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Republic of Kenya

VIEWS: 39 PAGES: 40

									      Republic of Kenya




  Ministry of Medical Services

       Client
Satisfaction Survey
       Report

            Final Draft


           March 2009
                                        ----------------- Final         Draft ------------------

TABLE OF CONTENTS
List of Figures ............................................................................................................................. iii
Acronyms and Abbreviations.................................................................................................... iv
Foreword ...................................................................................................................................... v
Executive Summary ................................................................................................................... vi

CHAPTER ONE Introduction ................................................................................................ 1
 1.1   Background .................................................................................................................. 1
 1.1.1 Health Status................................................................................................................ 1
 1.1.2 National, regional and global challenges.................................................................... 2
 1.1.3 Client/Patient Satisfaction ........................................................................................... 2
 1.2   Rationale ...................................................................................................................... 3
 1.3   The objective of the study ............................................................................................ 4
 1.4   Scope of work............................................................................................................... 4
 1.5   Outputs /Deliverables .................................................................................................. 4

CHAPTER TWO Methodology ............................................................................................. 5
 2.1   Survey design ............................................................................................................... 5
    g) Selection of the districts and health facilities .............................................................. 5
    h) Selection of clients ....................................................................................................... 5
 2.2   Structure of questionnaire ........................................................................................... 6
 2.3   Recruitment and training of the Research Assistants and Research Supervisors........ 6
 2.4   Field Work ................................................................................................................... 6
 2.5   Limitations of the study ................................................................................................ 6
 2.6   Data processing and analysis ...................................................................................... 7

CHAPTER THREE Findings ................................................................................................ 8
 1.1      Socio-demographic characteristics of the Clients ....................................................... 8
    a) Gender .............................................................................................................................. 8
    b) Client socio-demographic information............................................................................. 8
 1.2      Health facility utilisation ........................................................................................... 10
    a) Reason for seeking health services ............................................................................ 10
    b) Reason for choosing health facility ........................................................................... 11
    c) Availability of medicine ............................................................................................ 13
    d) User fees .................................................................................................................... 14
    e) Waiting time .............................................................................................................. 16
    f)    Attendance by staff .................................................................................................... 18
 1.3      Overall Satisfaction ................................................................................................... 19
 1.4      Suggested improvement ............................................................................................. 21

CHAPTER FOUR                                           Conclusions and Recommendations ............................. 23

References .................................................................................................................................. 25




                                                                                                                                              ii
List of Tables

Table 2.1: Distribution of the sample of health facilities, 2008 .................................................................. 12
Table 2.2: Distribution of Clients by type of health facility, 2008 ............................................................. 18
Table 3.1: Distribution of respondents by gender ....................................................................................... 16
Table 3.2: Client Background Information ................................................................................................. 15
Table 3.3: Travel to Health Facility ............................................................................................................ 16
Table 3.4: Reasons for seeking care ............................................................................................................ 18
Table 3.5: Is this your first time visit? ........................................................................................................ 17
Table 3.6: Clients main reasos for choosing a specific facility type, 2008 ................................................. 20
Table 3.7: Did you obtain the medicine that was prescribed?..................................................................... 16
Table 3.8: If you received some/none, what were the main reasons? ......................................................... 18
Table 3.9: Did you pay for the following goods and services? ................................................................... 16
Table 3.10: Client views on user fees ......................................................................................................... 18
Table 3.11: Suggested improvements in health facilities ............................................................................ 24




List of Figures
Figure 3.3: Average waiting time between registration and seeing the clinician ..........................15
Figure 3.4: How would you describe the staff who attended to you? ...........................................17
Figure 3.5: Will you return or recommend a friend to this facility? ..............................................17
Figure 3.6: Client satisfaction by province ....................................................................................19
Figure 3.7: Client satisfaction by facility type...............................................................................19




                                                                                                                                    iii
Acronyms and Abbreviations

AOP       Annual Operational Plan
CHEWS     Community Health Extension Workers
DH        District Hospital
DMS       Director of Medical Services
DPM       Directorate of Personnel Management
EN        Enrolled Nurse
ERS       Economic Recovery Strategy for Wealth and Employment Creation
FBO       Faith Based Organisation
FY        Financial Year
HR        Human Resources
HRD       Human Resource Development
HRH       Human Resources for Health
HRIS      Human Resource Information System
HRM       Human Resource Management
HRP       Human Resource Planning
KEPH      Kenya Essential Package for Health
KHPF      Kenyan Health Policy Framework
KHSWAp    Kenyan Health Sector Wide Approach
MDG       Millennium Development Goals
MOH       Ministry of Health
MOMS      Ministry of Medical Services
MOPHS     Ministry of Public Health and Sanitation
NGO       Non-Governmental Organisation
NHSSP     National Health Sector Strategic Plan
NSHIF     National Social Health Insurance Fund
OPD       Out-Patient
PAS       Performance Appraisal System
PGH       Provincial General Hospital
PRSP      Poverty Reduction Strategy Paper
PS        Permanent Secretary
PSC       Personnel Service Commission
PSRP      Public Sector Reform Programme
RRI       Rapid Results Initiative
SDH       Sub District Hospital
ToRs      Terms of Reference
WHO       World Health Organisation




                    Client Satisfaction Survey, 2008                      iv
Foreword


T      his report presents the findings of the 2008 client satisfaction survey and contains
       information on clients’ perspective of health services in public health facilities. The
       results of the survey was used in conjunction with the 2007 client satisfaction survey
results as well as other information to identify areas where improvements can be made or
policies changed. It is hoped that the information contained in this report will be used to help
health facilities to continue to improve health care services. Data which was used to
generate this report was collected in December 2008.

The Ministry would like to acknowledge and thank the following people who played a
crucial role in implementing this survey and developing the resulting report. We are grateful to
the Department for International Development (DFID) and the World Health Organisation
(WHO) for providing financial assistance towards implementing the survey and their
representatives who provided valuable guidance, insight, and logistical support to the team. In
particular, we wish to acknowledge the support and assistance of Dr Richard Pendami of
LATH and Dr Humphrey Karamagi of World Health Organisation (WHO). We are also
particularly grateful to Mr. Boni Mbuvi who worked tirelessly to ensure that data was entered
and analysed and Ms. Jane Kibisu for leading the survey and writing the report, their assistance
is much appreciated.

The heads of departments and divisions provided overall direction and guidance to the
survey process including the strategic approach and the review of survey instruments.
They also provided valuable assistance in extensively and critically reviewing the
survey draft findings of this report. Their dedication is highly commended.

Finally, we are grateful to the survey data collection personnel who administered the survey
instruments. Not forgetting also, the clients in the sampled health facilities who we had
privilege of interviewing. This study would not have been possible without their kind
cooperation and the rich information they provided forms the actual basis of this report. The
preliminary findings of this report were presented to the Ministry of Health and donor
agencies in January 2009.

Should you have any queries or comments regarding this report, please do not hesitate to
contact the Planning Department either by email to plan@health.go.ke, by telephone at (254)-
20 – 271 70 77.For further information on MOMS documents/publications and other activities,
you are encouraged to visit our website, www.health.go.ke.


Department of Policy Planning
Ministry of Medical Services, Nairobi
March 2009




                            Client Satisfaction Survey, 2008                                  v
Executive Summary

With the recent changes in the health care delivery system, health care consumers, and
health providers have become increasingly interested in assessing the quality of care.
Despite government efforts in instituting health reforms, global, regional and national
challenges such as Kenya’s post election turmoil which took place in early 2008, brain
drain and other emerging diseases continue to weigh down these efforts. However, the
government still continues to provide health care for all Kenyans and this study
provides a basis for understanding the extent to which service provision in government
public health facilities are meeting client’s expectation. The survey gathered
information from a representative sample of thirty two public health facilities under the
Ministry of Medical Services. The survey collected information from clients visiting
sub-district hospitals, district hospitals and provincial general hospitals. The referral
hospitals were not included in the sample. A total of nine hundred and fourteen (914)
out of the targeted nine hundred and thirty (930) clients participated in the survey whose
main purpose was to determine the levels of customer satisfaction with the services
being provided in levels 4 and 5 public health facilities. The survey which was
undertaken in December 2008 also forms a benchmark to measure the extent to which
the client service charter is being implemented. We hope that the survey results will be
used to design specific initiatives or programs tailored to patients’ needs as perceived
by patients and service providers.

