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International Journal for Quality in Health Care Advance Access originally published online on July 11, 2008
International Journal for Quality in Health Care 2008 20(5):339-345; doi:10.1093/intqhc/mzn024
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© The Author 2008. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved

Caring for children: a model of healthcare service quality in Bangladesh

Syed Andaleeb

Black School of Business, Pennsylvania State University, Erie, USA

Address reprint requests to: Syed Andaleeb, Black School of Business, Pennsylvania State University, Erie, USA. E-mail: ssa4{at}psu.edu


   Abstract
Top
 Abstract
Introduction
 Background
 Methods
 Results
 Discussion
 Conclusion
 Appendix 1
 References
 
Objective. This study assesses the links between service quality and patient satisfaction in the context of health services delivered to children in a developing country. With the growing importance of patients' voice in the healthcare environment, it is important to assess the factors that are best able to explain patient satisfaction to influence the art and science of patient care and health service delivery.

Design. A field survey was conducted using a household survey to assess the quality of services provided to children who had been to a hospital in the past 12 months.

Participants. Caregivers who had accompanied an afflicted child to a hospital in Dhaka City.

Main outcome measures. Patient satisfaction was the main outcome/dependent variable as reflected in surrogate measures obtained from the children's accompanying caregivers.

Results. A regression model was tested. The independent variables were nurse composite, doctor composite, tangibles, health inputs and facilitation payments. The model explained 67.4% of the variation in the dependent variable (R2). The behavior of nurses had the greatest impact on satisfaction (P < 0.001) as reflected in the standardized betas, followed by the behavior of doctors (P < 0.001). Facilitation payments had a negative effect on satisfaction (P < 0.01).

Conclusions. Bringing about attitude change among doctors, nurses and support staff is vital for improving children's satisfaction with hospital care. Installing proper recruitment procedures, training, supervision, and reward systems are most likely to facilitate this change. But similar changes are also needed elsewhere: in the Ministry of Health and Family Welfare, other facilitating ministries, as well as the development partners to achieve enduring and positive effects.

Keywords: children, healthcare, quality measurement, quality management, patient satisfaction


   Introduction
Top
 Abstract
 Introduction
Background
 Methods
 Results
 Discussion
 Conclusion
 Appendix 1
 References
 
The quest for delivering quality healthcare, in addition to increasing access and lowering costs continues to represent a significant challenge to healthcare establishments around the world. Concerted effort at addressing a diverse set of health issues is reflected in the agenda of global organizations entrusted with addressing healthcare needs worldwide. For example, the Commission on Macroeconomics and Health, the Millennium Development Goals, the World Development Report, and the Human Development Report, all address health as a major policy prerogative [1–4]. Their assessment of service provision in the health sector, however, is not very savory. According to the World Development Report [3]:

"Services are failing because ... they are inaccessible and prohibitively expensive. But even when accessible, the.y are often dysfunctional, extremely low in technical quality, and unresponsive to the needs of a diverse clientele."

The above-given quote reflects, in a nutshell, the state of the healthcare environment in many developing countries.

Health services in Bangladesh reflect a particularly grim picture. For example, the Baseline Service Delivery Survey of 26 207 households [5] highlights many problems: lack of separate room for consultation and examination, water supply problems and lack of electricity, medicines available to only a third of the patients, lack of medicines, poor quality of medicines, bad attitudes of workers, and extra payments for supposedly ‘free services’.

A recent policy document of the Bangladesh government [6] also admits to serious deficiencies in the quality and delivery of healthcare in Bangladesh, pointing out that health facilities need to open in time with healthcare providers present there; providers' behavior should make users comfortable; problems should be explained better to patients; privacy should be maintained during consultations; necessary drugs should be readily available; and the environment should be clean.

These deficiencies point to a healthcare system in Bangladesh that is itself ailing and in need of healing. The healthcare need of children, perhaps the most vulnerable segment of any human society, is one of special concerns. Given the disparities reflected in global health indicators, it is important that children in Bangladesh are availed much greater support and care from their health network to enjoy improved quality of life. This exhorts hospitals and healthcare providers to seriously imbue the notion of ‘quality of care’.

Interest in children and their health status is gaining greater attention [7–10]. For example, Child Advocacy International proposed the Child-Friendly Health Initiative [11], suggesting the need to focus on the combined physical, psychological and emotional well-being of children attending healthcare facilities, particularly as inpatients. Twelve standards were proposed to achieve this in accordance with the UN Convention on the Rights of the Child.

