Effect of Institutional Factors on the Quality of Ghana’s ... · PDF fileEffect of Institutional Factors on ... to examine the effect of institutional factors on the quality

JAD Journal of African Development

Spring 2013 | Volume 15 #1

Effect of Institutional Factors on the Quality of Ghana’s Healthcare Delivery

EUGENIA AMPORFU JUSTICE NONVIGNON

and

SCHOLASTICA AMPADU1

ABSTRACT Quality of care refers to all aspects of treatment that are beneficial to the patient. Process quality is used to mean beneficial aspects that arise during the process of providing healthcare, including the action of health professionals, waiting period, and the clarity of communication. This study uses the principal-agent framework to examine the effect of institutional factors on the quality indicators above in the public health facilities of Ghana. The study utilizes new survey data from malaria outpatients, health workers and administrators from sixty two health facilities in three regions across the country. Ordered logistic regressions and duration estimation were used. The results show that job satisfaction and involvement of health workers in decision making are important for the improvement of process quality. Job satisfaction had a positive effect on all process quality indicators while the involvement of health workers in decision making also had a positive effect on attitude of health workers. Cordial relationship between administration and health workers might have a negative effect on attitude of health workers and waiting period.

1 Amporfu (corresponding author: email: [email protected]): Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Nonvignon: University of Ghana, Legon, Ghana; and Ampadu: Nursing and Midwifery Training College, Sekondi, Ghana. �

99

JOURNAL OF AFRICAN DEVELOPMENT

� �

INTRODUCTION

Quality of care refers to all aspects of treatment that are beneficial to the

patient (Chalkley and Malcomson, 2000). When the beneficial aspect occurs during the process of treatment it is referred to as process quality. Process quality then refers to the action of health professionals in the process of providing health care. Attitude of health care workers towards patients, waiting period in the hospital, and the way in which treatment is communicated to patients are important examples of process quality of care. Bad attitude of health workers could intimidate patients and prevent them from asking relevant questions that could make treatment beneficial. Long waiting periods for treatment represent opportunity cost to a lot of patients especially those in the informal sector who may have to give up a whole day’s income in order to seek care in the hospital. Besides, long waiting period delay treatment and hence can deteriorate health status. Finally, when treatment, such as drug dosage, is not clearly communicated to the patient, the resulting wrong treatment could deteriorate patient’s health.

All three types of quality are underprovided in the Ghanaian health system. The attitude of health workers has been described by the literature as rude, uncaring, and indifferent (Ghana Health Service (GHS), 2007; Bannerman et al., 2010). In 2006, the GHS commissioned several researches on quality of care. The poor attitude of health care workers and long waiting periods were the most common complaints made by patients (GHS, 2007). Health facilities have even been advised to keep unfriendly workers away from patients (Owusu-Ampratwum, 2011). The poor attitude has persisted despite increase in salaries of health care workers (GHS, 2007). The GHS has also responded to the complaints by producing a handbook on customer care for health care workers (Brobbey-Mpiani, 2005). The problem however persists.

Clarity of treatment communication has not been examined in the quality literature. However it is an important type of process quality since proper communication of treatment is required for patient compliance to treatment (Gupta et. al., 2007). Clarity of treatment communication is very important for treatment because there may be several treatment options and it is important that the patient is well informed about the requirements for adopting the treatment and the possible reactions to treatment. For example, some medications do not

100

AMPORFU ET AL: QUALITY OF GHANA”S HEALTHCARE DELIVERY

work well when taken on empty stomach and can reduce energy level and hence constrain some activities. Such information should be clearly provided to patient to ensure the adoption of the right behaviour.

Given that salary increase has not improved process quality in the Ghanaian health sector, there might be the need to strengthen the accountability relationship between policy makers and healthcare providers as well as between health facility administrators and health workers. The purpose of this study is to use new survey data to find the effect of institutional aspects of accountability relationship between policy makers and providers and/or between administrators in health facility and health workers on process quality of health care provided in the public sector of the Ghanaian economy.

Strong accountability relationship is especially important in the public sector because process quality can be affected by several factors depending on the type of health facility that is providing health care. In a public health facility, health care is provided as a merit good and so is operated in a non-market setting with the objective of providing health service to the public. The ownership of public health facilities does not belong to those supplying the service but to the citizenry. The people elect politicians (policy makers) to liaise with the facility. The relationship between the operators of the facility and the policy maker then is a principal agent relationship. The principal, the policy maker, hires the agent, the workers of the health facility, to provide services in accordance with the objectives of the principal. Since the principal cannot observe all treatment activities of the agent, there exists asymmetric information between the two and hence the need for a principal to adopt some mechanisms to induce the desired response from the agents; i.e., strengthen the accountability relationship between the principal and the agent.

The strength of the accountability relationship between the principal and the agent is affected by institutional factors such as the principal’s effectiveness as well as agent incentives (Kimenyi, et al, 2012). Principal’s effectiveness refers to the type of governance adopted by the principal to induce the desired behaviour from the agent. The agent incentives refer to the reward system that the principal uses to induce the desired behaviour of the provision of high process quality (Kimenyi, et al, 2012). The principal then uses these institutional factors to induce the desired behaviour from the agent. Since good institutional factors ensure good accountability, process quality is likely to be high when institutional factors favour strong accountability relationship between the principal and the agent.