Through exit client interviews, the survey collected information on customer
satisfaction. Several components of the quality of health care was assessed by patient
reports on their experience such as access to care (travel distance to get to health facility
as well as waiting time) and access to treatment (drugs), interpersonal aspects of
medical care, and some aspects of outcomes of care. Other aspects of affordability of
health care as well as clients views on health facility infrastructure were also sought.
Information about patients’ satisfaction with medical care and perceptions of outcome
has to date, been extremely limited. This study as well as the 2007 client satisfaction
survey results combined provides a good basis for understanding levels of client/patient
satisfaction in public health facilities.

Respondent background information
    Respondent’s characteristics were relatively similar in 2008 compared to 2007.
      The respondents were predominately female representing 65% of the survey
      population compared to 72% in 2007. Majority of the respondents (43%) had
      attained primary education compared to 50% in 2007, 27% were self employed
      while 21% were housewives.

Health service utilisation
    The findings show that clients with up to primary level education (81%) use the
      district hospitals and sub district hospitals than provincial hospitals (19%).
      Clients with secondary and post secondary education sought health care service


                           Client Satisfaction Survey, 2008                               vi
       more from provincial and district hospitals (71%) than sub district hospitals
       (29%). In addition, majority of the unemployed persons and students seek health
       services from the sub district hospitals and district hospitals than provincial
       hospitals (15%). This finding compares to the 2007 findings which showed that
       59% of clients with post secondary education tend to visit hospitals more than
       health centres and dispensaries.

Access to care
    The results show that 44% of survey population took public transport and 39%
       walked to get to the facility. The overall average distance that clients travelled to
       reach a health facility was about 11 kilometres. However, 53% of the survey
       population were within 5 kilometres to a health facility compared to 67% in
       2007 (the 2007 study included interviews with respondents also visiting health
       facilities in levels 2 and 3).

      Proximity to home continues to be the most important factor, overall, cited by
       two-thirds (72%) of the respondents for choosing a health facility compared to
       63% in 2007. Medicine availability (27.7%) and good staff advice (21.6%) in
       that order were also cited as important factors clients consider in choosing to
       visit a health facility.

      Thirty seven percent of the sample population bypassed a closer government
       facility on the day of the interview to seek services from another facility mainly
       on account of good advice given by staff (cited by 41% of the respondents) in
       PGHs compared to 29% in sub-district hospitals. Thirty four percent (34%) of
       clients visiting DHs cited availability of medicine (34%) compared to 26% in
       sub-district hospitals.

      The most common reason cited for attending the health facilities was to receive
       treatment (56.2%), for medical examination (20.7%) and under preventive care,
       immunizations (7.79%).

Waiting time
   The findings show that the average waiting time between registration and seeing
      the clinician was 56% below acceptable standards as per the citizen’s service
      charter for delivery of medical services. However waiting time during
      consultation met the standards by 75% and service delivery at pay point met the
      standards by 80%.

      One in four respondents (28%) reported waiting for up to 10 minutes to see a
       clinician, another less than half (48%) was served within an hour. Less than 8%
       reported waiting for more than two hours. Half of the clients (58%), considered
       30 minutes the maximum time they could wait in order to be satisfied, whereas
       only 16% would accept more than one hour.




                           Client Satisfaction Survey, 2008                              vii
Availability of drugs
    Most of the clients according to the survey reported to receive a partial
      prescription (48%) which is an increase of 14% between 2007 and 2008.
      However, results also show a decline of 12% of clients who reported to receive
      all the drugs following consultation.

      The proportion of respondents that received all the medicine is substantially
       higher (averaging, 58%) in sub district hospitals, compared to 42% in provincial
       hospitals. This similar trend was observed in the 2007 survey where 81% of
       clients who visited dispensaries received all the medicines prescribed compared
       to 66% in health centres, 57% in district hospitals and 40% in PGHs. Majority of
       the respondents who did not receive all the drugs reported that the drugs were
       unavailable (84%) as opposed to clients not having enough money to purchase
       the drugs (11%).

User fees
    The survey results show an increase of 20% of client’s who reported user fees as
       being high.
    About 30% of clients rated charges for medicine and consultation as high
       compared to charges for laboratory services (29.4%). These results vary
       significantly compared to the findings in the 2007 survey where most of the
       clients (about 60%) reported user fees as being within limit.

Attendance by staff
    The findings show an overall increase in satisfaction with staff attendance by
      17% between 2007 and 2008
    Over 90% of clients were satisfied with the staff attendance. Ninety three
      percent of the clients said that the staff were friendly, 94% said that they were
      helpful and 90% said that the staff were courteous. There was a very big
      variation in client satisfaction rating of staff in the various provinces. The lowest
      rating for client satisfaction was North Eastern province where only 76.2% of
      staff described the staff as being friendly, helpful, courteous and attentive.
    However, of the four attributes which was used to measure staff attendance
      (friendly, helpful, attentive and courteous) the lowest attribute was courteous
      where 10% of the clients reported the staff as not being courteous.

Overall satisfaction
   The overall findings show a slight decline in client satisfaction between 2007
      and 2008.
   The survey results show a decline of 12% of clients who reported to receive the
      entire prescribed medicines post consultation visit. There was also an increase of
      20% of clients who reported user fees as being high between 2007 and 2008.
   The results also show no significant improvement in waiting time with most
      clients waiting for up to 47 minutes to see a clinician. This finding is almost
      similar to that observed in 2007 (49minutes).


                           Client Satisfaction Survey, 2008                            viii
      However, gains were noted in the 2008 survey and this needs be commended.
       Main areas where improvements were observed were in the manner in which the
       staff handled the patients/clients (staff attendance) and health facility
       environment. The results of the survey revealed that over 90% of clients
       reporting to be satisfied with the manner in which they were handled by health
       providers compared to 76% in 2007.
      Most of the clients also applauded the facility for being clean (83%)
      Results of client making return visits to health facilities show that two out of
       three respondents (68%) were satisfied because they received better information
       about service than in the previous visit, 62% reporting that the service was
       friendlier; 60% received required medicine while 57.3% reported shorter waiting
       time.
      The satisfaction rate with the health care services received was high (88%) with
       a cumulative measurement (satisfied, very satisfied). Results show that
       overwhelming majority (95%) would come next time they are ill. Again, 92%
       of the survey population said they would recommend the facility to others when
       they are ill. This results show a slight decline from the findings observed in the
       2007 survey were cumulative measurement of client satisfaction was 94%.

Suggested improvements by clients
    Key improvements suggested by the clients were: drug availability, cited by
      57% of the respondents, increase staff (36%) and reduce waiting time (28%).

D. Recommendations
The following summarises key recommendations to address patient/client satisfaction
with public health services;

 a)    Positive relations between clients and staff needs to be sustained through
       engaging the community in priority setting and in allocation of resources.

 b)    Health facility managers need to streamline patient/work flows in order to
       address the long waiting time observed by clients.

 c)    Health facility service charters needs to be displayed publicly at the facility in
       order to strengthen accountability. The charters need also to set out complaints
       and redress mechanisms in the event that the provider does not meet these
       standards.

   d) There needs to be a transparent system for user fees waiver. More funding needs
      to be allocated to funding waivers of facility fees to alleviate financial
      constraints to health services access by the poor.
 e)    In depth analysis will need to be done at health facility level to collect regular
       information on patient satisfaction.




                          Client Satisfaction Survey, 2008                             ix
   f) Logistics supply chain management for essential and public health goods needs
      to be strengthened in GoK facilities to ensure there are equitable supply of
      essential drugs at all levels.
Future studies should focus on evaluating the impact of rural diversity on client
satisfaction. In this case, the studies will need to define rural versus urban health
facilities. It would also be interesting to gather information on inpatient client
satisfaction and see how the results compare with exit interviews. The reason for in
patient client satisfaction stems from the fact that the experiences of in patients are
unique, the services provided to in patients are also more, there is longer patient
provider interaction than out clients and their observations are therefore likely to be
different from out patient. This should be able to give an interesting picture of overall
client satisfaction.




                          Client Satisfaction Survey, 2008                             x
CHAPTER ONE                                                            Introduction

1.1 Background
As part of Government’s re-organisation process, the Ministry of Health was split into two
new entities: the Ministry of Public Health and Sanitation and the Ministry of Medical
Services. The roles of the respective Ministries and functions were stipulated in the
presidential circular No.1/2008. Generally, the Ministry of Public Health and Sanitation
(MOPHS) was responsible for preventive and promotive health while the Ministry of
Medical Services was generally responsible for curative and rehabilitative services.