A review of the literature, however, indicates that precious little research has been done on the quality of healthcare that children receive, especially in Bangladesh. In fact, very few studies have addressed healthcare ‘service quality’ in Bangladesh [5, 12, 13].

This paper focuses on ‘service quality’ afforded to children in the healthcare environment in Bangladesh. The broad purpose of the study is to address two research questions: what is the level and quality of healthcare service delivered to children in hospitals and what factors or dimensions of service quality are important in explaining their satisfaction?


   Background
Top
 Abstract
 Introduction
 Background
Methods
 Results
 Discussion
 Conclusion
 Appendix 1
 References
 
Service quality and its link to patient satisfaction is beginning to receive attention in the healthcare literature in the developing countries [12, 14–18]. Interest in this link is pervasive in the developed world as the role and importance of service quality and patient satisfaction are beginning to influence the art and science of patient care. In this paradigm, the ‘patient's voice’ is becoming increasingly important in the design of service delivery [19–22], exhorting hospitals to recognize the importance of delivering patient satisfaction as a crucial determinant of long-term viability and success. In this regard, the recent Consumer Assessment of Health Providers and Systems or CAHPS® survey used in USA reflects the importance accorded to clients' experiences with a variety of services including Medicare and Medicaid [23].

This literature suggests that low quality services breach the central promise in the healthcare relationship between service providers and recipients [24, 25] which can lead to a variety of dysfunctional behaviors among the service recipients, some immediate (anger, confrontation, complaints) and some long-term (decline in loyalty, badmouthing and diversion of customers, and loss of a customer base via defection). Poor service in healthcare in some instances has been particularly devastating, resulting in unfortunate consequences such as amputation of the wrong limb, the administration of drug doses that have driven patients to or near death, and of doctors coming late to assist with a delivery that was fatal because of the bleeding during the long interlude.

Perceptions of quality can have a strong influence on one's inclination to avail health services. Perceptions of poor service quality may, in fact, dissuade people from using specific services, especially if options are available and if the service delivery system in question cannot be trusted to guarantee a threshold level of quality. As a result, it will remain underutilized, be bypassed, or be used only as a measure of last resort [13]. It can also mean that patients will not follow treatment regimen, fail to show up for follow-up care, and even resort to negative word-of-mouth that can dissuade others from seeking healthcare services from specific providers. This study examines patient satisfaction in relation to health service quality for children's healthcare in Bangladesh.


   Methods
Top
 Abstract
 Introduction
 Background
 Methods
Results
 Discussion
 Conclusion
 Appendix 1
 References
 
Secondary research
In addition to the literature cited in the background on service quality and patient satisfaction, this study also involved reviewing research articles and the policy manuals of the government and/or the development agencies [4, 6, 7, 10]. A few published studies were found to lack the specific focus of this research (health services to children). Hence the literature and models developed in other countries, as discussed in the previous section, were examined for guidance.

Qualitative research
The study began with a general discussion on the hospital service environment with a wide variety of people connected with health services to gain a comprehensive picture. For scale development, subsequently, exploratory research was used with 25 conveniently selected caregivers (generally parents) from Dhaka, Bangladesh, who had accompanied a child to a hospital in the past 12 months. Caregivers were opted, as they were better able to articulate the problems and challenges encountered and the treatment that their children received. The qualitative approach involved face-to-face in-depth interviews. During this phase they were asked to reflect on their satisfaction or dissatisfaction with the hospital's services and how its quality could be improved. The answers were recorded and sorted into general categories to identify the core issues attenuating satisfaction. Many of these issues (waiting time, gruff doctors, unclean surroundings) corresponded rather closely with constructs developed in the SERVQUAL literature that has been applied to hospitals and other service providers [26–29]. Based on the interviews, the following model was tested linking service quality to satisfaction:

Satisfaction = a + b1 (assurance) + b2 (tangibles) + b3 (empathy) + b4 (responsiveness) + b5 (communication) + b6 (input adequacy) – b7 (facilitation payments) + error.

Measurement
The constructs in the model were measured using bi-polar or semantic differential scales (e.g. hot–cold or excellent–poor). These particular scales have not been used earlier in the context of healthcare in Bangladesh. The constructs are defined as follows:

Assurance: Knowledge and courtesy of hospital staff and ability to inspire trust and confidence.

Tangibles: Appearances of physical facilities, personnel, equipment, etc. that help infer quality.

Empathy: Caring individualized attention given to patients.

Responsiveness: Willingness to help patients and provide prompt service.