101


� �

To reduce cumbersomeness the accountability relationship between the principal and the agent is referred to in this study as compact. When the principal is the policy maker, e.g., government, and the agent is the provider, external compact was used. Internal compact was used when the principal is the health administration and the agent is the health worker. Strong compact, both external and internal, is required to ensure high process quality. INSTITUTIONAL ASPECTS OF EXTERNAL COMPACT IN THE GHANAIAN HEALTH SYSTEM

For the purposes of this study the institutional aspects of external compact focused on the principal’s effectiveness which refers to the type of governance adopted by the government to induce quality health care. Specifically, the type of governance here focused on the extent to which decision making is decentralized, and the government’s ability to provide human resources required for the provision of care.

According to the available literature, decentralization is an effective way of inducing quality healthcare (Mliga, 2000). The type of decentralization that can improve quality of healthcare is the delegation of authority to an autonomous government organization delinked from the general civil service regulations and hence can run a more disciplined personnel system (Leonard and Leonard, 2004). The Ghanaian health system has been following a decentralization reform which groups the public health facilities into two: teaching hospitals and all other public health facilities. Teaching hospitals are autonomous in generating and disbursing funds from government. They are accountable directly to the Ministry of Finance through the Ministry of Health. These hospitals are governed by an Act of Parliament (GHS and Teaching Hospitals Act 525, 1996) with Board of Governors appointed directly by the President. In the principal agent relationship, the central government then is the principal to the teaching hospitals. The hospitals are able to hire their own health workers.

The rest of public health facilities are governed by the GHS which is an executive agency, responsible for implementing national health policies (GHS and Teaching Hospitals Act 525, 1996). Using the principal agency relationship described above, the GHS is the principal to these health facilities. The creation of

102


the GHS was part of the government’s decentralization policy3 (Agyepong, 1999) as a result of which hospital administrations now have some control over government budgetary allocations for recurrent expenditure. Thus only limited decision making is allowed at the district level for facilities governed by the GHS. Having full control over recurrent expenditure allows Teaching Hospitals to procure variable inputs required for operation and hence speed up service. Teaching Hospitals are then likely to have a shorter waiting period than the facilities governed by the GHS.

It is therefore hypothesized in this study that 1) waiting period is shorter in the Teaching Hospitals than the other health facilities governed by the GHS. Clarity of treatment communication and attitude of health workers were not expected to be affected by any of the institutional aspects of external compact. INSTITUTIONAL ASPECTS OF INTERNAL COMPACT IN THE GHANAIAN HEALTH SYSTEM

The institutional aspects of internal compact considered in this study are principal’s effectiveness and agent incentives. The principal’s effectiveness here referred to the type of governance followed by the facilities’ administration to induce quality services from the health workers. The type of governance was measured by the extent of decentralization, as well as the relevance and quality of instruments procured. As regards agent incentives, the indicators of interest in this study were opportunity for professional development, job satisfaction, and cordial relationship between administration and health workers.

Decentralization within health facility, i.e., between the administration and the health workers, and its effect on quality have not received much attention in the available literature. Some studies have focused on its effect on the quality of service in the education sector. For example, Kingdon (2006) showed poor school performance in national examinations in schools where the principal was self-rated as particularly powerful since such behaviour could be interpreted by staff as a sign of lack of trust.

Decentralization at the health facility level could be interpreted by workers as a sign of trust by the administration because health workers are involved in the decision making process. The attitude of health workers and waiting period could improve by the resulting reduction in over-monitoring.

3�Obviously the relationship between the government and he GHS is also a principal agent relationship but that will not be examined in this study.

103


� �

Similarly, a cordial relationship between health workers and the administration can also enhance workers attitude and motivate a good coordination to reduce waiting period.

The procurement of instruments used by health workers is undertaken by the facility administration and it is possible for the procured items to be faulty. Since the use of instruments that are faulty, in terms of quality and relevance, can affect the user’s mood, faulty instruments can deteriorate the attitude of health workers. It is part of the training of health workers to communicate treatment clearly to patients to ensure that the patients can comply. Even though patients’ ability to understand and comply with treatment requirement depends largely on the patients’ education level, it also depends on the health worker’s ability to communicate treatment given the education level of the patient. Because faulty instruments could make the health workers communicate wrong information to patients, health workers’ ability to communicate treatment could be enhanced or reduced by quality of instruments, such as machines for diagnostic tests. Thus quality and relevance of instruments are likely to improve attitude of health workers and clarity of treatment communication.

Job satisfaction is likely to affect workers’ attitude towards patients. All things being equal, a less stressed health worker is likely to be friendly to patients, take time to communicate treatment to patients, and cooperate with policies to reduce patients’ waiting period in the health facility. Closely related to job satisfaction is opportunity for professional development through furthering of formal education and seminars as well as through learning by doing. In the Ghanaian health system these two factors are related to both internal and external compact. Even though it is the facility administration that grants study leave, the Ministry of Health provides the sponsorship. Also external bodies including the GHS organize seminars for health workers across health facilities. In general, any such professional development can enhance health workers’ competence and improve their ability to communicate treatment clearly to patients.