In its effort to deliver on an ambitious 30 year plan under vision 2030, the Government is
instituting reforms that seek to introduce efficiency and effectiveness in operations of
government institutions. This is intended to deliver on the overarching vision 2030 of a
globally competitive and prosperous nation, transform the health sector delivery systems
and more importantly reverse the worsened trends in health indicators. The health sector
therefore expected to play a critical supportive role in maintaining a healthy working
population. This enjoyment of individual well-being is important for the achievement of
goals in all other sectors of the economy, including, education, agriculture, tourism, trade
and manufacturing. The five year medium term plan (2008-2012) also clearly illustrates
the roadmap for achieving the health sector goals.

1.1.1     Health Status
Despite significant milestones that country has attained in embarking on a series of health
sector reforms intended to address the challenges in health care delivery, the levels of some
key health status indicators associated with mortality and morbidity of the population
observed in the 1990s have been worsened while the country has made little inroads to
achieving the Millenium Development Goals (MDGs). Some of the indicators including
infant mortality rate has increased from 71 per 1,000 live births in 1998, to 77 per 1,000
live births in 2003, maternal mortality is also high with approximately 14,700 women of
reproductive age dying annually due to pregnancy related complications. Immunization
coverage in Western province, Nyanza and Rift Valley, fall below the national average 1
and HIV/AIDS is still a serious problem though the prevalence rates in the country
declined from 13% to 7.8% (among persons age 15-49 years) between 2003 and 20072

The mid term review of progress towards achievement of NHSSP II done in November
2007 showed clear health inequalities between urban and rural areas as well as at regional
and district levels. It was also recognised that the goal of the health sector of reversing the
declining health status of Kenyans can only be achieved by involving the local population
in priority setting and in allocation of resources. The review also recognised the
importance of the ministerial service charter for health service delivery, the community as
customers with rights and as claimants with legitimate demands on the health services.
According to the review team, the challenge for the Ministry was to develop health facility

1
    MoH (2007) Joint Design Mission Report
2
    KAIS (2007) Kenya AIDS Indicator Survey Report



                                                                                             1
specific service charters as planned by the ministry. The health facility level charter was to
provide information on the services available and specific standards of care. These health
facility service charters will then need to be displayed publicly at the facility in order to
strengthen horizontal accountability. The governance structures will need to undergo
fundamental change to allow the community ownership3

1.1.2    National, regional and global challenges
The political instability in the Eastern Africa region and subsequent displacement of
people has resulted in increasing the demand for health services in the country. The influx
of refugees from neigh boring countries has contributed to the demand for services and at
the same time increased the risk of spreading communicable diseases. In early 2008,
Kenya experienced post-election violence that led to an estimated 1,500 deaths and
displacement of nearly 300,000 people. Medical staffs were displaced or could not access
the workplace. About 30 per cent of the health facilities in affected areas became non-
functional. Patients with chronic diseases such as tuberculosis, hypertension, diabetes, and
HIV/AIDS and those in need of reproductive and maternal and child health services were
seriously affected. In particular, the supply of drugs for PMTCT and ART were disrupted 4

Brain drain is another pervasive challenge facing the country. Data from the Kenya
Nursing Council indicate that many nurses have left or are planning to leave Kenya for
work overseas. Between 2000 and 2006, 4,757 nurses have applied to have their
certificates validated to enable them to work for employers overseas. The most noteworthy
losses are to the UK and the USA5.It is the most qualified and experienced staff in
employment that migrate, which means the health service has to rely on more junior and
less experienced staff.


1.1.3        Client/Patient Satisfaction

One of the primary concerns of the Ministry therefore revolves around the issue of
patient/client satisfaction. In today’s market, individuals are faced with many different
options when deciding on a specific healthcare provider. Due to the varying options,
quality and service stands out as two essential elements that influence the selection
process. Thus, a healthcare provider’s reputation for its commitment to quality and patient-
centred customer service stands as one of the main criteria for individuals in choosing a
healthcare service provider. The Ministry strives to ensure that the health of every Kenyan
underscores all programs and activities that drive its operation. This will be achieved
through the efficient utilization of the available resources to deliver services. Thus in
improving health care service delivery, employee and patient satisfaction become crucial.
One of the most effective tools that the government uses to measure how well services are
provided to clients is through a client satisfaction survey. Client/Patient satisfaction is a
relative concept, a reflection of the patients’ evaluations on the quality of care, which relies


3
    MoH (2007) NHSSP II Mid Term Review Report
4
    Draft Ministry of Public Health and Sanitation Strategic Plan (2008-2012)
5
    Nursing Council of Kenya Out Migration Statistics, 2007



                                                                                              2
on a subjective standard. The study described here evaluates patient satisfaction, as a
measure of the quality of health care services provided by the public health system.

Client/Patient satisfaction is an attitude about service, service providers or patient’s health
status6. It is a component of healthcare quality and is increasingly being used to assess
medical care in many countries. Patient satisfaction is deemed an important outcome
measure for health services. As part of providing quality health care, addressing consumer
satisfaction becomes paramount. Patient satisfaction is an important measure of healthcare
quality because it offers information on the provider’s success at meeting the expectations
of the client. Patient satisfaction has been an important issue for health care managers.
Many previous studies have developed and applied patient satisfaction as a quality
improvement tool for health care providers7. Following increased levels of competition and
the emphasis on consumerism, patient satisfaction has become an important measurement
for monitoring health care performance of health plans8. This measurement has developed
along with a new feature: the patient's perspective of quality of care9.

Various dimensions of patient satisfaction have been identified, ranging from admission to
discharge services, as well as from medical care to interpersonal communication. Well-
recognized criteria include responsiveness, communication, attitude, clinical skill,
comforting skill, amenities and food services. It has also been reported that the
interpersonal and technical skills of health care provider are two unique dimensions
involved in patient assessment of hospital care

Determinants of patient satisfaction have been reported extensively. According to previous
studies, patient characteristics such as age and education may influence a patient's
assessment of hospital performance10.A patient's health status and the severity of illness is
also important predictors of the patient's overall satisfaction level. Hospital features such as
hospital size have been reported to be associated with consumer assessment of hospital
quality. The relationship between health care providers and patients (i.e. interpersonal skill)
has been reported to be the most influential factor for patient satisfaction11.

1.2 Rationale
The main aim of conducting the client satisfaction survey was to find out the level of
customer satisfaction with the health care delivery at public health facilities. Patient
feedback is important for gaining an understanding of the level of client satisfaction. An

6
    Hall JA, Dornan M. (1988-1). What Patients Like About Their Medical Care.
7
    Young GJ, Meterko M, Desai KR (2000) Patient satisfaction with hospital care
8
    Jatulis DE et al (1997) Identifying predictors of satisfaction with access to medical care and quality of care .
9
    Rubin HR (1990) Can patients evaluate the quality of hospital care?


10
   Hargraves JL et al (2001), Adjusting for patient characteristics when analyzing reports from patients about
hospital care.
11
   Cleary PD, McNeil BJ. (1988) Patient satisfaction as an indicator of quality care




                                                                                                                       3
understanding of the determinants of client satisfaction helps policy and decision makers to
implement programmes tailored to meet patients’ needs as perceived by patients and
service providers. This is in line with the vision, outlined in the current National Health
Sector Strategic Plan II (NHSSP II), as “an efficient and high quality care system that is
accessible, equitable and affordable for every Kenyan”. The data gathered through
measuring patient satisfaction accounts for the level of care delivered by health staff and as
a result holds health staff accountable for their service. The information generated from the
survey will not only be used as a tool in decision-making but will also be used as a
barometer for assessing any improvements that has occurred since the earlier survey
conducted in 2007 and make further recommendations on improving the experience of
clients being seen at public health facilities in Kenya.

1.3 The objective of the study

The objective of this study was to: (1) determine the level of patient satisfaction related to
care received; (2) determine what variables are correlated to satisfaction with healthcare;
and (3) identify any unique characteristics associated with the care provided.


1.4 Scope of work
The client satisfaction survey was commissioned by MOMS. The sample for purposes of
collecting data covered public health facilities in level 4 (district and sub district hospitals)
and level 5 (provincial hospitals). Level 6 facilities were not covered in this scope of work.


1.5 Outputs /Deliverables
As indicated in the TOR, the following were the expected outputs:

  Draft report to be presented to the recipients for comments which would subsequently
   be incorporated into the final report.

