
interviewing in order to minimize any confusion about questions and missing data.
Stratified random sampling had been carried out to avoid selection bias. Moreover the
researcher conducted research with other three interviewers to enhance the quality of
data. The interviewers were three senior staff nurses working at the inpatient
department of this hospital. They interviewed the patients in colored dress therefore,
the personality and recognition of these interviewers could not certainly influence
In literature review about patient satisfaction, there was none of the study
conducted in Maldives. The methodology of study, variables and method and instant
of questioning varies. In the previous client satisfaction study was evaluated services
from units of OPD (25) and specific department (8). In this study, which have same
characteristics of services include in order getting a real picture of satisfaction
towards services of IGM hospital.
Asma Ibrahim Discussion / 46
5.2 Patient satisfaction towards health services of IGM hospital
According to the overall satisfaction pointed out by this study, three quarter of
the patients were lowly (89.64%) satisfied and only (10.36%) were highly satisfied
with the services provided by the IGM hospital. It may be due to higher cut-off point
in this study.
As shown in Appendix B Table 15. If measured with lower cut-off point; >
75% as high satisfaction the patient with higher satisfaction rate was 29.4% and low
satisfaction was 70.6% with services.
In relation with this result, the proportion of high satisfaction level of this
study was study was also lower than the satisfaction level found by the study of
Tangmankongworakoon T. who informed that the level of the overall satisfaction of
the clients towards the services of Lad Yao district hospital was 52% (25). According
to another study conducted by P. Roy in Sampran community hospital in Thailand
(2002) shows, that 53% of patients were highly satisfied (35). From a study conducted
in a tertiary care hospital in India, it has seen that 90-95% of patients are satisfied
with the services offered in the hospital (15). The patient satisfaction varies in
different health care settings and circumstances. This variation may be due to
difference in quality of services provided or difference in expectations of the patients
or it can be in difference cultural setting among service providers and consumers as
well. For example, this study divide into two levels of satisfaction as high and low by
using 80% of total score as the cut- off point, but in some other studies classified
research as Ny Net ‘s study (33) satisfaction into three levels; low, medium and high
satisfaction by using mean score + and – one standard deviation. Due to different
determination of satisfaction level might be one most important factor of having broad
variation in the proportion of satisfaction level got from other studies.
Regarding the level of satisfaction in terms of convenience, courtesy, quality
of care, out of pocket cost and physical environment shows low levels of satisfaction.
When compared with all the components of satisfaction, courtesy gained highest
percentage of high satisfaction (45.8%). Quality of care gained the second highest
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 47
44.2% highly satisfied and 55.8% lowly satisfied. Patient satisfaction is certainly a
useful measure, and to the extent that it is based on patients’ accurate assessments, it
may provide a direct indicator of quality care. According Aldana et al, the most
powerful predictor for client satisfaction with government health services was the
provider’s behaviour towards the patient, particularly respect and politeness (36).
In physical environment 41.83% were highly satisfied and 58.2% was lowly
satisfied. The most negative result about satisfaction in this section was convenience
and out of pocket cost. In cost out of pocket shows that only 23.51% patients were
highly satisfied and 76.49% were having low satisfaction while in convenience were
24.7% highly satisfied with services whereas 75.3% proves low satisfaction. This
shows that the cost that has to spend for medical treatment is costly for average
income patients. These findings could reflect that patients were more concerned about
out of pocket cost than other components.
Patient satisfaction is an important indicator in evaluating the quality of the
patient care in the outpatient department. In a study conducted at the out-patient
department clinic of Wangnumyen Community hospital, Sakeo province, Thailand by
Ny Net, (33) stated that highly satisfied with interpersonal manner was 30.3% and
physical environment with (36.9%) highly satisfied. She also asserted that
accessibility, medical expense, and quality of care received low level of satisfaction:
13.9%, 14.8% from other components. In this study almost all component shows low
level of satisfaction. Poor patient satisfaction can lead to poor adherence to treatment
with consequently poor health outcomes. In another study conducted on a sample of
dermatology outpatients, (37) out of 1385 randomly selected patients, 722 patients
agreed to participate, 424 fulfilled the inclusion criteria and 396 of these patients
(93.4%) completed the study. Overall satisfaction was reported by 60% of patients.