The additional hypotheses are that (2) job satisfaction has positive effect on all three types of process quality; (3) decentralization within health facilities has a positive effect on attitude of health; (4) cordial relationship between health workers and administration has a positive effect on health workers; (5) quality of instruments has a positive effect on clarity of treatment information and attitude of health workers; (6) relevance of procured instruments has a positive effect on

104


health workers attitude and clarity of treatment information; (7) professional development has a positive impact on clarity of treatment information. DESCRIPTION OF THE SURVEY DATA

We employ a new set of survey data for this study. Healthcare administrators, healthcare workers, as well as malaria outpatients in teaching hospitals, regional hospitals, district hospitals, and health centres were interviewed in three selected regions in the country. The survey focused only patients of a single disease, malaria, and health workers who treat such patients. The use of a single disease validates comparison. This ensures that any variation in quality across health facilities is not affected by the type of disease. Moreover, malaria is the most common disease in Ghana accounting for more than 40 percent of outpatient cases in health facilities. This made it easier to get a large number of patients and health care workers for the interview.

The results from the study need not be relevant to only malaria patients and health workers. This is because the types of quality examined in the study can be applied to other patients. Since malaria outpatients share the same waiting space and the same health care workers with other outpatients, the results on the indicators can be generalized to all other patients. For example if a hospital has rude health workers, then both malaria and other patients will be affected by such rude behaviour.

EMPIRICAL SPECIFICATION

Our focus is on how various institutional factors affect the three types of process quality. Regressions were run for each type of quality and were specified as follows:

iiiii SQXy �� (1)

The dependent variable for each type of quality is an indicator of that quality. The independent variables included patient profile, health facility fixed effects, as well as institutional factors. Dummy variables were used as fixed effects to control for unobservable characteristics of the health facilities in terms of their type and location.

105


� �

DEPENDENT VARIABLES

In (1), yi is the dependent variable representing indicators for the different types of quality. The dependent variables used for attitude of health workers and clarity of treatment communication were integers between one and seven with one representing poor score for the indicator and seven representing excellent score for the indicator. Waiting period represented the length of time measured in minutes the patient spent waiting to see a doctor. INDEPENDENT VARIABLES

There were three categories of independent variables in (1). Xi is a vector of fixed effects dummies on the unobserved characteristics of the health facility as a teaching hospital or a regional hospital, or a district hospital, or a health centre. Location fixed effect dummies were also included according to region and whether it is a rural or urban facility. The data covered three administrative regions of Ghana, hence a total of six fixed effects dummies. There were two additional (non-dummy) variables in this vector – number of nurses and doctors – to capture the size of the health facility. The variable Qi is a vector of institutional factors for both external and internal compact. The content of the vector depended on the dependent variable. When the dependent variable was attitude of health workers then only the institutional aspects of internal compact were relevant and these were workers’ view of internal decentralization, quality and relevance of procurement, cordial relationship between health care workers and administration, and job satisfaction. Again, only institutional aspects of internal compact were relevant when the dependent variable was clarity of treatment communication. The relevant variables were opportunity for professional development, job satisfaction, and quality and relevance of instruments. Finally, when waiting period was the dependent variable, then the institutional aspect of external compact was the hiring procedure. The institutional aspects of internal compact were job satisfaction, quality of instruments, workers view of internal decentralization, and cordial relationship between health workers and administration.

The variable Si in (1) is a vector of variables on patients’ characteristics: gender, age (in years), education, and occupation. Controlling for these variables was important since they could influence patients’ perception of quality. For

106


example, an uneducated patient working in the formal sector may not know his/her rights and so may find a poor attitude of workers as normal. Diagnosis was not included in the patient characteristics because all the patients were malaria outpatients who were given oral medication with or without injection. Since a lot of the patients interviewed worked in the informal sector it was difficult to obtain reliable information on their income. Thus occupation was used as a proxy for income. There were four categories of occupation, farmers, those who worked in the informal sector, those in the formal sector, and the unemployed as the control group. Education also had five categories, the uneducated (as control group), those who had up to primary education, Junior Secondary education, Senior Secondary education and tertiary education. Finally, εi represents the i.i.d error term. SPECIFICATION PROBLEMS

The model does not have enough independent variables to identify the structural relationships. Two of the institutional variables related to internal compact in the regression with attitude of health workers as a dependent variable, could be endogenous. These variables are workers’ view of decentralization and cordial relationship. Both variables are likely to be affected by workers’ cultural background or their personalities which in turn affect their attitude towards patients. Workers’ cultural background and/or their personalities are thus captured in the error term implying that workers’ view of decentralization and cordial relationship are likely to be correlated with the error term. Under such circumstances, estimation of the coefficients is inconsistent. The estimated coefficients would have two components. One component would reflect the effect of workers’ view of decentralization and cordial relationship on attitude of health workers. The other component, which represents the bias, would reflect the combined effect of cultural background and/or personality on one hand and workers’ view of decentralization or cordial relationship on the other hand on health workers’ attitude.

