East African Journal of Public Health East African Public Health Association ISSN: 0856-8960 Vol. 5, Num. 2, 2008, pp. 67-73

East African Journal of Public Heath, Vol. 5, No. 2, August, 2008, pp. 67-73

Patient Satisfaction At The Muhimbili National Hospital In Dar Es Salaam, Tanzania

E.P.Y. Muhondwa¹, M.T. Leshabari¹, M. Mwangu², N. Mbembati³, M. J. Ezekiel¹

 ¹Behavioural Sciences Department, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam., ²Department of Development Studies, School of Public Health and Social Sciences, ³Department of Surgery, School of Medicine , Muhimbili University, Dar es Salaam, Tanzania
Correspondence to: Prof. Eustace P.Y.Muhondwa, Muhimbili University of Health & Allied Sciences,  P. O. Box 6501 5, Dar es Salaam, e-mail: emuhondwa@muhas.ac.tz

Code Number: lp08014

Abstract:

Objectives: Patients are the primary beneficiaries of the services and care that hospitals provide. The Patient Satisfaction study examined the extent to which patients at the Muhimbili National Hospital (MNH) were satisfied with the services and care they received at MNH. This was part of a baseline study that sought to determine the level of performance of the hospital before massive restructuring, reform, and renovations were undertaken.
Methodology: Exit interviews were the main research method used to determine patient satisfaction. Patients were interviewed as they were leaving the OPD clinics, laboratory, X-ray, pharmacy and inpatient wards.
Results: The study found that most patients were satisfied with the services and care they received. This high level of satisfaction must be viewed within the context of a hierarchical public health care delivery system, with MNH at the apex. The services and care MNH provides can only be excellent compared to that provided by lower level health facilities. Indeed, patients covered by this study perceived the services provided by MNH as superior, and this was reflected in the high level of satisfaction they reported. Some patients expressed dissatisfaction with specific aspects of the services that they received. They were particularly dissatisfied with long waiting times before receiving services, the high costs of treatment and investigations charged at MNH, poor levels of hygiene in the wards, and negative attitudes of staff towards patients.
Conclusion: Although only a small proportion of patients expressed dissatisfaction with these aspects of the services provided, they are significant in that they constitute a call for action by the MNH management to encourage the health personnel to embrace a new staff-patient relationship ethos, in which the patient is a viewed as a customer.

Conflict of interest: the authors declare no conflict of interest regarding this study.

Keywords: patient satisfaction, reform, Muhimbili National Hospital, referral hospital, Tanzania

Introduction 

The Muhimbili National Hospital (MNH) is the largest of four referral hospitals in Tanzania. It is positioned to serve patients from different parts of the country and is, in effect, the apex of the public health service hierarchy in Tanzania. MNH has the highest number of highly qualified health services personnel, who provide the widest range of services, and is equipped to provide the highest quality services in the country. Until very recently, it has been the only site that has provided training for medical and health professionals, including a wide range of allied health personnel.

The MNH has embarked on an ambitious reform process financed by the Government of Tanzania and Abbott Fund with the overall aim of improving the quality of services provided at the hospital. This reform will involve renovation of the physical plant and refurbishment of the laboratories so that MNH can provide state-of-the-art health care and related services commensurate with its status as the biggest national referral hospital. As part of the preparations for the reform process, Axios initiated a comprehensive baseline assessment including studies on organization and management, worker motivation, patient satisfaction, patient referrals, surgery and lab performance indicators, health facility utilization, and drug and investigation ordering. These studies will be repeated in 2007, using comparable methodology, allowing an assessment of the impact of the current reforms at MNH. Study results could inform similar hospital reform processes in other developing countries.

The component of this baseline assessment which is reported here sought to determine patient satisfaction with the care and services provided by the hospital.