According to Jones and Sasser, (20) the most familiar insight about patient
satisfaction is that higher is better. If market share and revenue are important to
services, only patient loyalty will do. And if patient satisfaction is a ladder to climb,
experts agree that you’ll find loyalty only on the top of the range. Exceptionally
satisfied customers were six times more likely to buy again as one who was just
Asma Ibrahim Discussion / 48
merely satisfied (20). Therefore health care system is basically a service based
industry and customer satisfaction is at utmost importance just as in other service-
5.3 Association of Socio-demographic factors and patient satisfaction.
It is commonly believed that satisfaction with health care may be dependent
upon variables such as social class, marital status, gender, and in particular age.
According to the gender, the result showed that female patients were more satisfied
than male. In female 11.5% were highly satisfied and only 7.8% males were highly
satisfied. The result was same as in Ny Net, (33) as females were more satisfied than
males. In that study 24.1% females and 9.1% male were satisfied with the services. In
general gender does not affect levels of satisfaction (18).
The younger age group had range of 16-32 years. In this group, 12.0% of
patients had high level of satisfaction. Second group in age range was 33-49 years and
7.3% of patients were highly satisfied. The eldest group 50-66 years, 10.2% patients
were highly satisfied. Perhaps the most consistent determinant characteristic was
patient age, with a body of evidence from various countries to suggest that older
people tend to be more satisfied with health care than do younger people (38).
According to Williams and Calnan (1991) older people have found to be far more
satisfied with most aspects of their hospital care than younger or middle aged people
(38). Most studies on satisfaction have found that older patients report higher levels of
satisfaction than younger patients, (31) which were contrast with this study. In
certainty older patients tend to be more dependent to the other member of the family
and younger take initiative to improve the services.
Most of the patients were married, since the study population was from age
not less than 16 years. In marital status, the widowed/divorced and married group had
higher proportion of high satisfaction score when compared with other groups in this
category. This can be explained that the satisfaction may be effected by frequent
exposure to the services. Married patient utilized more medical services than single
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 49
due to their families from both sides. However, was no significant association
between marital status and satisfaction in this study.
According to the patient education, the secondary school group were highly
(14.7%) satisfied with services of IGM hospital. The least percent found in no
education groups, only 3.5% with high satisfaction. In most of the surveys higher
educated patients tend to be less satisfied with the services and low educated patients
would be more satisfied with services (39). Educational attainment has been identified
as having a significant bearing on satisfaction, the trend being that greater satisfaction
was associated with lower levels of education (37). In general respondents with high
levels of satisfaction tend to be older, women, less well educated, or in poorer health
than respondents with low levels of satisfaction (2). These high levels of client
satisfaction are thought to be related to the influence of respondents' acquiescence
response biases. In this study statistically it shows that there was no relationship
between education and satisfaction.
The association between occupation and satisfaction level of patients was not
detected by statistical test. Whether they work in government or private sectors their
level of satisfaction from IGM hospitals services were not different. When compared
with studies conducted by Partha P R. in Sampran Community Hospital, Thailand
were also same unemployed group (69.5%) satisfied than employed groups (44%)
There was no association between income and satisfaction. In this study higher
income (25,501-50,000) levels tend to be higher level (11.8%) of satisfaction than any
other groups. The least satisfaction showed in middle income group with only 7.7%.
The results were same finding with Ny Net who found that the patients who earned
more income were more satisfied than the group that earned less (33).
There was no association between number of visits to hospital and level of
satisfaction. In the group of less than 3 visit 8.5% were highly satisfied while in more
than 3 visits were only 11.5% satisfied with the services. This shows that they don’t
Asma Ibrahim Discussion / 50
have any choice or other means to get better health services other than IGM hospitals
in the country, so if they utilize more or less the quality of care remains same.