Typically, the endogeneity problem of independent variables is solved by the use of instrumental variable estimation. The problem here is that it is difficult to obtain instruments for these variables. To deal with the problem, the artificial regression in Murphy (1996) is used to test for the relevance of the two variables. The test statistic was 289.32, leading to the rejection of the null hypothesis that the two variables were not relevant. Omission of the variables

107


� �

could affect consistency of estimation. The regression was thus run with and without the two variables and interpretation done with caution.

Waiting-time may also be endogeneous to the hospital type fixed effects. Typically, severely ill patients choose high performing health facilities and severely ill patients may be allowed to jump a queue. Thus, severity of illness also affects the waiting period. This implies that the hospital dummies may be correlated with the error term. Unlike the case of the attitude regression, here instrumental variable estimation was used. For a variable to qualify as instrument it should be highly correlated with the hospital dummies and uncorrelated with the severity of illness. Following Gowrinsankaran and Town (1999), the distance between the patients’ residential address and each hospital, whether or not the patient received care from there, was used as an instrument. The rationale is that distance is an important factor when patients are choosing hospitals, however patients can be severely ill regardless of the distance between patients’ residence and a hospital.4 Road quality and traffic can prolong travel time even when distance is short. Thus travel time, instead of distance, was used to purge the hospital type fixed effects and the predicted values used for the estimation of the waiting period regression. METHODS OF ESTIMATION

Ordered logistic regression estimation was used for the regressions with attitude of health workers and clarity of treatment communication indicators as the dependent variables. The appropriateness of such a choice was due to the nature of the dependent variables as ordered response categories. The variables were multiple ordered response categories representing the attitude or the clarity of communication by health workers as perceived by patients. Each variable had seven categories coded from one to seven, with one meaning poor performance and seven meaning excellent performance in the indicator. The unobservable index of ‘attitude’ or ‘clarity of communication’ is as specified in (1) above without the intercept. The indices increase as one moves up the ordering of alternatives. Thus the index for poor attitude was less than that that of good friendliness.

4�See Gowrinsankaran and Town (1999) for more on the validity of distance as an instrumental variable.�

108


Duration model was used for the regression with waiting period as the

dependent variable. Typically, the duration estimation requires censored and uncensored groups. However the data covered only uncensored group (because their waiting period ended before data were collected). To validate duration estimation, the waiting period was right censored from above the mean waiting period so that those who waited longer than the mean were classified as the censored group and those who waited up to the mean were the uncensored group.

DATA COLLECTION AND MEASUREMENT OF EXPLANATORY VARIABLES

Patients were randomly selected and interviewed in the facilities after they had received care. Three administrative regions were purposively selected based on the existence of teaching hospitals. In addition, the facility administrators or their representatives and health workers were also interviewed. The sample size of patients chosen for each facility varied according to the size and the type of the health facility. Hundred patients were interviewed in each of the teaching hospitals, seventy in each of the regional hospitals, fifty in each of the district hospitals, and twenty in each health centres.

The targeted health care workers were medical practitioners, and nurses. The targeted sample size for medical practitioners and nurses for the hospitals was at least 50 percent of the respective workers in the hospitals. In the case of health centres, all available workers that were willing to be interviewed were interviewed. This was due to the small number of such workers in the health centres. The interviewers visited each health facility and interviewed fifty percent of health care workers (mainly doctors and nurses) that treat malaria. Thus the interviewer, during a visit, interviewed all the workers on duty if they were up to fifty percent of the total health workers. Else a follow-up visit is arranged. To ensure random selection of workers, the dates for visits were picked randomly. For the health centres, all health care workers were interviewed. This often required several visits. THE METHOD OF DATA COLLECTION

The Report Card Survey method was used for patient survey. Following this approach, a questionnaire was designed for patients. The questionnaire focused on patients’ perception of the quality of care provided by the relevant

109


� �

health facility and their satisfaction with the services. The questions focused on the characteristics of the patients as contained in the Si variable in (1) and the complaint codes used in Montini et al, 2008: quality of interaction, and communication as well as waiting period. The information from respondents was provided on a scale of 1 to 7, with 1 representing low rating and 7 representing the highest rating. For example, in response to the question of whether the health care workers communicated treatment information clearly to patient, the choice of 1 represented poor communication and 7 represented excellent communication.

The report card survey approach was also used for health facility administrators and health workers to gather information on the institutional factors. The variables were created as follows.

INTERNAL COMPACT

Internal decentralization: Both health workers and health facility administrators were interviewed for this variable. Administrators were asked to what extent they were involved in decision making. The response was on a scale of 1 to 10 with 1 meaning no involvement and 10 meaning complete involvement. Health workers were also asked how involved they were in important decision making that affected operations of the facility and procurements. Again the response was on a scale 1 to 10 with 1 meaning no involvement and 10 meaning high involvement. The average score by health workers was coded for the health facility.