The patient satisfaction aspect of hospital care has been highlighted in a study undertaken in a Nigerian hospital (1), which found that patients were most satisfied with staff–patient relationships. However, patients were dissatisfied with the amount of time they were able to spend with their doctors. Two studies of patient satisfaction with primary health care in provincial hospitals in South Africa done in 1999 and 2002 (2) are particularly relevant for this study at MNH in terms of their purpose. They sought to determine the extent to which the new government had managed to provide acceptable primary health care to people irrespective of their ability to pay as part of its commitment to extend political and human rights to all the people following the end of the “apartheid” government. The studies measured the expectations and perceived performance of patients regarding the quality of primary health care and to determine the problem areas that still exist, and to suggest how these could be addressed. The additional impetus for the second study was the apparent preference by people who could pay for health care for private hospitals because they were perceived to provide better services. The authors argue that quality control is not only relevant in the private sector, and that the Government must also strive to provide satisfactory care within the resources available. By providing excellent service, the authors maintain, it may be possible to attract patients who are able to pay, and hence contribute to the overall efficiency of health care in a competitive market. A recent South African study of patient satisfaction (3) has noted that the real test of the transformed health system in South Africa is whether it delivers quality care equitably across the barriers of race and socioeconomic status. The authors posit that patient satisfaction is a fundamental indicator of the success.

Most patients are referred to MNH from lower level hospitals and other health facilities. For some patients, attending MNH is the end of a long journey through health facilities that offer less-than-optimal quality of care. This must be kept in mind when appraising their opinions about the quality of care received at MNH and their satisfaction with the care they received, as these patients will invariably compare this with the care they received in lower level health facilities.

This is the first hospital-wide patient satisfaction study at MNH, and has great relevance to public hospitals in Tanzania and beyond. It underscores the importance of developing mechanisms for assessing the overall performance of the hospital, and patient satisfaction with this performance, as Tanzania and other countries strive to implement health sector reforms. It is an essential aspect of the quality assurance initiatives and equity interventions accompanying the reforms. 

Methods

Observational and interview methods were used for the time period 9^th February, 2004 to 20^th February, 2004, to assess satisfaction of inpatients and outpatients. The observational methods were designed to objectively capture important aspects of services about which patients usually express dissatisfaction, namely waiting time and consultation time. The interviews were designed to capture the subjective expression of satisfaction with services. Observations, open-ended interview questions and rating scales were used together in order to enhance the validity of our findings. This is a multi-method research approach, and one indicator of the validity of its findings is the consistency of each method yields. Issues of validity and reliability are particularly germane in patient satisfaction data (4).

Observations

Observations sought to obtain objective information about the time patients spend waiting to get a service and the time they spend with the service providers in the process of getting the service (i.e., duration of the service). A common complaint made by patients concerns the length of time they spend waiting to be attended. Another common complaint regards the inadequate time spent with service providers, who are perceived as perfunctory. This reflects the distinction between objective satisfaction reports about care providers or about the care itself, and satisfaction ratings, which capture a personal and hence subjective evaluation of the care that cannot be elucidated by direct observation.

A group of 159 OPD patients was observed and followed up as they waited for or received services at different service delivery stations (reception, medical records, clinics, laboratory, X-ray unit and pharmacy). Observers were positioned to watch patients as they approached the stations, and selected every third patient for observation. Observations were made at each station over a two-week period by two trained Research Assistants. Each research assistant was expected to follow up a maximum of four patients each day for four consecutive clinic days at each station. The expected number of observations was not realised due to variations in attendances and the varying duration of the observations. The 159 patients followed up (Table 1) constituted 82.3 percent of the expected sample.

Interviews

The interview contained closed- and open-ended questions. These delved into demographic characteristics of the patients, the time and effort taken to reach the hospital, and health-seeking behaviour in relation to the current illness episode. Patients were also asked about their experiences of obtaining services at the hospital and the extent to which they were satisfied with the services, ranging from the assistance they received at the gate and reception, to the services they received at all the service delivery stations to which they went. Patients were also asked to make recommendations for improving the delivery of services at the hospital.

Patient satisfaction was measured in two ways. Firstly, patients were asked specific open-ended questions that sought to elicit expressions of satisfaction or otherwise about specific aspects of services/care or caregivers. This provided them with the opportunity to explain in their own words what they were satisfied or dissatisfied with, and to suggest changes that could improve the situation. Secondly, a simple five-point Satisfaction Scale was used, with 1 and 5 indicating the lowest and highest levels of satisfaction, respectively. Patients were asked to appraise the way they had been treated or the services they had received and to indicate the scale point which best reflected their level of satisfaction with the treatment or service. Our decision to use a five-point scale in the interview is in accordance with Sanderson-Austin and Wetzler (5), who maintain that there are five possible responses for the satisfaction item: Excellent, Very Good, Good, Fair, and Poor. Unlike these authors, we used the verbal statements of Very good, Good, Noncommittal, Fair and Poor, following the Semantic Differential approach (6,7). This provides polar opposite responses with a neutral mid-point. In the course of pre-testing, these responses were easier to explain to respondents in an interview situation, and it was easier for them to rate different items. We also reported all of the scores, to highlight both the best practices and to give equal significance to low scores as indications of problem areas that require intervention during the reform process at MNH.