Health problems with ENT and Eye were highly satisfied (13.79%) with
services when compared with all groups of health problems in this study. The ENT
and Eye department may provide more concern to health problems of patients than
other departments. However, there was no significant association between health
problem and satisfaction level. This relationship has been investigated by researchers,
some of whom have reported that there is no significant association between patients’
perceived health status and their satisfaction with health care (31). In contrast, other
researchers reported that patients who perceive their health status to be poor were less
satisfied with their medical care (12). Although healthier patients were generally more
satisfied with their care than less healthy patients, there lack of clarity on the
relationship between health status and the component of satisfaction. When
considered these relationships would assist in making more rational quality
improvement strategies, thereby contributing to the increased effectiveness of health
Most of the patients in this study used their private scheme or cost out of
pocket for health care and they also showed highest (11.7%) the level of satisfaction
than other groups. There was no significant association between type of payment and
satisfaction. It might be due to higher income level they don’t bother much about the
cost of services, only poor or less income groups worried much about the cost.
5.4 Patient expectation towards health services of IGM hospital.
In this study, the results of overall expectation showed that 15.4% of high
expectation group had high satisfaction and only 1.9% of low expectation group had
high satisfaction. The association between expectation and satisfaction was not
significantly associated. It can be concluded that patients got higher expectation when
they were satisfied with health services. The roles of consumers assume regarding
their relationship to the health care system has significant meaning for understanding
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 51
satisfaction. One of the central tenets of the prevailing model of satisfaction was that
patients judge themselves to be satisfied when care has met their expectation.
However, there was evidence from several studies that patient’s expectations only
have indirect affect on their level of satisfaction, and that patients are satisfied even
their expectations have not been met (18).
5.5 Patient attitudes towards health services of IGM hospital.
In this study 21.2% of good attitude group had high satisfaction level. For fair
attitude group with high satisfaction was 10.0%. While, all in poor attitude group had
less satisfaction. The association between attitude and satisfaction level they were
significantly associated at p = 0.002. The finding was similar to
Tangmankongworakoon; Satisfaction survey in district hospital was determined the
association between attitude and level of satisfaction. The finding also shows the
higher level of attitude towards the hospital patient had, patients were more likely to
satisfy with services provided by that hospital (25).
5.6 Comments and suggestions from the patients.
Among 251 patient 72.9% of the patient provided comments and suggestions
to improve the quality of health services. Most of the patient gave more than three
suggestions to improve. Quality of care was very important indicator in any health
sector. Poor quality was costly; it leads to loss of lives, loss of time, and loss of public
confidence, low staff morale and also results in wastage of our limited resources (40).
This tends to provides plenty of comments and suggestions to improve the services.
Most of the patient commented on Waiting time (24.0%), from the point of
entry to exit in a hospital, the patient has to wait at various stages i.e. enquiry/
registration counter, doctors chamber, laboratory and pharmacy etc. A study
conducted in a tertiary care hospital in India also revealed that 25% patients, waiting
time for consultation seems to be extends to more than three hours (15).
Asma Ibrahim Discussion / 52
Delay in counter services 11.5% patient commented. Next patient commented
on difficulty in getting appointment (9.9%) and takes time to get pharmacy services.
They recommend providing easy access to appointment and pharmacy services. These
two areas seems to be related to each other, if difficulty in getting appointment is a
problem and if the waiting time gets too long for consultation will leads to
dissatisfaction with services. Looking at the Table 11 shows that the waiting time was
too long seemed to prove the level of expectation for waiting time was the poor
(64.5%) among other respondents.
According to patient’s suggestions and comments the third priority was to
increase the number of specialists (9.4%). The next point was about the counter
services were being delayed due to various reasons; less staffs, less counters and less
qualified staffs to provide services. The next very important service to improve in this
hospital was to improve toilet facilities along with hand wash solution. In a study
conducted in a tertiary care hospital showed regard to the cleanliness in the hospital,
50% of patients were highly satisfied whereas 15.5% suggested that the cleanliness
can surely be improved (15).
Furthermore they commented on punctuality of most doctors were low and
communication gap were there in some doctors and medical staffs (6.8%). Lee 2004
mentioned that if patient has a poor ability to assess technical performance. And they
have difficulty distinguishing between the art of care and the technical aspects of care.