Relevance of Procurement: This information was obtained from the health care workers. They were asked if there was any discrepancy, in terms of relevance and quality, between the items requested and the items received from the procurement office. The response was on a scale of 1 to 10 with one representing a lot of discrepancies and 10 representing no discrepancy. Since more than one health care worker was interviewed in a health facility, the average score was coded for the health facility.

Professional development: Health care workers provided information on this variable. Questions focused on the opportunity for professional development. The response scale was also used here with 1 representing no chance for professional development and 10 meaning a high chance for

110


professional development. Since more than one worker was interviewed the average score for each variable was coded for the health facility.

Job satisfaction: Workers were asked if they are generally satisfied with their job and responded on a scale of: 1 to 10 with 1 meaning no satisfaction and 10 meaning highly satisfied. Since more than one worker was interviewed the average score was coded for the health facility.

Cordiality of relationship between health workers and administration: This variable was a dummy variable. The variable was created from the responses from the administrator and the health workers in each health facility on internal decentralization. If the administrator’s rating of the facility regarding the extent to which health workers participate in decision making was less or equal to the health workers’ average rating of the facility, the variable was coded as 1, meaning there was cordial relationship, otherwise it was coded as zero. The rationale behind such computation is that both administrator and health workers agreed on the existence or non-existence of decentralization. Thus a cordial relationship here did not necessarily imply decentralization but consensus from both sides.

All the institutional factors were transformed into dummy variables for the regression estimations. The values for each dummy variable equalled one if the code from the responses exceeded five and zero otherwise.

DATA SUMMARY STATISTICS Data were collected from eighteen facilities in the Greater Accra region and

twenty two from each of the two other regions for a total of sixty two. There were three teaching hospitals, three regional hospitals, twenty three district hospitals and thirty three health centres. The sample size of the patients’ data, after the removal of observations with missing variables was 2,248. Details of data description are shown in Table 1 below starting with the quality indicators.

111


� �

Table 1.a: Descriptive Statistics of Quality Indicators Quality indicator Percentage Quality indicator Percentage Attitude of health Clarity of

workers communication1 2 3 4 5 6 7

Average waiting period (minutes)

5.57.8

14.3 15.9 18.2 22.1 15.8

141.7

12 3 4 5 6 7

2.43.7 9.1

14.9 22.5 32.1 15.2

The indicators for attitude of health care workers show that more than

84 percent of the patients found health workers attitude below 7 while about 94 percent found their attitude above 1. On average a patient waited for 141.7 minutes, which is more than two hours, before seeing a doctor. Unlike the attitude indicator, the distribution of the scores of the communication indicator was uneven, with more than fifty percent categorized as excellent.

The variables for patient characteristics show that with an average age of 36.3 years, most of the patients used in the regression were females with an average education at the Junior Secondary School level, mostly working in the formal sector. Reflective of the regional sizes the largest percentage of the patients was from the Ashanti Region and the smallest from the Northern region. Most of the patients received care from district hospitals, followed by health centres.

The data on institutional variables showed that most of the health workers and administrators chose codes above five (in favour) in responding to the questionnaire.

112


Table 1.b: Descriptive Statistics of Explanatory Variables Variable Percentage Institutional variables Percentage in

favour Age (years) Females Primary education Junior Secondary (JSS) Secondary Education Tertiary Education Formal Sector Informal Sector Farmer Greater Accra Region Ashanti Region Northern Region Teaching Hospital Regional Hospital District Hospital Health centre

36.3(average) 57.6 9.4 33.5 17.9 10.9 16.2 53.8 17.0 33.3 39.0 27.7 11.8 6.7 45.1 36.4

Job SatisfactionCordial relationship Quality of instruments Relevance of procurement Decentralization according to workers Professional development

76.1 58.0 83.4 73.9 40.6 90.5

Thus, more than 70 percent of the workers said they were satisfied with their job, had quality instruments in their facilities, found items procured relevant, had opportunity for professional development through furthering of formal education and attendance of seminars and workshops. While only forty percent of the facilities received high scores from health workers with regard to decentralization, more than fifty percent of the facilities scored high in cordial relationship.

RESULTS

The results of the regressions are reported in Table 2 and Table 3. Table 2 has information on the regression results on the attitude of health workers with and then without the endogenous variables. The coefficients and the p-values are reported for each regression. Table 3 has the results of the regression on the

113


� �

clarity of treatment communication and that of the duration model. The results on the regressions to purge the hospital fixed effects were not reported but the authors will be more than happy to provide it upon request.

ATTITUDE OF HEALTH WORKERS

As shown in Table 2, two regressions were run for attitude of health workers regression: one with the endogenous independent variables (health workers’ view of internal decentralization and cordial relationship between health workers and administration) and the other without the endogenous variables. The omitted variable test showed that the two variables were relevant so their exclusion from the equation could bias the variances of the estimated coefficients. Thus the interpretation of the difference in the results as a result of the removal of the two variables focused on the difference in the signs and magnitude of the coefficients and not on their statistical significance. The signs of two coefficients, number of doctors and favourable policies by government became negative after the removal of the variables however, they remained insignificant in both results. In general the signs did not change when the variables were removed. The statistical significance of the coefficients however changed probably because of the omission of the relevant variables. The interpretation focused mainly on the results with the two variables.