Interviews were conducted with 2582 patients, which included 2270 outpatients (795 male, 1475 female) and 312 inpatients (116 male, 196 female). Interviews were conducted with OPD patients (543 male, 1106 female) when leaving the clinics after their consultations with clinicians. The instrument was in Kiswahili language and was pre-tested. All patients gave verbal consent before interviews and none refused to be interviewed. The clinics in question were Obstetrics and Gynaecology, Maternal and Child Health (MCH), Surgical, Ophthalmology and Medical clinics.Our aim was to achieve total coverage of all clinics available at the hospital. However this was not achieved because during data collection MNH was undergoing a major rehabilitation which necessitated the closure of some clinics and relocation of some services to other locations.All the clinics operated between 8.30 and 13.00 hours five days a week, except the Internal Medicine clinic, which operated in the afternoon between 14.00 and 17.00 hours. The study obtained ethical permit from Muhimbili University Ethical Review Board.

Other patients were intercepted and interviewed as they were leaving the laboratory (62 male, 90 female), the X-ray unit (57 male and 93 female) and Pharmacy (133 male, 186 female). Interviewers were stationed close to these service delivery stations and requested interviews with every third patient seen leaving the station until their quota of interviews for the day were realised. Inpatients were interviewed outside the wards after being discharged and as they were preparing to go home.

Data analysis

Questions from interview guide were coded before data entry. Data entry was done using Epi-Info software. Statistical analysis was done both manually and using SPSS version 10.

Results

Observational Results

Table 1 shows the waiting and service delivery times at six service delivery stations experienced by the 159 OPD patients involved in the observational segment of this study. With regard to waiting times, the OPD clinics and the reception had the longest waiting times, where the median times were 52 and 26 minutes, respectively.

With regard to service delivery times, we found that patients spent a substantial time with service providers at the X-ray Unit and the OPD clinics. The median times in these stations were 39 and 18 minutes, respectively. These findings provide the backdrop against which expressions of satisfaction and dissatisfaction by patients were appraised.

Socio-demographic characteristics of respondents

As described in the Methods section, the majority of patients involved in this study were females (64.7%). Patients came from different parts of Dar es Salaam; some of them had come from outside Dar es Salaam to seek medical and surgical care at MNH but were staying in the city with relatives and friends. Over 90% of the patients used public transport to get to the hospital, and some of them had to change buses more than three times before reaching the hospital.

MNH operates a preferential treatment system called “Fast Track”. For an additional fee a patient is taken through the service delivery station more quickly than usual. Most of the patients involved in this study could not afford to get on the “Fast Track” system; indeed some of them were exempted from paying the statutory cost-sharing fees. In other words, the patients attending MNH were ordinary Tanzanians who could not afford to go to the private hospitals in the city. This has implications for patient–service provider relations at the hospital. There is a tendency for health care providers to treat patients of low socio-economic status poorly. This is one of the issues in the discussion of the findings.

OPD clinics: patient experiences at the entrance gate, reception and medical records

Since most of the patients had come for a second or subsequent visit, they did not seek help at the entrance gate or the reception. Those who did had the opinion that the people at the gate were generally helpful. More than 50% of patients rated the assistance given at the reception at Scale Point 4 or 5. 

The majority of patients (62.6%) reported that they waited for a short time at the medical records section. A few patients (7.2%) said they did not have to wait at all. They rated the attention they received at the records section as satisfactory. Conversely, a substantial proportion (25.6%) of patients reported waiting for a very long time before being attended to and was not satisfied with the attention they received. These reports are in line with the observations presented in Table 1.

OPD clinics: consultation waiting time

Most patients had to wait up to one hour to be called into the consultation room. A third (33.4%) of the patients reported that they waited for less than thirty minutes, while 36.9% respondents waited between thirty minutes and one hour. Another 22.5% reported that they waited for more than one hour. Only a very small number (6.3%) said that they did not have to wait, but were called in instantly. These reports were also in line with the observations presented in Table 1, and show that the proportion of patients who rated the OPD services highly decreased with increasing waiting times (P = <0.001).