Communication: Answering questions of concern to patients.

Input adequacy: Availability of critical health support inputs.

Facilitation payments: Staff expectation of ‘extra’ payment for normal services provided.

Satisfaction: Patients' judgment of the pleasurable level of service-related fulfillment.

Multiple items were used to denote the constructs (except facilitation payments). For example, satisfaction comprised four scale items (Appendix 1).

Questionnaire design
A preliminary version of the questionnaire was first developed in English that went through several iterations until the measures were deemed acceptable. Items were drawn from the past research [5, 13, 14, 18] and in-depth interviews. Next, the measures of service quality and patient satisfaction were translated to the local language (Bangla). The final local version was endorsed by experts including health officials, service providers, researchers, and local university faculty, well versed in both English and Bengali languages. The questionnaire was pre-tested to ensure that the wording, format, length, and sequencing of questions were appropriate. During the pre-test, feedback was obtained from 10 conveniently selected caregivers to fine-tune the clarity and quality of the scale items.

Sampling and data collection
Four hundred interviews were planned for Dhaka City. The population was defined as the caregivers who had accompanied a child to a hospital for services in the past 12 months. This time frame was selected because a hospital visitation represents salient experience that is not easily forgotten and because hospital visits are not frequent, for time, lack of insurance and costs, especially in the case of Bangladesh. Considerable effort was devoted for obtaining a probability sample. In the absence of lists for drawing a random sample, stage-wise area sampling was combined with systematic sampling so that the sampling units had a known chance of being selected. Areas were selected in a manner such that different socioeconomic groups were represented.

From selected Thanas in the city, streets were listed and a subset of streets was randomly selected. Residential homes were then selected from each chosen street using systematic sampling. Interviewers were given a letter from a well-recognized university to introduce them to the households and explain the purpose of the study.

Those who agreed to be interviewed were explained the purpose of the study, assured anonymity, and given the option of not answering particular questions or withdrawing from the interview at any stage. After a quick screening question on whether the adult had accompanied a child to avail hospital services, interviewers proceeded with the survey questions. When respondents were able to read, self-administration of the survey was used.

A total of 317 surveys were ultimately completed of which nine were dropped due to excessive missing data, ‘do not know’ answers, and response biases. Of the 308 surveys finally analyzed, respondents obtained services from 35 private and public hospitals and clinics in Dhaka City.

The sample demographics indicated a diverse cross-section responded. Of the caregivers, 13.3% were males and 86.7% females. The age of the children were as follows: 26% were up to 2 years, 14% were 2–5 years, and 60% were 5+ years of age. Also 68% of the children were males and 32% females. The age of the caregivers (respondents) were as follows: 15–20 years (8.4%), 21–25 years (17.5%), 26–30 years (23.1%), 31–35 years (23.4%), 36–40 years (12%) and 40+ years (15.6%). Finally, the income category of the respondents were <Tk. 5000 (42.6%), Tk. 5000–10000 (22%), Tk. 10 000–15 000 (10.8%) and >Tk. 15 000 (24.6%), where $1 = ~Tk. 70. It may be noted that the caregivers were mostly female while the care recipients (children) were mostly male.

Analysis
Frequency distributions were obtained to check for data entry errors and to obtain descriptive statistics. The measures of service quality were also factor analyzed using principal components analysis and varimax rotation (Table 1). Instead of extracting six expected dimensions that preliminary investigations suggested, four factors emerged that could be meaningfully interpreted. However, most of the items measuring service quality were retained, although they loaded differently. The final four factors comprised of 20 items from the original 24 (Appendix 1) and explained 67.65% of the cumulative variation.


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  		Table 1 Factor analysis results

 
The derived factors or composites were re-labeled as ‘nurse composite’, ‘doctor composite’, ‘tangibles composite’ (or tangibles) and ‘input adequacy’ (or availability of needed inputs). These factors were assessed for reliability using Cronbach's alpha (Table 2). Given the recommendations of Nunnally [30], that alpha values should be ≥70, only one variable had a value <70. Based on a prior study [14], a separate single-item measure—extra payments via baksheesh—was also included to assess the effects of facilitation payments on satisfaction. Multiple regression analysis was conducted to test for significant effects and to assess the model's prescriptive ability.