The thresholds estimated represent points on the latent variable, the degree of friendliness, which is unobservable continuous mechanism that results in different observed values on the proxy variable for attitude. Threshold one represents the lowest degree of friendliness as perceived by patients. Values of -2.243 or less on the latent variable were classified as the poorest attitude. Similarly, values between -2.243 and -1.231 distinguished the next degree of friendliness from the remaining classified attitudes.

The results on patients’ characteristics showed that consistent with the Ghanaian culture health workers’ attitude towards patients improved with the age of the patient but did not change with patients’ gender. Patients with higher education were also likely to receive friendly attitude from health workers. This could be because educated patients are more likely to know what to do and also understand the hospital culture better than the less educated. Health workers were likely to be unfriendly towards patients who were farmers and patients working in the informal sector.

114


The regional fixed effects for hospitals were both significant and a test of

the equality of the coefficients showed that patients in the Greater Accra Region were most likely to find their health workers polite while patients in the Ashanti region were the least likely to find them polite. The hospital type fixed effects showed that only teaching hospitals had a significant difference with health centre. Teaching hospital health workers were found friendlier than the health centres. Since Teaching hospital variable also represents the external decentralization, the results also imply that providing more autonomy to health facility could have a positive impact on health workers’ attitude.

The results on the institutional factors also showed that, as expected, internal decentralization and job satisfaction had a positive effect on health workers’ attitude. Thus when health workers were allowed to participate in decision making and are satisfied with their job they were likely to be polite towards patients. Caution is however to be taken here because the positive effect of workers’ view of internal decentralization could be partly due to the combined effect of workers’ culture or personalities. If the combined effect reinforces the effect of internal decentralization then the results exaggerated the positive effect of internal decentralization. The results also showed that cordial relationship between health workers and administration was likely to reduce the value of the latent variable implying a reduction in friendly attitude. This could mean that cordial relationship between the workers and the administration support a cover up behaviour, or vice versa, in which workers are not reprimanded for unprofessional behaviour towards patients. The effect of the cover up on cordial relationship could affect the proportion of health workers with poor attitude, hence exaggerating the effect of cordial relationship on attitude. CLARITY OF TREATMENT COMMUNICATION

The estimated thresholds show the values on the latent variable, the degree of clarity of treatment communication. Values up to -2.190 represent the lowest degree of clarity while values equal or above 3.911 distinguish the excellent clarity of treatment communication from the others. The remaining values show the ranges in which the remaining observed responses represent. For example, values between 0.855 and 2.038 are classified as the third best clarity of treatment communication. The results on clarity of information to patients showed that patients’ ability to understand treatment instruction increased with age and education. Women

115


� �

found treatment information less clear than men, after controlling for education. The result on education so far is consistent with Grossman (2000) which emphasized the importance of education for good health. The information communicated was clearer to the highly educated such as those with tertiary education. High clarity of communication was also recorded among the patients in the formal sector while no statistically significant difference in clarity was found among those in the informal sector, farmers, and the unemployed. The results on the health facility fixed effects showed that clarity of information was higher in the Ashanti Region than the two remaining regions. All the facility type fixed effects were statistically significant and a test for the equality of the coefficients showed that clarity was highest in the Teaching hospitals, and lowest in the Regional hospitals. Clarity of information decreased with the number of nurses and doctors.

As expected the results on institutional factors showed that increase in job satisfaction and quality of instruments improved the clarity of treatment communication with patients. Thus, the hypotheses of positive relationship between clarity and relevance of procurement as well as professional development were rejected. Improvement in the relevance of procurement was associated with low clarity of communication. Professional development had no impact on clarity. This could be due to high correlation between professional development and job satisfaction.

WAITING PERIOD

The results on the hazard regression showed that patient’s characteristics did not affect waiting period except JSS education and workers in the formal sector. The hazard rate fell with junior secondary school but increased with workers who worked in the formal sector. This implies that the probability of seeing a doctor, conditional on not having yet seen the doctor was higher for patients with JSS education than the uneducated and lower for those who work in the formal sector. This is not surprising because people working in the formal sector are more likely to adapt to the formal environment in the health facility than those that are unemployed. The hospital fixed effect (instrumented) variables were all significant and less than one, implying that the probability of seeing the doctor, conditional on not having yet seen the doctor was higher in the health centres than the other hospital types.

116


The results on the institutional variables showed that only job satisfaction

was statistically significant implying that the probability of seeing the doctor given that one has not yet seen the doctor is low in facilities where workers had high job satisfaction. Contrary to expectation, job satisfaction then increased the waiting period.

In general, the fixed effect of Teaching hospital showed that workers in Teaching hospitals had better attitude than the other hospital types. In addition Teaching hospitals health workers communicated clearer to patients than the workers in other hospital types. Finally, Teaching hospitals on average had longer waiting period than health centres but shorter waiting time than the other hospital types. Thus, the hypothesis that teaching hospitals have shorter waiting period than the other hospital types was partly rejected. As already explained, the main difference between teaching hospitals and the other hospitals types is that Teaching hospitals have more autonomy than the GHS hospitals. Teaching hospitals are able to hire health workers directly.