  Detailed interpretative report describing the results from the survey also showing
   quantitative cross-tabulated analyses by the key variables.

  The report which must contain an executive summary which fully summarises the
   survey aims, processes and key findings.

  Verbal presentation with associated visual aids (PowerPoint or similar) to be made to
   the recipients, which fully summarises the survey aims, processes and key findings.




                                                                                               4
CHAPTER TWO                                                           Methodology

2.1     Survey design
The results of this survey were based upon information obtained from a randomly drawn
sample of 930 clients attending public health facilities in Kenya. The respondents were
randomly selected from 32 health facilities (7 provincial general hospitals, 16 district
hospitals and 8 sub districts). The second stage involved the selection of the appropriate
numbers of respondents from the different health facilities based upon the reported
workload and establishing a selection-rule for interviewers, such that gender mix was
taken into account. Very ill patients were excluded from participating in the survey.


g)     Selection of the districts and health facilities

The survey covered 10% of the districts in the country. Sixteen districts were randomly
sampled, apportioning two districts per province. All the provincial general hospitals
(Level 5), district and sub district hospitals (Level 4) in the selected districts automatically
became part of the sample. In total, 31 health facilities were selected for the survey. Table
2.1 below shows the distribution of facilities selected for the 2008 client satisfaction
survey.

Table 2.1: Distribution of the sample of health facilities, 2008
 Province            District                         PGH            DH             SDH            TOTAL
 Nairobi             Nairobi North & West                             2              1                3
 Central             Kiambu & Nyandarua                  1            2              1                4
 Coast               Kwale & Voi                         1            2              1                4
 Eastern             Meru & Kitui                        1            2              1                4
 North Eastern       Garissa & Wajir                     1            2              1                4
 Nyanza              Kisii & Homabay                     1            2              1                4
 Rift Valley         Kajiado & Koibatek                  1            2              1                4
 Western             Bungoma & Vihiga                    1            2              1                4
                     TOTAL                               7           16              8               31

h)      Selection of clients
Overall, 930 clients were targeted for interviews. The number was considered adequate as
the clients were randomly selected from the outpatient departments and excluded very ill
clients/patients. Table 2.2 shows the distribution of clients in the sampled facilities.

Table 2.2: Distribution of Clients by type of health facility, 2008
 Type of facility           Number of Clients to be           Number of Clients              Response
                                    interviewed              actually Interviewed              rate
 Provincial Hospitals                   210                           208                      99%
 District Hospital                        480                             390                 81.3%



                                                                                              5
 Sub District Hospital                    240                           316                  131.7%
 Total                                    930                           914                   98.3%

A total of 914 clients were interviewed, thus resulting in an overall response rate of about
98.3%.

2.2       Structure of questionnaire

The key socio-demographic variables covered by the survey instrument included gender,
age, work status and education. Information on the distance to get to the health facility,
means used to get to the health facility as well as time taken to reach the health facility was
also sought. The questionnaire also captured client perceptions on various health aspects
including availability of drugs, waiting time, fees for services; cost of drugs and their
personal experience at the facility. The questionnaire was designed to be brief enough,
practical and user-friendly but thorough enough to cover key factors that are important to
outpatient health care service. The questionnaire is presented in Annex 1.

2.3      Recruitment and training of the Research Assistants and Research Supervisors

A team of thirty two Research Assistants were recruited to participate in the survey. A two
day training workshop was held in Nairobi for the Research Assistants together with 8
MOMS staff who were pre-selected by the Ministry to act as Research Supervisors. The
participatory training included a review of the survey objectives and methodology,
introduction and discussion of the questionnaire, discussions on ethics, integrity, as well as
data quality and best field practices. Other areas covered were field logistics. Since the
questionnaire had been pre-tested in the 2007 survey, it was agreed that the Research
Assistants proceed to the field after the training. However to increase familiarity with the
instrument, role plays were used during the training.


2.4      Field Work
After a two day training with Research Assistants and Supervisors, comments and
feedback on the questionnaire was incorporated to generate the final survey questionnaire.
A team of four Research Assistants and one MOMS field supervisor per province were
then deployed to the field for data collection, where each team covered two districts. The
MOMS Field Supervisors ensured that data gathering activities went on smoothly and
efficiently. The data was collected through interviews to clients in the sampled facilities.
The survey instrument was administered to the clients exiting from the outpatient
departments in the sampled health facilities.

2.5      Limitations of the study

This study had limitations which must be acknowledged. First, comparing results of 2007
and 2008 in some instances was also difficult as health facilities in 2007 was categorised as
hospitals (comprising provincial general hospitals, district hospitals, sub district hospitals


                                                                                             6
together) while these health facilities were categorized separately in 2008. As a result, the
reader should be cautioned that overall satisfaction in 2007 may also include client
satisfaction in levels 2 and 3 public health facilities. Second, the research relied on
subjective data provided by the respondents and it was not possible to externally validate
these responses. Despite these limitations, results of these interviews should provide some
valuable feedback regarding the level of satisfaction that the Ministry can use over the next
year.

2.6   Data processing and analysis
Completed questionnaires were returned to Afya House where they were cleaned, entered
and edited by data processing personnel specifically trained for this task. The coded data
were initially entered using EPI Data entry software. Data were analyzed using the
Statistical Package for the Social Sciences (SPSS) for Windows, version 12, SSPS Inc.,
Chicago, IL, USA). Excel application was also used. Data processing took place between
17th December 2008 and 16th January 2009.




                                                                                           7
 CHAPTER THREE                                                                Findings

 1.1 Socio-demographic characteristics of the Clients

 The survey gathered demographic and other social data including gender of respondent,
 level of education and socio-economic status. Comparing the 915 clients interviewed in
 this survey to those interviewed in 2007 (1,170), the two samples were similar in
 composition, except for a few differences.

 a) Gender
 Customer information often starts with demographics; gender, age, household income,
 place of residence, and other information that is generally gathered from sources such as
 census data. There is need to know the main consumers of public health services. Knowing
 the customers, will help the government to know which products or services are most
 important to the clients, the type of products or services that they would like offered, the
 times/ hours that fit the client schedules, and other matters that are important to the client.
 To ensure that a good base is set to understanding the customer, the survey sought to find
 out client socio-demographic details key among them is gender. From the survey findings
 summarised in table 3.1 and 3.2, majority of clients were interviewed after seeking services
 for a child or family member (52%). Of these clients, majority were females (65%).

 Table 3.1: Distribution of respondents by gender
                                   2007                                    2008
                         Frequency     Percentage (%)          Frequency          Percentage (%)
Male                        323             27.6                  318                  34.8
Female                      847             72.4                  594                  65.2
Total                      1,170            100                   912                  100



 b) Client socio-demographic information
 Additional information was sought regarding level of education, employment status and
 travel distance to facility. All this was geared towards understanding the client’s literacy,
 health seeking behaviour and household income sources. About 35% of these respondents
 who were interviewed had secondary education, another 27% were self employed while
 21% were house wives. The main means of transport which was used to get to the facility
 was public transport 44% whereas 39% walked to the facility. The results show that
 majority of people seek health facilities which they can easily access. The findings also
 show that the majority of the clients are literate with primary level education.

 The results for the survey also indicate that survey population with up to primary level
 education (81%) use the district hospitals and sub district hospitals than provincial
 hospitals (19%). Respondents with secondary and post secondary education sought health
 care service more from provincial and district hospitals (71%) than sub district hospitals



                                                                                              8
(29%). In addition, majority of the unemployed persons and students seek health services
from the sub district hospitals and district hospitals than provincial hospitals (15%)


Table 3.2: Client socio-demographic information

                                                           2008               2007
                                                       Number   %         Number   %
Time of Interview            After Services               435      48%      724       58%
                             Received Self
                             After Services               477      52%      446        42
                             Provided Child or
                             Family Member
Highest Level of             None                          99      11%      154      13.2%
Education Attained By        Primary                      390      43%      589      50.3%
Respondent
                             Secondary                    316      35%      373      31.9%
                             Post Secondary               108      12%       54       4.6%
Current Work Status of       Formal Employment            107      12%      126       12.1%
Respondent                   Self-Employed                247      27%      208       20.0%
                             Farmer                       158      17%      246       23.7%
                             Housewife                    190      21%      256       24.6%
                             Student                       39       4%      119       11.5%
                             Unemployed                   140      15%       57        5.5%
                             Other                         30       3%       27        2.6%
Main method of               Public transport             406      44%      385       32.9%
transportation to get to     Private transport             38       4%       20        1.7%
the facility                 Walked                       360      39%      682       58.3%
                             Bicycle/motor cycle          103      11%       58        5.0%
                             others                                          25        2.1%
Total                                                     915     100%     1,170     100.0%


Further results show that 44% of survey population took public transport and 39% walked
to get to the facility. The overall average distance that clients travelled to reach a health
facility was about 11 kilometres. However, 53% of the survey population were within 5
kilometres to a health facility. The table below (Table 3.3) shows the respondent travel to
facility information.