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  		Table 2 Descriptive statistics and reliability coefficients

 

   Results
Top
 Abstract
 Introduction
 Background
 Methods
 Results
Discussion
 Conclusion
 Appendix 1
 References
 
Descriptive statistics (mean and standard deviation) are presented in Table 2 and indicate that the sample mean for satisfaction is 3.75 on a five-point scale. This value has a positive valence, being above the scale mid-point of 3.0. The average score for the doctor composite is 3.94, suggesting that doctors are doing a credible job, although there is still some room for improvement. Nurses obtained a score of 3.54, which is also in the positive territory; however, this rating also has room for improvement.

The score on tangibles—the physical evidence of quality—was 3.49 and exhibits greater variability (s = 1.005) than the other variables, suggesting that this dimension of service varies from one facility to another. The input adequacy factor (availability of drugs and equipment) obtained a negative valence with a mean score of 2.63; it also reflected higher variation (s = 1.19), indicating inconsistencies in supply. Finally, the mean score on whether the staff expected baksheesh or facilitation payments is low (2.41) and in the right direction. However, this item reflects the highest variability in the responses (s = 1.54), suggesting that this issue receive managerial attention at various hospitals.

The regression model finally tested was different from the one proposed, where people evaluated medical care not so much by service factors but by personages or key actors (e.g. nurses and doctors). In the past study employing 25 scale items [13], key actors (doctors) were identified only once; for the remaining items, the generic term ‘staff’ was used which may have influenced the factor structure. However, when the terms ‘doctor’ or ‘nurse’ (instead of staff or personnel) was used in this study, instead of assessing medical services along dimensions such as assurance, or empathy, respondents assessed key actors and evaluated them comprehensively on the service dimensions posited. Thus the regression model tested is as follows:

Satisfaction = a + b1 (nurse composite) + b2 (doctor composite) + b3 (tangible evidence of service) + b4 (input adequacy) – b5 (facilitation payments) + e

The results indicated that the model is significant (P < 0.001), and the coefficient of determination (R2) explained 67% of the variation in the dependent variable. The nurse and doctor composites explained a high percentage of variation in patient satisfaction, suggesting where resources ought to be allocated to build a more satisfying healthcare system for children.

Table 3 shows that three of the five independent variables are significant where the variable having the greatest impact on patient satisfaction is the ‘nurse composite’ followed by the ‘doctor composite’. Expectation of baksheesh was also significant with a negative coefficient, i.e. when the service staff expected baksheesh (facilitation payments), patient satisfaction was attenuated. The ‘tangibles composite’ and ‘input adequacy’ were not significant in explaining satisfaction and is explained in the following section.


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  		Table 3 Regression results of patient satisfaction with hospital services

 

   Discussion
Top
 Abstract
 Introduction
 Background
 Methods
 Results
 Discussion
Conclusion
 Appendix 1
 References
 
Doctors may have received a higher rating than nurses because the respondents may have met the doctor and not the nurses again since discharge. However, since nurses had the greatest impact on satisfaction, disaggregating the nurse composite measures and correlating the individual items with the satisfaction construct suggested that nurses must provide good service, be prompt, show they understand their work, be caring and helpful, foster confidence, demonstrate ability or expertise, be available when needed, and take care of patients in the order as suggested by the correlations.

Similarly, disaggregating the doctor composite suggested that doctors must demonstrate their expertise, provide answers to questions, behave well, foster confidence, explain the condition of patients, and be available.

To address staff expectations of extra compensation, given its adverse effects on patient satisfaction in an environment where staff salaries are often generally quite low, hospitals may charge a small fixed fee from patients and disburse this among the staff so that expectation of gratuities are not imposed on patients who may already be spending beyond their anticipation and capacity on medical care. The allocation of this fee may be tied to patient evaluations of the quality of care received.

Although input adequacy was not significant, its negative rating (mean = 2.62) reflects a supply-side deficiency (HNPSP 6), suggesting the need to improve the availability of drugs and ensure proper functioning of the hospital equipment. This critical ingredient, despite the positive and professional care that children receive, is probably most problematic system-wide, causing failures in service delivery that ultimately downgrades an otherwise functioning system.

To bring about improvements in behaviors reflected in the doctor and nurse composites, some form of regular feedback from patients (or their caregivers) must be integrated in the health service delivery system so that the quality of service can be effectively monitored via patients' voice. In the quest to provide better medical care in Bangladesh, it is also important that training, evaluation and reward systems are methodically instituted and carefully nurtured in the system.

From a measurement standpoint, using a set of measurement scales that identifies personages or key actors led to substantial changes in the service constructs. Yet, not much was lost from the model; instead of the service factors grouping together, they were merely re-distributed into ‘person’ factors. The explanatory power (R2) of the model was also comparable with previous studies [13].