CONCLUSION

This study has examined the effect of institutional factors on process quality in the Ghanaian public health system. The institutional variables examined affect the accountability relationship between the policy maker and healthcare providers as well as between health facility administrators and health workers. In the principal agent framework, the focus is on the ability of the principal to hold the agent accountable for the delivery of expected service. Three indicators of process quality examined were attitude of health workers, clarity of communication and waiting period. The results showed that patients with higher education were better able to get a higher quality care than the less educated. The health facility fixed effects also showed that, with the exception of waiting period, Teaching hospitals gave the best quality care. Health centres had the shortest waiting period followed by teaching hospitals. While health workers were found most polite in the Greater Accra Region and least in the Ashanti region, clarity of communication was best in the Ashanti Region.

The results on institutional factors showed that job satisfaction and involvement of health workers in decision making, are important for the improvement of process quality. Job satisfaction had a positive effect on attitude of health workers and clarity of communication while the involvement of health

117


� �

workers in decision making also had a positive effect on the attitude of health workers. Clarity of treatment communication improved with the use of quality equipment and instruments but reduced with the relevance of procurement. Cordial relationship between administration and health workers had a negative effect on attitude of health workers and waiting period. The results on the two variables could be biased and so were interpreted with caution. Cordial relationship between health workers and administration was found to deteriorate health workers’ attitude. This could be due to too much familiarity between workers and administrators leading to the inability of administration to reprimand health workers. The possibility of a bias in the estimation could exaggerate the negative impact of cordial relationship. However, the quality reducing effect could be solved by regular transfer of administrators across health facilities.

The results on Teaching hospitals imply that external decentralization in the form of providing more autonomy to health facilities in on government budgetary allocations for recurrent expenditure as well as in the hiring of health workers. Thus, the results in general also showed that institutional aspects of accountability relationship between health facility administrators and health workers was more important in improving quality than that between policy makers and providers. Improvement in the facility administrators’ ability to induce the desired quality from the health care workers is more quality improving than relying on the government. It is the responsibility of policy makers to ensure that health facilities, deliver quality services to society. The study has shown that to achieve such goals, it is important that the working conditions of health workers be improved to ensure job satisfaction. Further studies are needed to find the factors that affect job satisfaction of health workers. Even though opportunity for personnel development is likely to improve job satisfaction, the study has shown that workers in facilities with such opportunity did not exhibit the statistically significant different attitude towards patients. While this could be due to high correlation between job satisfaction and professional development, it could also be that on average workers do not utilize the skill upgrades that are taught at workshops. There could be the need for follow-up workshops to evaluate effect of workshops on performance. Patients need to be educated on their rights and be given outlet to report bad behaviour of health care workers. Making health workers wear name

118


tags has been shown to improve workers behaviour. This, however, may not be effective in an environment where illiteracy rate is high. The health system has rules to reward good behaviour and punish bad behaviour. Enforcing such rules could induce good behaviour from health care workers. In addition, facilities administrators could be trained on how to manage their human resource. Management of human resources could simply mean moving workers to help in certain departments during certain times of the day.

REFERENCES

Agyepong, I. (1999), “Reforming health service delivery at the district level in Ghana: the perspective of a medical officer”, Health Policy and Planning, 14(1), 59-69.

Bannerman, C., S. Larbi Wumbee, A. Plange, Y. Brobbey, N.Y. Konadu, M.Osei, W. Asare, C. Boye, and A. Sarpong, (2010), Customer Care Mystery Shopping Report, Ghana Health Service, http://www.scribd.com/doc/33672041/Mystery-Shopping-Ghana-Health-Service

Brobbey- Mpiani, (2005). “Ghana Health Service Customer Care Training. Unit 1, Introduction to Customer Service Training in GHS”, www.ahsag.org/workshops/Customer%20Care%20-%20Mr.%20Brobbey9.pdf

Chalkley, M. and J.M. Malcomson, (2000), “Government purchasing of health services”, in Handbook of Health Economics, Vol. 1A, Eds. A.J. Culyer, and J. P. Newhouse

GHS, (2007), Quality Assurance Strategic Plan for Ghana Health Service 2007 – 2011, www.ghanaqhp.org/.../GHS_Quality_Assurance_Strategicplan_FINAL.pdf

GHS and Teaching Hospital Act, (1996), http://ghanalegal.com/?id=3&law=140&t=ghana-laws

Gowrinsankaran, G. and R. J. Town, (1999) “Estimating the quality of care in hospitals using instrumental variables” Journal of Health Economics, 18, 747-767.

Grossman, M. 2000 “The Human Capital Model”, in Handbook of Health Economics, Vol. 1A; A.J. Culyer and J. P. Newhouse (Eds).

Gupta, D., Bhatnagar, S, Nagar, A. Mishra, S. 2007 “Defaulting oncology patient in a multispecialty state-run hospital in India” American Journal of Hospice and Palliative Medicine, 24 (1), 59-62.