As a result, patients judge the hospital by the way they’re treated as a person, rather
than the way they’re treated for their disease (20). Adequate information and the
ability to communicate caring create confidence. The comment about clinical
assistance communication skills were rude or impersonal way. Patient gives
suggestion to improve their skills to except patient as a patient. According to Taylor
(2004) “Doctors' training and knowledge of new medical treatments are less important
to many patients than their interpersonal skills—treating patients with respect,
listening carefully, being easy to talk to, taking patients' concerns seriously, spending
enough time with them, and really caring." Of the three top drivers of patient
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 53
satisfaction, two (nurses anticipated your needs, and staff responded with care and
compassion) measure the staff’s ability to show empathy (20).
The most another important point that patient suggests was to arrange a free
medical services or insurance scheme in a near future. And also the costs of some
services were too high like laboratory investigation and some advanced procedures.
Some patient suggests to minimize the cost to level that patient can afford.
In general there were about 22 key comments summarized in Table 11, in
discussion part included the highest in number of patient comments and suggestion.
Therefore it can be concluded by phrase sums by Fred Lee (2004) “…it is possible to
improve systems, improve the registration process, improve explaining tests and
procedures, improve waits, and improve the performance of ancillary and support
services in the patient’s eyes; yet all of these combined improvements could not raise
overall satisfaction when staff miss the opportunities to anticipate people’s needs and
show some empathy in their times of stress, pain, and grief” (20).
Asma Ibrahim Conclusion and Recommendations / 54
CONCLUSION AND RECOMMENDATIONS
Patient attending each hospital are responsible for spreading the good image of
hospital and therefore satisfaction of patients attending the hospital is equally
important for hospital management. The IGMH policy is to deliver an affordable and
wide-ranging health care service to Maldivians. To achieve this IGMH has been
conducting several methods to enhance their services; however they need to go
through a long path to reach the goal. The customer image of the hospital still desired
better quality of services appropriately throughout whole country.
In this study, dependent variable of concern was patient satisfaction towards
the hospital services which were considered according to component of care such as
convenience, courtesy, quality of care, out of pocket cost and physical environment.
Independent variables included; predisposing factors such as age, gender, marital
status, educational level, occupation, number of visits and state of attitude towards
services. Enabling factors included family income and type of payment for this visit.
And need factors were health problem and expectation towards services.
A structured questionnaire was used as a study instrument for data collection.
There were five sections in questionnaire: socio-demographic factors, patient
expectation towards health services, patient attitude towards health services, and
patient comments and suggestions to improve the quality of health services at the
OPD of Indira Gandhi Memorial Hospital. Cronbach’s alpha coefficients were used
for reliability test of questionnaire and got the result for expectation part - 0.72,
attitude part - 0.76 and satisfaction part - 0.67. Some questions for satisfaction parts
were unclear and some statements have been changed in order to increase the level of
reliability. The number of patient was calculated by using the statistical formula and
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 55
Stratified random sampling was applied to draw the patients from OPD of hospital.
Data collection was carried out by researcher and with help of 3 interviewers. The
data were collected when patients were waiting for consultation at OPD. It was from
21st -31st January 2008. There were 251 patients participated in this study, the data
was analyzed by Minitab version 14. The results were presented by using frequency,
percentage, minimum, maximum, median, mean, standard deviation, quartile
deviation; Chi-square test was performed to determine the association between
independent and dependent variables.
When taking into consideration the overall satisfaction score for groups of all
patients’ satisfaction level was 10.4% highly satisfied and 89.6% lowly satisfied with
services of IGM hospital. The low proportion of high satisfaction level might have
resulted from, among other reasons, the high criteria (80% of total score) of
classification of satisfaction level. Regarding the components of satisfaction, it was
found that overall patient had low satisfaction with services except courtesy and
quality of care.
Patient’s attitude towards services of IGM hospital was significantly
associated with the level of satisfaction in this study. Patients with good attitude were
21.2% satisfied with health services and 10.0% with fair attitude and poor 0.0%
showed with high satisfaction. Majority of the patients with poor attitude had low
satisfaction towards services of IGM hospital.