                                                                                            9
Table 3.3: Travel to Health Facility
                                                  Mean (2007)        Mean (2008)
            What distance did you cover to
                                                      8.8                  11.7
            get to the facility? (Km)

            How long did it take you to get to
                                                      48                   45
            the facility? (Minutes)




1.2 Health facility utilisation
The survey examined various aspects of utilisation of health facility and satisfaction levels
for the services received. The table below highlights the feedback which was received from
the clients. (Table 3.4)

a) Reason for seeking health services
In order to seek responses on service utilisation, the clients were asked “What are the
reasons for seeking medical care at this facility”. Multiple answers were accepted in their
responses. A majority of respondents (56%) said that they were seeking to receive
treatment and while others (20.7%) mentioned medical examination as the reason for
seeking care. Few respondents (1.2%) mentioned that they had come for delivery and 1.6%
minor surgery as shown in Table3.4 below
Table 3.4: Reasons for seeking care
 Type of
facility          PGH %            DH    %        SDH %            Total (2008) Total (2007)
                  Count %          Count %        Count %          Count %      Count %
 Receive
treatment            114 43.85       277 55.4      244 66.12         635 56.2      1016 86.8



Immunization          16    6.15      41    8.2     31       8.4      88 7.79      208 17.8

Antenatal             17    6.54       8    1.6     10      2.71      35     3.1   145 12.4
 Family
planning               6    2.31      15      3     11      2.98      32 2.83      136 11.6
Delivery               5    1.92       9    1.8      0         0      14 1.24       59 5.0
Minor
Surgery (inc
circumcision)          5    1.92      12    2.4      1      0.27      18 1.59        18    1.5




                                                                                          10
 Type of
facility           PGH %             DH    %             SDH %          Total (2008) Total (2007)
                   Count %           Count %             Count %        Count %      Count %

 Medical
Examination             60 23.08          112 22.4         62    16.8     234 20.7      332 28.4
Other health
related
matters                 37 14.23          26      5.2      10    2.71      73 6.47    96        8.2
                                                                          112        112
                      260      100        500 100         369 100       9      100 9            100


Most clients in 2007 (86.8%) and 2008 (56.2%) said they had visited the hospital to
receive treatment and for medical examination, 20.7% (2008) and 28.4% (2007). Clients
visiting SDH for treatment in 2008 was the highest 66% and lowest at PGH (43%) Clients
who had visited the health facility for minor surgery were more in DH than in the other
facilities, 2.4% and 1.9% in PGH, 0.27% in SDH. Figure 3.1 below summarises the
findings.

b) Reason for choosing health facility

Clients were also asked whether the facility they were visiting was the nearest government
health facility to them and whether this was their first visit. Twenty percent of the clients
were visiting the facility for the first time compared to eleven percent in 2007. Thirty seven
percent of the sample population had bypassed a closer government facility on the day of the
interview to seek services from another government facility on the day of the interview.
Table 3.5 summarises clients’ response to health visit practices.

Table 3.5: Visit to health facility, 2008?

                                            TYPE OF FACILITY                TOTAL

                                       PGH            DH           SDH         2008      2007
                                     No. %         No. %         No.  %     No. %      No. %
Is this your first time visit to
this facility? YES
RESPONSES                            31    14.9     94    24.1   71   22.47 196 20.49 113 11.4
Is this the nearest government
health facility to your home?
YES                                  99    47.6 240 61.7 252 79.75 591 63.01            -   -


From the above Table 3.5, there was an increase in the number of respondents who were
visiting the facility for the first time, 20.4% (2008) compared to 11.4% in 2007. Seventy
nine percent of clients interviewed at the SDH said that the government facility is the


                                                                                                11
nearest facility to their homes, compared to 61% of clients interviewed in DH and 47.6% in
PGH. The results show that a majority of clients who visited the PGH (47%) came from far
while those visiting the SDH lived close to the facility.


Clients who had made previous visits to the facility were asked how the visit compared to
their previous experience. The responses were cross tabulated with level of satisfaction and
Figure 3.2 below illustrates their responses. The result show that two out of three
respondents (68%) were satisfied that they received better information about service than
in the previous visit, 62% were satisfied with the friendlier service than previous; 60%
were satisfied that they received required medicine while 57.3% were satisfied with the
shorter waiting time.



            Figure 3.2: Level of satisfaction with current visit compared with your
                                     previous experienc e?

    Shorter waiting time
                                        n=412         57.3
       than previous

  Received the required
                                                     n=432            62
 medication than previous

     Received better
                                        n=496                                         68
information about service

  More friendlier service
                                            n=448                     62
      than previous

                            50   52    54       56    58     60   62       64   66   68    70

                                      % of satisfied or very satisfied responses
                                                        Total n=716




Respondents were also asked to give three main reasons for visiting the health facility. The
Table 3.3 below presents the findings

Majority of the clients who were interviewed said that the main reason why they chose to
visit the health facility was because it is close to home (54%). The second most important
reason that clients gave for visiting the health facility was availability of medicine (28%)
while the third was that staff give good advice (21.9%). The results of the findings show
that most clients visit health services that they can easily access, where they can get the
medicines available and where the staff give good advice. The clients also valued the cost
for service (11.2%) and good staff attitude (11.2%). The table below shows the variation
per facility level




                                                                                            12
Table 3.6: Clients’ Main Reasons for choosing a specific facility by type, 2008

                          Provincial                                                   Total*
                                             District      Sub District       Total*
        Reason            General                                                       2007
                                             Hospital      Hospital            2008
                          Hospital
Number                            212           385               330           927     1170
                                 33.3          26.2              12.5
Was referred                                                                    22.5      8.5
                                n=69         n=101              n=39
                                 40.1             49                72
Close to home                                                                   53.7     67.1
                                n=83         n=191             n=224
                                 12.3            8.3             13.7
Good staff attitude                                                             11.1     18.9
                                n=26          n=32              n=45
                                   6.1           7.5             10.6
Less waiting time                                                                8.3     10.1
                                n=13          n=29              n=35
                                 18.4             34                26
Medicine available                                                              27.7     45.3
                                n=39         n=131              n=87
                                 20.7          11.2                9.5
Less costly                                                                     11.2     29.8
                                n=44          n=43              n=17
                                   4.4           8.2               9.5           4.6
Cleaner facility                                                                          4.5
                                 n=6          n=21              n=17
                                 41.9          35.1              29.6
Staff give good advice                                                          21.6     16.2
                                n=57          n=90              n=53
                    * Don’t add up to 100% as multiple choices were allowed

The survey findings revealed that 53.7% of clients who visited public health facilities in
2008 did so because the facilities were accessible to them. The findings revealed that
clients visited the provincial hospitals more because of the good advice they received from
the staff 41.9%. They also chose to visit the PGH when they are referred, 33.3%, and
because of the low cost 20.7%. On the other hand, the main unique reason for visiting the
district hospitals emerged as availability of medicine 34% while the sub district hospitals
were preferred for being close 72%, good staff attitude 13.7%, and less waiting time
10.6%. The sub district hospitals were also preferred for their cleanliness 9.5% than other
facilities (DH, 8.2% and PGH 4.4%)


c) Availability of medicine
Adequate and regular supply of medicine is necessary for effective and efficient health
service delivery. Information on the availability of prescription medicine was sought from
clients. The survey results show that most clients received at least some drugs following
consultation: 52.9% another 38% received only some while 8% got none. The availability
of prescription medicine by facility was forty two percent in PGH, 55.7% in DH and
58.1% in SDH. Thirty four percent of the clients said that the reason why they did not get
the medicine was because it was not available. The table 3.7 below gives further details.