Although input adequacy and tangibles were not significant in explaining satisfaction, that does not diminish their importance. The non-significant findings may be because patients are so inured to lack of drugs and availability of even basic equipment that they have little expectation that such inputs would be provided, especially in the public hospitals. This is evident from the mean rating obtained on the input adequacy construct. As for tangibles, cleanliness was deemed important during the qualitative phase. One study [13] also found it to be a significant factor. In this study, it is plausible that when children's health is of concern, the focus is on the child's immediate relief and well-being for which one turns to doctors and nurses and their competent and caring demeanor, not to their appearances.


   Conclusion
Top
 Abstract
 Introduction
 Background
 Methods
 Results
 Discussion
 Conclusion
Appendix 1
 References
 
Medical care for children in Bangladesh may be improved further by instituting behavior change among the doctors, nurses, and the support staff. Bringing about such change requires proper attention to hiring, training, empowering, evaluating and rewarding the service providers.

But the matter may go deeper; focusing only on doctors, nurses and support staff to change their behaviors is unlikely to be successful unless additional and wide-ranging organizational issues are also addressed in the healthcare system. For example, in Bangladesh, there is a need for greater commitment of the higher authorities of the Health Ministry (especially those in the Directorate of Health) to reforming healthcare. Other affiliated ministries such as the Ministry of Establishment (for recruitment purposes) and the Ministry of Finance (that makes funds available) must also be cooperative and make the needed resources available. Concerns were also raised about the appropriate level and quality of involvement of the development partners (e.g. The World Bank, USAID, WHO, UNFPA, etc.) during consultations with health officials, doctors and health researchers. Changes in attitudes, as well as practices, in these higher tiers of the system are also essential for the healthcare system to respond optimally and provide the needed services to the suffering children.

Publicly available ratings via customers' voice can create social pressures and can be an important behavior change tool to make healthcare providers respond appropriately; otherwise the children will remain neglected by a seemingly impervious and monolithic healthcare system. The challenges ahead are many and must be resolved in reasonable, pragmatic, and meaningful ways for the children—nay, the entire population of Bangladesh—to be better served by those responsible for delivering better healthcare.


   Appendix 1
Top
 Abstract
 Introduction
 Background
 Methods
 Results
 Discussion
 Conclusion
 Appendix 1
References
 
Measurement scales (translated from Bangla)
Semantic differential (bi-polar) scales originally used to measure the constructs using a five-point scale. Measures for each hypothesized construct are as follows


Assurance:
Staff understood their work well 5 4 3 2 1 did not understand it at all
Doctors behaved very well 5 4 3 2 1 behaved very badly
Nurses behaved very well 5 4 3 2 1 behaved very badly
I had confidence in the nurses 5 4 3 2 1 had no confidence in the nurses
I had confidence in the doctors 5 4 3 2 1 had no confidence in the doctors
Nurses were experts in their job 5 4 3 2 1 did not seem to be experts
Doctors were experts in their job 5 4 3 2 1 did not seem to be experts
Staff provided good service 5 4 3 2 1 did not provide service at all
Tangibles:
Toilets were kept clean 5 4 3 2 1 were always unclean
The hospital was always neat and clean 5 4 3 2 1 was never neat and clean
Staff was always neat and clean 5 4 3 2 1 was never neat and clean
Empathy:
Employees were very caring 5 4 3 2 1 not caring at all
Employees were helpful 5 4 3 2 1 were never helpful
Responsiveness:
Doctors were available when needed 5 4 3 2 1 were unavailable when needed
Nurses were available when needed 5 4 3 2 1 were unavailable when needed
Services were available promptly 5 4 3 2 1 never available promptly
Facilitation payments:
Staff always expected baksheesh 5 4 3 2 1 never expected baksheesh
Communication:
Doctors answered any question 5 4 3 2 1 hardly answered any question
Child's condition was explained 5 4 3 2 1 not explained at all
Input adequacy:
All medicines were available 5 4 3 2 1 no medicines were available
All equipment was available 5 4 3 2 1 was never available
Satisfaction:
Overall level of satisfaction with treatment (very satisfied to very dissatisfied)
Overall level of satisfaction with service (very satisfied to very dissatisfied)
Willingness to recommend hospital to others (very willing to very unwilling)
Willingness to return to the hospital with child very willing to very unwilling)


   References
Top
 Abstract
 Introduction
 Background
 Methods
 Results
 Discussion
 Conclusion
 Appendix 1
 References
 

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Accepted for publication June 16, 2008.


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