In terms of expectation was not significantly associated with satisfaction level.
The patient with high expectation had nearly high (15.4%) satisfaction and moderate
expectation with high satisfaction was 11.6% of the patient and low expectation was
only 1.9% with high satisfaction. According to these results most of the patients was
having low expectation with low satisfaction towards hospital.
Among Socio demographic factors none were significantly associated with
Asma Ibrahim Conclusion and Recommendations / 56
The comments and suggestion resulting from respondents were related to
convenience which was negative comments than positive. The complaints about
inconvenience mostly stressed on long waiting time to consult doctor and access to
pharmacy services, shortage of specialist doctors and health care providers.
6.2.1 Recommendations for service improvement.
The OPDs mission should be to provide comprehensive and accessible
services that anticipate, meet and exceed the expectations of patients, staff,
investigators and the public and also supports professional development of staff and
promotes a positive work environment which facilitates open communication and
team spirit between staff and patients. Regarding the level of satisfaction most of the
component were having low satisfaction level, should promptly reassess their conduct
to improve the satisfactory matters where the services achieving the higher
satisfaction level needed to be improved very much. To increase the satisfaction level
of the component of satisfaction Indira Gandhi Memorial hospital, the fine picture of
the hospital must be promoted by;
1. Improving the interpersonal manner, the way in which providers interact
personally with patients. Example; respect, concern, friendliness and
2. Technical quality of care by improving competence of providers and
adherence to high standard of diagnosis and treatment.
3. Accessibility/convenience should be arrange to receive proper medical
care to minimize waiting time and ease of reaching providers.
4. The government should consider proper health care financing scheme to
provide equity with all patients.
5. Physical environment should be improved by arranging clear signs and
directions, orderly facilities and equipment and with pleasantness of
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 57
6. Management needs to update the front office staff periodically and orient
them to new developments in the hospital.
There was one factor that found to be associated with satisfaction level. The
hospital has to improve the actual performance to meet the patient’s expectation and
the good reputation to improve the attitudes towards the hospital.
This study leads to several numbers of recommendations for contributing to
the improvement of quality of health services as a whole at the OPD of Indira Gandhi
Memorial Hospital as follows:
1. To maximize accessibility to health services at the OPD has been the
major concerns of the patients who participated in this study. Most of the
patents comments given that hospital should consider waiting time for
seeing doctors and pharmacists as the priority issue that needs to be
improved as soon as possible in order to meet the patient’s satisfaction.
2. According to this study overall picture of services to be improved in all
aspects of services, particularly, convenience and quality of care. Change
attitude of employees about nonconforming services, it does not mean
deficiency in the department; rather it means that things should improve to
meet customer satisfaction.
3. A set of connections between the atoll / regional hospitals and health
centers should be strengthen in order to share the responsibility for
managing health care at secondary level or at primary level. Patients with
simple or common diseases can be treated at primary level. So that it will
help to reduce the workload of doctors at the OPD at IGM hospital. As an
end result, the doctors would have more time to examine the patient
carefully and treated appropriately.
4. This study also pointed out that patient is less satisfied with their cost out
of pocket. Even though they did not showed with level of expectation.
Asma Ibrahim Conclusion and Recommendations / 58
Being a government hospital the medical expense is not affordable for
most of the poor patients.
6.2.2 Recommendations for future research
1. Further study about patient satisfaction survey should be conducted
systematically in each unit of services with higher number of respondents in order to
get the real picture of service system. In this study only considered the units which
have same characteristics. As this study reveals, higher proportion of dissatisfaction
with services provided by IGM hospital.
2. Another study with the lower criteria using 75% of total score as a
cut-off point. The result might show different and the association with satisfaction
3. Patient satisfaction survey should be carried out in the community
and where a health service provides. With different environment setting and with
various variables the result might be different from this study. Moreover, patients may
be more willing to answer in their own environment and data will be more genuine.