                                                                                          13
Table 3.7: Did you obtain the medicine that was prescribed
                                                                            Total
                                Facility Type
                                                                          2008            2007
                PGH        DH       SDH
             Count %    Count %  Count %  Count %   Count %
Yes     2008  69   42.5 182 53.6 161 58.1 412 52.96 640 63.9

        2007     73      39.7    124     57.4
                                                   -      -
Some 2008        69      42.5    137     40.4     93     33.5    299     38.43      348   34.7

        2007     107     58.2     86     39.8
                                                   -       -
None    2008     24      14.8     20      5       23      8.4     67      8.61      14      1.4

        2007      4      2.2      6      2.8
                                                   -         -
                                 Total                                     100    1002     100


From the results, availability of medicine is seen to be more at the level 4 levels than at the
level 5 facilities with 58% of clients seen at the SDH reporting to receive medicine
compared to 53.6% at the DH and 42.7% at the PGH.

The Clients were also asked, “If you received some/none, what were the main reasons?”
Eighty four percent (84.9%) of the clients said that the reason why they did not receive
medicine was because the drugs were not available. Another 11.8% said that did not have
enough money to buy the drugs. Table 3.8 below summarises the findings.

Table 3.8: If you received some/none, what were the main reasons?

                                                  Frequency        %
   Drugs not available
                                                       316        84.9
   Did not have enough money                            44        11.8
   Drugs expensive, will buy elsewhere                  11        3.0
   Will use drugs available at home                      1        0.3
   Total                                               372        100


d) User fees
Cost-sharing has contributed tremendously towards the country’s health care financing by
supplementing non-wage recurrent expenditures, thus keeping many government hospitals
running at a time of economic difficulties. These benefits notwithstanding, fears have been


                                                                                            14
expressed that, with the policy, the vulnerable groups may be denied access to health care
as has been found in various countries including Kenya12,13. Against this background, a
number of questions were asked, particularly concerning whether fees were charged for
user fees and how the clients rated the cost for various services.

Thirty one percent of the clients who were interviewed rated the charges for the various
services as high. Clients who rated charges for medicine as high was 34.1% of clients
followed by consultation fees (32%) and lab charges (29.4%).

Clients were also asked whether they paid for various services; 53% of the clients who
visited the various health facilities said that they paid consultation fees and 46% said that
they paid for medicines. On the other hand only 33% said that they paid for laboratory
services. Table 3.9 below summarises the responses.

Table 3.9: Did you pay for the following services or goods?


Service               PGH                  DH                    SDH                  Total
                      Count     %          Count      %          Count     %          Count     %


Consultation    Yes       103       51.5        190       56.5      143        51.8      436         53.7
                No         97       48.5        146       43.5      133        48.2      376         46.3

Lab             Yes        64       32.7         94       27.5      117        42.5      275         33.8
                No        132       67.3        248       72.5      158        57.5      538         66.2

Medicine        Yes        89       46.1        184       52.1      115        39.7      388         46.4
                No        104    53.886         169       47.9      175        60.3      448         53.6

TOTAL                   208                  390                  316                  836


Fifty three percent of the clients who were interviewed had paid consultation fees. Fifty six
percent of the clients who visited the DH paid for consultation fees compared to 51% who
visited the PGH and the SDH. The clients were further asked how they rate the charges
34% of the clients rated the fees for medicine as high, an almost equal number rated the
fees for consultation (32%) and for laboratory services (32%) as high. Further analysis by
facility type showed that 37% of the clients seen in the Provincial Hospital said that the


12
   Moses, et. al (1992), “ The Impact of User Fees on Attendance at a Referral Centre for Sexually
Transmitted Diseases in Kenya.” Lancet 340 (August 22): 463-66
13
   Mwabu, G. and Wang’ ombe, J. (1995), “User Charges in Kenya: Health Service Pricing Reforms in
Kenya: 1989 – 93.” A report on work in progress. Ihpp working paper Moses * delete as applicable


                                                                                                      15
fees charged for consultation was high while 49% of clients seen at the Sub-District said
that the fees for consultation and lab services were within limits.


Table 3.10: Client views on user fees

                              Consultation             Lab              Medicine

Facility
type                          Count          %          Count     %        Count         %
                  High         50            37.9         41     32.0        54         40.6
Provincial        Low          24            18.2         37     28.9        39         29.3
General        Within limit    58            43.9         50     39.1        40         30.1
Hospital
                  High          69           31.9         56     30.1        88         35.8
                  Low           45           20.8         48     25.8        55         22.4
District       Within limit    102           47.2         82     44.1       103         41.9
Hospital
                  High         51            27.9         45      27         67         28.9
                  Low          41            22.4         40      24         55         23.7
Sub District   Within limit    91            49.7         83      49        110         47.4
Hospital



e) Waiting time
Client waiting time is a key determinant of quality service as well as access to service. If a
health facility has restrictive hours of operation, individuals in need of its services may not
be able to access service as and when they need to for health reasons. Client waiting time
may also have an impact on clinical outcome. Information on waiting time was provided
by the clients rather than being based on interviewer’s observation.

Findings following interviews with the clients show that one in four respondents (28%)
reported waiting for up to 10 minutes to see a clinician, another less than half (48%) was
served within an hour. Less than 8% reported waiting for more than two hours. Half of the
clients (58%), considered 30 minutes the maximum time they could wait in order to be
satisfied, whereas only 16% would accept more than one hour.

Further questions included in the survey instrument related to the length of waiting time
between seeing the clinician and dispensing of drugs as well at pay point/cashier. Twenty
three percent of the clients said that they had noticed a difference in waiting since 2007.




                                                                                             16
              Figure 3.3 : Average waiting time between registration and seeing
                                           clinician

              60
                             58                             54
                       52
              40                                   46              46
                                         40
          %                                                                          2008
              20                                                                     2007

               0
                       PGH                    DH             SDH




In terms of waiting time, clients reported that it took an average of 47minutes between
registration and seeing the clinician; 15 minutes during consultation and an average of 6
minutes at pay point. The findings reveal that the waiting time at SDH was longest 54min,
followed by PGH 52minutes then DH 40minutes. Services at SDH seem to take longer
than other facilities with clients reporting waiting time between registration and seeing
clinician as 54 minutes and between clinicians and pharmacy as 22 minutes. However it
took a shorter time at pay point than the PGH and DH. According to Citizens Service
Charter, client waiting time has been set for only 20 minutes at consultation and other
various service points except laboratory services, pay point and registration which is set at
30 minutes. The findings confirm that although more clients (10.6%) are visiting the SDH
because of the lower waiting time compared to other facilities, 7.5% in DH and 6.1% in
PGH, they are actually taking longer in SDH than in the other facilities. This finding
highlights one main cause of client dissatisfaction. The Table 3.10 below details the
findings.




                                                                                            17
Table 3.10: Time taken to access services

                                                             Time (Minutes)
                                            PGH              DH          SDH          Total
Average length of time between                       52.69       39.61         54.4       47.66
registration and seeing clinician

Average length of time with the                      13.74       14.69       18.62        15.81
clinician (Consultation)
Average length of time between seeing                15.82       13.13       22.35        16.91
a clinician and dispensing of drugs


Average length of time between seeing                15.14       11.33       10.16        11.78
a clinician and lab/x-ray services


Average length of time between seeing                 8.63        6.09         4.78        6.21
a clinician and payment point




f) Attendance by staff
Aspects of the client-provider interaction (counseling, information provision, and duration
of visit) have been consistently associated with increase use of health service. Client
satisfaction with health provider is known to have an effect on service utilisation. When
clients have a negative perception of the health workers, they are less likely to seek health
services. In assessing nature of health provider relationship with the client during the visit,
various attributes (such as friendly, helpful, courteous, rude, corrupt) to describe the client
- provider relationship was used. Questions included in the survey related to the manner in
which the clients perceived how they were attended to by the staff. The overall client
satisfaction with the staff attendance was 92.5%. Ninety three percent of the clients said
that the staff were friendly, 94% said that they were helpful, 90% said that the staff were
courteous and 92% said that the staff were. There was a very big variation in client
satisfaction rating of staff in the various provinces. The lowest rating for client satisfaction
was North Eastern province where only 76.2% of staff described the staff as friendly,
helpful, courteous and attentive as opposed to 99.2% of clients in Eastern Province.

As per the analysis, overall satisfaction with staff was lowest in sub district hospitals 90%
followed by provincial hospitals 93%. Overall satisfaction was highest with staff working
at the District Hospitals (95%). Over 90% of the clients interviewed said that they would
return to the facility and would also recommend a friend or relative. However the clients




                                                                                              18
who had visited the District Hospital were more optimistic than the clients who visited
other facilities.