119


� �

Kimenyi, M.S., S. Ray, and L. Chen, forthcoming, Tools and Techniques for Evaluating Service Delivery, in African Economic and Research Consortium, Institutions and Service Delivery.

Kingdon, 2006 As quoted in Collier, P. 2007 Accountability in the Provision of Social Services: A Framework for African Research, http://www.aercafrica.org/documents/isd_workingpapers/PaulCollierAccountabilityinProvisionofSocialServices.pdf

Leonard, K and D. Leonard, (2004), "The political economy of improving health care for the poor in rural Africa; institutional solutions to the principal-agent problem" The Journal of Development Studies, 40(4), 50-77.

Mliga, G. R. (2000). Decentralization and the quality of health care. In K. L. Leonard (Ed.), Africa's changing markets for human and animal health services, London, also available at http://repositories.cdlib.org/uciaspubs/editedvolumes/5/: Macmillan (Chapter 8)

Murphy, A. 1996 “Simple LM tests of mis-specification for ordered logit models, Original Research Article” Economics Letters, 52(2), August 1996,137-141

Owusu-Ampratwum, K. Jan 12, 2011, Hospitals Asked to Keep Unfriendly Workers Away from Patients, http://news.myjoyonline.com/health/201101/59184.asp

120


Table 2: Results on Attitude of Health Workers

Dependent Variables

Attitude of Health Workers (with the endogenous covariates)

Attitude of Health Workers (without the endogenous covariates)

Independent variables Coefficient P-value Coefficient P-value

Threshold 1 -2.243 0.000 -2.182 0.000

Threshold 2 -1.231 0.000 -1.432 0.000

Threshold 3 -0.228 0.383 -0.743 0.004

Threshold 4 0.638 0.016 0.361 0.163

Threshold 5 1.581 0.000 1.400 0.000

Threshold 6 3.054 0.000 2.909 0.000

Age 0.017 0.000 0.015 0.000

Gender (Female=1) -0.102 0.193 -0.040 0.632

Primary Education -0.221 0.161 -0.308 0.068

Junior Secondary School -0.119 0.236 -0.123 0.258

Senior Secondary School 0.313 0.016 0.234 0.085

Tertiary Education 0.484 0.005 0.355 0.045

Formal 0.037 0.803 0.046 0.766

Informal -0.384 0.001 -0.323 0.007

Farmer -0.378 0.009 -0.361 0.019

Greater Accra Region 1.656 0.000 1.563 0.000

Ashanti Region -0.334 0.019 -0.432 0.004

Teaching Hospital 1.400 0.000 0.709 0.003

Regional Hospital -0.255 0.227 -0.139 0.521

District Hospital -0.128 0.202 -0.101 0.314

Number of nurses -0.002 0.057 -0.002 0.062

Number of doctors -0.001 0.710 0.002 0.561

Workers view of internal decentralization 0.708 0.002

Job Satisfaction 0.284 0.033 0.128 0.353

Quality of instruments 0.139 0.416 0.438 0.011

Relevance of procurement 0.022 0.865 0.098 0.454

Cordial relationship bet. adm. and workers -0.396 0.041

121


� �

Table 3: Results on Clarity of Treatment Communication and Waiting Period Dependent Variables

Clarity of Treatment Communication to Patients

Waiting Period

Independent variables Coefficient P-value Hazard Ratio P-value Threshold 1 -2.190 0.000 Threshold 2 -1.210 0.000 Threshold 3 -0.190 0.442 Threshold 4 0.855 0.001 Threshold 5 2.038 0.000 Threshold 6 3.911 0.000 Age 0.011 0.000 0.998 0.341 Gender (Female=1) -0.018 0.000 0.961 0.322 Primary Education 0.004 0.817 1.051 0.484 Junior Secondary School 0.001 0.981 0.862 0.003 Senior Secondary School 0.290 0.990 0.941 0.363 Tertiary Education 0.485 0.027 1.029 0.724 Formal 0.256 0.005 1.246 0.003 Informal -0.103 0.086 0.915 0.110 Farmer -0.006 0.371 0.981 0.798 Greater Accra Region 2.038 0.969 0.968 0.640 Ashanti Region 1.464 0.000 0.988 0.874 Teaching Hospital 0.686 0.000 0.639 0.002 Regional Hospital -0.675 0.002 0.588 0.000 District Hospital -0.228 0.001 0.469 0.000 Number of nurses -0.003 0.020 0.998 0.005

122


Table 3 (continued): Results on Clarity of Treatment Communication and Waiting Period

Dependent Variables

Clarity of Treatment Communication to Patients

Waiting Period

Independent variables Coefficient P-value Coefficient P-value

Number of doctors -0.005 0.010 1.000 0.798 Workers view of internal decentralization 1.131 0.243 Job Satisfaction

0.787 0.000 0.847 0.003 Quality of instruments

0.443 0.011 1.017 0.825 Relevance of procurement

-0.322 0.009 Cordial relationship bet. adm. and workers

0.933 0.509

Professional development -0.007 0.968

123

Documents

Effect of Institutional Factors on the Quality of Ghana’s ... · PDF fileEffect of Institutional Factors on ... to examine the effect of institutional factors on the quality