The suggestion and comments to improve services would be more accurate and the
level of satisfaction might be lower than those studies conducted within the adjacent
4. Patient satisfaction survey may be conducted in private hospital to
know the satisfaction level. Further studies should include other atoll hospitals.
Moreover, services of public hospital can to compare the results with private hospital
Therefore it can be concluded that OPD services form an important
component of hospital services and feedback of patients are vital in quality
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 59
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Asma Ibrahim Appendix / 64
QUESTIONNAIRE ID no. -------------------
Patient satisfaction towards Outpatient department services
This questionnaire is constructed for assessing your satisfaction towards services
provided by Indira Gandhi Memorial Hospital. Information obtained will be used for
the hospital service improvement and will be kept confidential. Your honesty in
responding is most helpful. Thank you in advanced for your response.
Hospital number: ……………………………….
Date of data collection: ………………………...
Name of interviewer: …………………………..
Part- I Socio-demographic Factors
Please tick mark ( ) the appropriate answer in the box or fill in the blanks as required.
1. What is your sex?
1. Male 2. Female
2. What is your Age (in years)?
3. What is your marital status?
1. Single 3. Married
2. Divorce/ Separated 4. Widowed
4. What is your highest level of education attainment?
1. No education
3. Primary school
Fac. of Grad. Studies, Mhidol Univ. M.P.H.M. (PHC Management) / 65
4. Secondary school
5. Higher secondary school
6. Higher education
7. Others (please specify) …………………………………..
5. What is your occupation?
1. Civil Servants
2. Private sector
6. Other (please specify) ……………………………………..
6. Average family income per month? ……………………………Ruffiya.
7. Total number of visits to this hospital (during last six months)
………………………………………………..................(including this visit)
8. What is the current problem that you came to hospital today?
9. How you are going to pay for this visit?
1. Private scheme
2. Government scheme (skip Q10)
3. Insurance scheme (skip Q10)
4. Others (specify)…………………………………………
Asma Ibrahim Appendix / 66
Part- II Patient expectation towards health services at OPD of Indira Gandhi
Before utilizing the services, what is your expectation towards the services of IGM
(Please select the choice that is closest to the level of your expectation)
10.What is your expectation to the total cost paid out of your pocket for health
services (e.g. Payment for registration, laboratory and medication)?
1. I expected the total cost out of pocket might not be affordable
2. I expected that total cost out of pocket might be affordable
3. I expected that total cost out of pocket might be enough to cover this visit
4. I don’t have any expectation
11. What is your expectation towards the quality of care (e.g. quality of equipment,
service providers and medication)?
1. I expected that the quality of care will not be good
2. I expected that the quality of care will be acceptable
3. I expected that the quality of care will be excellent
4. I don’t have any expectation
12. What is your expectation towards waiting time?
1. I expected that the waiting time will be long
2. I expected that the waiting time will be acceptable
3. I expected that the waiting time will be short
4. I don’t have any expectation
13. What is the expectation towards the surrounding of the hospital (e.g. cleanliness,
ventilation, health messages)?
1. I expected that the condition of the OPD surrounding might not be good
2. I expected that the condition of the OPD surrounding might be acceptable
3. I expected that the condition of the OPD surrounding might be excellent
Fac. of Grad. Studies, Mhidol Univ. M.P.H.M. (PHC Management) / 67
4. I don’t have any expectation
14. What is your expectation about the information that you would acquire from the
doctor concerning your illness?
1. I expected that any useful information might not obtained
2. I expected that some of useful information might be obtained
3. I expected that a lot of useful information might be obtained
4. I don’t have any expectation
Part III Patient attitude towards health services at the OPD of IGMH.
How do you feel about the medical services you have received from OPD?
Please read each one carefully and circle one number. How strongly do you “Agree”
or “Disagree” with each of the following statements.
Strongly Agree = 5 Agree = 4 uncertain =3 Disagree =2 Strongly Disagree =1
Patient Attitude 1 2 3 4 5
15. The hospital has a good reputation
16. Queuing system in IGMH are trouble free.
17. The doctors here are competent.
18. Doctors are not acting businesslike and impersonal
19. Medical staff treat in a friendly and courteous
20. Overall health care services get from this OPD is
Asma Ibrahim Appendix / 68
Part IV: Satisfaction towards health services at OPD
Please tick ( ) the appropriate answer in the box.