                Figure 3.4 How would you describe the staff who attended to you?

       800

       700         92.3                93.8                                                  92.3
                                                          90              93.1
       600         95.8                93.1                               76.4               85.8
                                                          77.8
       500         95                  96.7               86.8            98.3               94.2
                   78.5                77.6               75.7            72.9               76.2
   %




       400
                   99.2                100                99.2            98.4               99.2
       300
                   95.9                98.6               96.6            95.3               96.6
       200
                   97.5                96.7               95.9            99.2               97.3
       100
                   92.5                95.7               92.5            93.5               93.5
          0
                 friendly             helpful        courteous          attentive           overall

                 Nairobi    Central    Coast    Eastern    N/Eastern   Nyanza    R/Valley   Western




A follow up question required the clients to indicate whether they would return to the
facility or recommend a friend. Most of the clients who were interviewed said that they
would visit the health facility (95% of clients interviewed in PGH, 97% in DH and 94% in
SDH) and also refer a friend (94% interviewed in PGH, 96% in DH and 94% in SDH).
However, the clients who visited the district hospitals were more optimistic than other
clients who visited the other facilities. The results compares with the findings in the 2007
survey where the clients were positive that they would return to the facility (97.7%) and
would also refer a friend (97.9%). Figure 3.6 below highlights the 2008 findings.


1.3 Overall Satisfaction
The findings of patient satisfaction did not vary significantly from the survey conducted in
2007. The results show that 88% of the clients interviewed were either satisfied (24.3%) or
very satisfied (63.9%) with the health care services they received. In 2007, 23.6% and
70.3% of the clients interviewed were either very satisfied or satisfied respectively.

a) Client satisfaction per province

From the chart below, overall client satisfaction was highest in Eastern province 98%,
followed by Coast province 97%, Nyanza 92%, Central 91%, Nairobi and Rift valley
88%, Western 82% and North Eastern was lowest with 67%. To the same extent, clients
who expressed dissatisfaction with the service were highest in North Eastern province
32%.


                                                                                                    19
                                      Figure 3.6: Client satisfaction by province



                                                 97             98
        100   88                91
                                                                                                    92
         90                                                84                                                         88             82
         80                               69                               67     67                                            74
         70             63
                                                                                                              63
                                                                                             52
         60
    %    50                                                                                                                               42
                                                                                                                                               39
         40                                                           31
                   25                                                                                    29
         30                          22                                                 15
         20                                           12                                                                   14
         10
          0
              Nairobi           Central           Coast            Eastern        N/Eastern         Nyanza            R/Valley       Western

                                                  Overall       very satisfied          satisfied




b) Client satisfaction by facility
The findings reveal that client satisfaction is highest in the district hospitals (91.8%),
followed by provincial hospitals (87.1%) and sub district hospital (84.5%). Client
dissatisfaction is also highest in sub-district hospital (15.2%). As earlier discussed, the
main reasons for dissatisfaction at the sub-district hospital was waiting time.

                                Figure 3.7: Client satisfaction by facility type

                         87.1                               91.8                             84.5
              100
                                                                           66.9                                63.3
                                          59.3
               50                27.8                                                                21.2
                                                                   24.9
                                               12.4                               7.4                              15.2

                0
                                 PGH                                 DH                                  SDH

                                     Overall      Very satisfied          satisfied      not satisfied



All the patients/clients were asked: “Overall, how would you rate the level of satisfaction
with the health care services received?” The responses were stratified as “very satisfied”,
“satisfied” or “not satisfied”. Table 3.11 presents the cross-tabulated results. With results
from this table, the satisfaction rate with the health care services received is high, with a



                                                                                                                                               20
cumulative measurement (satisfied, very satisfied) of 89%. However, this compared to
findings from 2007, the satisfaction rating has reduced by 0.6%.

The client satisfaction levels at the provincial hospitals decreased slightly from 90% to
88%. The satisfaction levels at the district hospitals remain unchanged at 93.20%.
Similarly the overall level of satisfaction at the SDH seems to have remained the same,
detailed analysis of the various categories of satisfaction shows that the number of clients
who were either very satisfied or satisfied in the PGH and DH had decreased.

c) Client satisfaction with service delivery
     Percentage of clients who were provided with a bench to sit while waiting to be
       served was 96%. One in three (38%) clients who were not provided with a bench
       as they waited to be served were dissatisfied with the service.
     Client satisfaction rating for waiting time of 30 minutes was 58% between
       registration and seeing the physician, 60% for laboratory services and 87% at pay
       point
     Satisfaction with user fees attracted an overall client satisfaction rating of 68.1%.
       Seven in ten clients were satisfied with the laboratory charges (70.5%),
       consultation fees attracted a client satisfaction rating of 67.9% and 65.9% was the
       satisfaction rating for charges for medicine in that order. Evidently, more clients
       were not satisfied with the pricing for medicine.
     Most of the clients who were visiting health facilities were satisfied on account of
       good advice given by staff (cited by 41% of the respondents) in PGHs compared to
       sub-district hospitals 29%, availability of medicine (34%) in DHs compared to 26%
       in sub-district hospitals. Evidently, these are some of the factor variables that policy
       makers and health managers can manipulate to alter patterns of choice.

1.4 Suggested improvement

The survey examined the major problems and priority areas for improvement from the
clients’ perspective. Table 3.12 presents the results. A strong suggestion was on
improvement in drug availability which was cited by 56% of the clients. The second
suggestion was to increase the staffing which was made by 36% of the clients, improve
waiting time by 28% of the clients. Another 28% of the clients also strongly suggested that
equipments should be made available. There was generally an increase in the number of
respondents who suggested that there be improvement in drug availability compared to the
last survey in 2007. The number of clients who suggested an increase in staffing reduced
from 43% in 2007 to 36% in 2008. These results provide direction for policy makers and
managers as to where prioritized interventions are needed.

Table 3.11: Suggested improvements in health facilities

                                         2007                     2008
                Suggested
               improvement Frequency            Percent  Frequency Percent
               Drug              560                47.9       518    56.6


                                                                                            21
                   2007                    2008
 Suggested
improvement Frequency     Percent    Frequency Percent
availability
Equipment         206         17.6        261      28
Change staff
attitude          102          8.7         59      6.4
Waiting time      240         20.5        261     28.5
Reduced fees      102          8.7        147     16.1
Increase staff    505         43.2        329       36




                                                         22
CHAPTER FOUR                                 Conclusions and Recommendations

Patient satisfaction survey is a key indicator on quality health care services. Through this
survey, policymakers are able to obtain concise information, demographic profile of
outpatient clients, their patterns of health care utilization, and their views regarding health
facilities. The results of this survey raise several important policy issues with respect to
socio-economic status of a typical patient/client, and satisfaction with health care. In view
of what has been discussed above, and in spite of the study limitation mentioned, the
following are the main recommendations:

   a) The patients/clients seem to value and appreciate the level of services that are
      currently being provided to them by public health facility staff. They feel that staff
      attitude towards them was good. Management needs to continue to sustain positive
      relations between clients and staff though engaging the community and patients in
      priority setting and in allocation of resources.

   b) While the relationship between staff and patients was rated well, most clients
      complained of long waiting time. Hospital Managers would need to look at
      patient/work flows with a view to streamlining the waiting time.

   c) Health facility service charters needs to be displayed publicly at the facility in order
      to strengthen horizontal accountability. The charters need also to set out complaints
      and redress mechanisms in the event that the provider does not meet these
      standards.

   d) There needs to be a transparent system for user fees waiver. More funding needs to
      be allocated to funding waivers of facility fees to alleviate financial constraints to
      health services access by the poor.
   e) Attention needs to be paid on aspects of care which clients say are important. In
      depth analysis will need to be done at health facility level to collect regular
      information on patient satisfaction

   f) The main cause of clients not receiving drugs in the health facility was because the
      drugs were not available as opposed to clients not having enough money to buy the
      drugs. With this back drop, logistics chain management for essential and public
      health goods needs to be strengthened in GoK facilities to ensure there are
      equitable supply of essential drugs at all levels.
Future studies should focus on evaluating the impact of rural diversity on client
satisfaction. In this case, the studies will need to define rural versus urban health facilities.
It would also be interesting to gather information on inpatient client satisfaction and see
how the results compare with exit interviews. The reason for in patient client satisfaction
stems from the fact that the experiences of in patients are unique, the services provided to


                                                                                              23
in patients are also more, there is longer patient provider interaction than out clients and
their observations are therefore likely to be different from out patient. This should be able
to give an interesting picture of overall client satisfaction.