Scale: 5 = very satisfied, 4 = satisfied, 3 = neutral, 2 = dissatisfied, 1 = very dissatisfied
Convenience 1 2 3 4 5
21. Simplicity and trouble free of service system.
22. Availability of instruments like BP apparatus,
thermometer, weighing scale and other
23. The arrangements for cooling in waiting area for
24. Availability of Nurse/clinical assistance for
25. Availability of doctors for consultation
26. Friendliness and courteous manner of medical
27. The attentiveness of doctors/nurses while
answering your questions.
28. Provide appropriate time for medical
29. Maintain privacy appropriately before doing any
Quality of care
30. Competency of doctor for treating the patient.
31. The qualities of instrument used for medical care.
32. Doctors examine patient carefully.
33. Pharmacists are skillful and dispensed drug.
Out of pocket cost
34. Costs of medical services are affordable.
Fac. of Grad. Studies, Mhidol Univ. M.P.H.M. (PHC Management) / 69
Convenience 1 2 3 4 5
35. Protected financially against medical problem
36. The atmosphere of this OPD is clean and tidy.
37. Sitting chairs are available at the waiting area.
38. Availability of drinking water and clean toilets.
39. Clear signs and directions to indicate where to
go in the service area and easy to follow.
40. The inside of the hospital has good ventilation.
Part V: Patient’s suggestion and comments to improve the quality of health
services at the OPD of IGM Hospital.
41. Do you have any comments or suggestion to improve the quality of health
services at the OPD?
................................................….Thank you very much for your kind cooperation.
Table 12 Frequency and percentage of patient’s attitude towards health services at OPD of IGM hospital
by item of question.
Frequency & Percent (%)
Questions Strongly Agree Uncertain Disagree Strongly
(5) (4) (3) (2) (1)
The hospital has a good reputation. 11(4.38) 149(56.36) 26(10.36) 32(12.75 33(13.15)
Queuing system in IGMH are trouble free. 9(3.59) 154(61.35) 8(3.19) 42(16.73) 38(15.14)
Doctors here are competent. 11(4.38) 154(61.35) 33(13.15) 31(12.35) 22(8.76)
The doctors are not acting businesslike and 13(5.18) 114(45.42) 26(10.36) 64(25.50) 37(14.74)
Medical staff treats in a friendly and courteous 12(4.78) 175(69.72) 34(13.55) 21(8.37) 9(3.59)
Overall health care services get from this 18(7.17) 162(64.54) 35(13.94) 27(10.76) 9(3.59)
hospital is very good
Appendix / 70
Table 13 Frequency and percentage of patient’s expectation towards health services at OPD of IGM hospital
by item of questions.
Frequency Percent (%)
Questions Poor Fair Good
What is your expectation to the total cost paid out of your pocket for health services 13(8.6) 20(13.2) 118(78.1)
(e.g. payment for registration, laboratory and medication)
Fac. of Grad. Studies, Mhidol Univ.
What is your expectation to the quality of care (e.g. quality of equipment, service 10(4.1) 62(25.6) 170(70.2)
providers and medication)
What is your expectation towards waiting time (e.g. registration, consultation and 162(64.5) 50(19.9) 39(15.5)
What is the expectation towards the surrounding of the hospital (e.g. cleanliness, 12(4.9) 52(21.3) 180(73.8)
ventilation, health messages)
What is your expectation about the information that you would acquire from the 12(4.9) 56(23.0) 176(72.1)
doctor concerning your illness
M.P.H.M. (PHC Management) / 71
Table 14 Frequency and percentage of patient’s satisfaction towards health services at OPD of IGM
hospital by item of questions.