                                                                                          24
References


   1) Cleary PD, Edgman-Levitan S, Roberts M et al. Patients evaluate their hospital
      care: A national survey. Health Aff 1991; 10: 254–267.
   2) Draft Ministry of Public Health and Sanitation Strategic Plan (2008-2012)
   3) Hall JA, Dornan M. (1988-1). What Patients Like About Their Medical Care and
      How Often They Are Asked: A Meta-Analysis of the Satisfaction Literature. Social
      Science Medicine, 27, 935-939.
   4) Hargraves JL, Wilson IB, Zaslavsky A et al. Adjusting for patient characteristics
      when analyzing reports from patients about hospital care. Med Care 2001; 39: 635–
      641
   5) Jackson JL, Kroenke K. Patient satisfaction and quality of care. Mil Med 1997;
      162: 273–277.
   6) KAIS (2007) Kenya AIDS Indicator Survey Report
   7) MOH (2007) Client Satisfaction Survey Report
   8) MoH (2007) Joint Design Mission Report
   9) MoH (2007) NHSSP II Mid Term Review Report
   10) Nursing Council of Kenya Out Migration Statistics, 2007
   11) Republic of Kenya, Ministry of Health, Service Charter for Delivery of Health
       Services, December 2006
   12) Republic of Kenya, Ministry of Health: National Health Sector Strategic Plan II,
       2005- 2010
   13) Rubin HR. Can patients evaluate the quality of hospital care? Med Care Rev 1990;
       47: 267–326.
   14) Young GJ, Meterko M, Desai KR. Patient satisfaction with hospital care: Effects of
       demographic and institutional characteristics. Med Care 2000; 38: 325–334.




                                                                                          25
                            MINISTRY OF MEDICAL SERVICES
                                                                          Section 1: Identification Information

    o
N 11
                                                                          Province: ________________________

                                                                          District: _________________________
                                                                                                                                   Type
            CLIENT SATISFACTION SURVEY – 2008                                                                         1. Tertiary (level 6)
                                                                          Name of Health Facility                     2. Provincial Gen Hospital (level
INTRODUCTION                                                                                                             5)
                                                                          _________________________                   3. District Hospital (level 4)
The Ministry of Medical Services is inviting you to participate in a                                                  4. Sub-District Hospital (level 4)
Client Satisfaction survey in an attempt to seek your views on the
quality of services you received in this health facility.
                                                                          Name of Interviewer         __________________________________
                                                                          Date of Interview:
The responses that you provide will be treated in strict confidence. If   Signature
you have questions about the survey, you may contact the Permanent        Name of Supervisor:
Secretary, Ministry of Medical Services P.O. Box 30016, Tel. 020-         Date:
717077, E-mail: plan@health.go.ke
                                                                          Signature



                  CONFIDENTIAL
              Survey Questionnaire
              Number: ___________




                              Page 1                                                  Patient/Client Exit Satisfaction Survey Questionnaire No 11
    Section 2: Respondent Background information                             No. Questions and Filters               Coding Categories                     Skip
No. Questions and Filters            Coding Categories               Skip                                            5) Other (specify)
1   Gender of respondent                  1) Male
                                          2) Female                         6       What distance did you            Kilometres: ______
2      Time of interview             1. after medical services has                  cover in Kilometres to get
                                     been received for self                         to the facility?
       Circle indicate the correct                                          7       How long did it take you             ________ Minutes
       response                      2. after medical services has                  to get to this health
                                     been provided for child or                     facility?
       Multiple answer               family member
       accepted                                                                 Section 3: Health Services Utilization
3      Highest Level of              1.   None
       education attained of         2.   Primary                           No. Questions and               Coding Categories                      Skip
       respondent                    3.   Secondary                             Filters
                                     4.   Post Secondary                    8   What are the                1.   Receive treatment
                                          (College, University)                 reason(s) for               2.   Immunization
4      Current work status of        1.   Formal employment                     seeking medical             3.   Antenatal
       respondent?                   2.   Self- employed (incl.                 care at this facility?      4.   Family planning
                                          Business)                                                         5.   Delivery
                                     3.   Farmer                                    [multiple answers       6.   Minor Surgery (inc
                                     4.   Housewife                                 accepted]                    circumcision)
                                     5.   Student                                                           7.   Medical Examination
                                     6.   unemployed                                CIRCLE the              8.   Other health related
                                     7.   Other (Specify)                           appropriate                  matters
                                                                                    answers                       ______________
                                                                            9       Is this your first      1.    Yes                              >>11
5      What was your MAIN            1) Public transport (e.g.                      time to visit this      2.    No
       METHOD of                        Bus, Matatu, taxi)                          health facility?
       transportation used to get    2) Private transport
       to this health facility?      3) Walked
                                     4) Bicycle/motor cycle




                                Page 2                                                       Patient/Client Exit Satisfaction Survey Questionnaire No 11
 No. Questions and          Coding Categories               Skip        No. Questions and          Coding Categories                      Skip
     Filters                                                                Filters
10   How does today’s       1) More friendlier service                      medicine?                   3) Not applicable
     visit compare with        than previous
     your previous          2) Received better                         14   Did you obtain the          1) Yes                            >>16
     experience                information about ailments                   medicine that was           2) Some
                               than previous                                prescribed                  3) None
      CIRCLE the            3) Received the required
      appropriate              medication than previous                15   If you received             1) Drugs not available
      answers               4) Shorter waiting time than                    some/none, what             2) Did not have enough
                               previous                                     were the main                  money
                            5) Other specify……………..                         reasons?                    3) Drugs expensive, will
11    Is this the nearest   1) Yes                                                                         buy elsewhere
      government health     2) No                                                                       4) Will use drugs
      facility to your                                                                                     available at home
      home?
                                                                       16   Did you pay for        Indicate whether:
12    What are the          1)   Was referred                               the:                    a. Yes
      THREE main            2)   Close to home                                                      b. No
      reasons for you       3)   Good staff attitude                                                c. N/A
      choosing this         4)   Less waiting time                                                 Services e.g.
      health facility?      5)   Medicine available                                                consultation, lab,
                            6)   Less costly                                                       Medicines
                            7)   Cleaner facility
                                                                       17   Overall , how          Indicate whether
                            8)   Staff give good advice
                                                                            would you rate the     1. High 3. Within limit
                            9)   Other (specify)
                                                                            charges for            2.low
      CIRCLE the
                                                                                                   Services e.g.
      appropriate
                                                                                                   consultation, lab
      answers
                                                                                                   Medicines
13    Were you                   1) Yes                     Continue
      prescribed any             2) No                      >>16       18   How long did you                                   Minute
                                                                            take:                  Between registration




                             Page 3                                                 Patient/Client Exit Satisfaction Survey Questionnaire No 11
 No. Questions and        Coding Categories       Skip    No. Questions and          Coding Categories                      Skip
     Filters                                                  Filters
                          and seeing clinician                                       1. visit this facility
                          Consultation                                               next time you are
                                                                                     sick
                          Between seeing                                             2. recommend this
                          clinician and                                              facility to a friend or
                          dispensing of drugs                                        family member when
                          Lab services, x-ray,                                       they are sick

                          Payment
                          point/cashier
19   Was there a bench        1) Yes
     for you to sit on        2) No                                                     Overall Satisfaction
     while you waited
     to be served?                                       22    Overall, how would you rate the                    1) Very satisfied
20   Generally, how         Indicator                          level of satisfaction with the health              2) Satisfied
     would you describe     1. Yes                             care services in this facility                     3) Not satisfied
     the staff who          2.No
     attended to you:
                          1.Freindly                      23   What are the THREE major                        1) Drug availability
                          2.Helpful                            improvements you would suggest for              2) Equipment
                          3.Courteous                          the health facility?                            3) Change staff
                          4.Attentive                                                                             attitude
                          5.Rude                                                                               4) Waiting time
                          6.Corrupt                                                                            5) Reduced fees
21   Would you:              Indicator whether:                Circle the appropriate answers                  6) Increase staff
                             1. Yes                                                                            7) None
                             2.No                                                                              8) Other (specify)
                                                                                                                  ________________
                                                                                                                  _




                           Page 4                                     Patient/Client Exit Satisfaction Survey Questionnaire No 11
      The End


Thank You for your
      Time




      Page 5         Patient/Client Exit Satisfaction Survey Questionnaire No 11

								
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