Frequency Percent (%)
Questions Very Satisfied Neutral Dissatisfied Very
(5) (4) (3) (2) (1)
Simplicity and trouble free of service system 5(1.99) 143(56.97) 15(5.98) 48(19.12) 40(15.94)
Availability of (BP, Thermometer and weighing 8(3.19) 173(68.92) 48(19.12) 18(7.17) 4(1.59)
The arrangement for cooling in waiting area for 11(4.38) 191(76.10) 10(3.98) 28(11.16) 11(4.38)
Availability of nurses/clinical assistance for 6(2.39) 171(68.13) 23(9.16) 44(17.53) 7(2.79)
Availability of doctors for consultation 5(1.99) 139(55.38) 16(6.37) 67(26.69) 24(9.56)
Friendliness and courteous manner of medical 8(3.19) 178(70.92) 28(11.16) 30(11.95) 7(2.79)
Appendix / 72
Table 14 Frequency and percentage of patient’s satisfaction towards health services at OPD of IGM hospital
by item of questions (cont.)
Frequency & Percent (%)
Very Satisfied Neutral Dissatisfied Very
Questions Satisfied Dissatisfied
(5) (4) (3) (2) (1)
The attentiveness of doctors/nurses while 5(1.99) 172(68.53) 25(9.96) 42(16.73) 7(2.79)
Fac. of Grad. Studies, Mhidol Univ.
answering your questions.
Provide appropriate time for medical 16(6.37) 158(62.95) 29(11.55) 38(15.14) 10(3.98)
Maintain privacy appropriately before doing 8(3.19) 164(65.34) 47(18.73) 25(9.96) 7(2.79)
Quality of care
Competency of doctor for treating the patients. 8(3.19) 177(70.52) 24(9.56) 30(11.95) 12(4.78)
The quality of instruments used for medical 10(3.98) 164(65.34) 43(17.13) 22(8.76) 12(4.78)
Doctors examine patient carefully. 14(5.58) 181(72.11) 28(11.16) 21(8.37) 7(2.79)
M.P.H.M. (PHC Management) / 73
Table 14 Frequency and percentage of patient’s satisfaction towards health services at OPD of IGM hospital
by item of questions (cont.)
Frequency & Percent (%)
Questions Very Satisfied Neutral Dissatisfied Very
(5) (4) (3) (2) (1)
Out of pocket cost
Costs of medical services are affordable 21(8.37) 158(62.95) 12(4.78) 39(15.54) 21(8.37)
Protected financially against medical problem. 11(4.38) 110(43.82) 23(9.16) 67(26.69) 40(15.94)
The atmosphere of this OPD is clean and tidy. 20(7.97) 72(28.69) 38(15.14) 63(25.10) 58(23.11)
Sitting chairs are available at the waiting area. 21(8.37) 168(66.93) 11(4.38) 41(16.33) 10(3.98)
Availability of drinking water and clean toilets. 12(4.78) 125(49.80) 36(14.34) 42(16.73) 36(14.34)
Clear signs and directions to indicate where to 18(7.17) 170(67.73) 16(6.37) 28(11.16) 19(7.57)
go in the service area and easy to follow.
The inside of the hospital has good ventilation 38(15.14) 189(75.30) 7(2.79) 9(3.59) 8(3.19)
Appendix / 74
Table 15 Frequency and percentage of overall patient’s satisfaction with 75% cut-off point.
Levels of satisfaction Frequency Percent (%)
High satisfaction 74 29.4
Low satisfaction 178 70.6
Fac. of Grad. Studies, Mhidol Univ.
M.P.H.M. (PHC Management) / 75
Asma Ibrahim Biography / 76
NAME Asma Ibrahim
DATE OF BIRTH 5th July 1976
PLACE OF BIRTH LH/ Kurendhoo, Nirolhuge. Maldives
INSTITUTION ATTENDED Faculty of Health Sciences Male’ Maldives.
1995-1998 / 2001-2002/2008
Diploma in Nursing and Midwifery
Monash University, Malaysia
Bachelor’s Degree in Nursing
Mahidol University, Thailand
Master of Primary Health Care Management
ASEAN Institute for Health Development
FELLOWSHIP / Ministry of Health, Maldives/ WHO
RECENT POSITION Senior Staff Nurse
Indira Gandhi Memorial Hospital