OPD clinics: practitioner-patient interactions

The majority of patients (62.8%) reported that they were able to see their doctor of choice. It is noteworthy that patients who are referred to MNH often have some information about the renowned consultants at MNH who are able to treat their condition. However, as MNH serves as a teaching hospital for the Muhimbili University of Health and Allied Sciences, postgraduate students (Residents) and Interns attend to patients along with consultants as part of their training, and therefore it may not always be possible for a patient to be seen by a particular consultant. This is often a cause for concern for the patients, who fear that they may not be receiving the best care possible.

A total of 1582 (95.9%) respondents expressed the opinion that they were well attended by the doctors. Only 25 (1.5%) patients said that they were not satisfied with their encounter with the doctors for various reasons. They complained about the doctor not being attentive because of talking on the phone during the consultation, and others complained about lack of auditory privacy, which made it difficult for them to talk about their illnesses. Most patients (96.2%) reported that the clinical examination done on them was satisfactory. Only 38 (2.3%) patients voiced some dissatisfaction with the medical examination done on them, indicating that the OPD services were rated highly by a much higher proportion of patients who felt that the doctor had done an adequate clinical examination compared to those who did not.

As indicated earlier, most patients were ordinary Tanzanians who had to pay for the services directly rather than through an insurance system. Many patients reported that the fees charged for various services were either just right (40.1%) or reasonable (3.4%) and were satisfied with them. However, 10.9% of patients believed that the cost of treatment was too high. The remaining 47% did not make any specific comments about the charges.

OPD clinics: complaints and recommendations

Some patients expressed complaints about specific aspects of the service delivery at the hospital. (The number or proportion of such patients is shown for each category of patients and where they were interviewed in subsequent sections of the paper.) These related to the availability and price/costs of drugs, costs for investigations, staff shortage and poor behaviour of some members of staff, the quality and quantity of facilities and medical equipment, and the time patients spend waiting for services. 

With specific reference to the poor behaviour of staff, patients complained about their use of humiliating words while attending patients. Nurses were particularly singled out as being rude, uncaring, and fond of using humiliating language. Patients also felt that the speed at which services were provided was very slow. This in turn led to patients milling around in the hospital for a long time. Patients reported that they spent a long time waiting for results of laboratory investigations.

Interviews with patients at the laboratory

Approximately three quarters of the patients interviewed at the laboratory reported that all of their prescribed laboratory investigations were performed at MNH. The remaining patients said that they had to go elsewhere for some of the tests. For 90.1% of the patients whose investigations were done at MNH, all the laboratory investigations for which they had come to the MNH laboratory had been done the same day. The remainder said they still had to come back for other tests. It is noteworthy that even patients who did not get all of their investigations done on the day they were interviewed still rated the laboratory services highly. A much higher proportion of patients who had completed all the investigations the doctor ordered rated the laboratory services highly compared to those who did not complete all of their investigations.

Twenty-three percent of patients reported that they had to wait for a long time before they were attended to, whereas the rest reported that they did not have to wait for long. Most patients expressed appreciation for the attention they had received from the technicians. Only 11.2% complained that the procedure they had undergone had been painful, and this was in reference to injections. These patients alleged that the needles used were blunt.

When asked for their views about the charges for laboratory investigations, 46.7% of the patients thought that charges were reasonable and 3.3% thought they were very cheap. Only eight patients (5.3%) thought that the charges were too high. The majority of patients (61.3%) rated the laboratory services highly, on Scale Point 4 or 5. Patient satisfaction with laboratory services was associated with the duration of the waiting period, with patients who did not have to wait rating the laboratory services highly (Table 2).

Some 58% of the patients interviewed at the laboratory did not make any specific comments. Those who did commented about poor services (24.3%), inadequate technicians and equipment resulting in long waiting times (9.8%), high charges for investigations (3.9%), and a lack of explanation about the system that patients should follow (3.9%).

Interviews with patients at the X-ray Department

Most of the patients had come to the X-ray Department for X-Ray and Ultrasound examinations. Some 85.3% of the patients said they had managed to get all the prescribed tests done. The majority of patients found that the charges for the examinations were either reasonable (56.7%) or very cheap (2.0%): only 19.3% claimed that the charges were too high. The remaining patients expressed no opinion on the matter. Almost all the patients (98%) indicated that they had received good or excellent service from the technicians who attended them. The services in general were rated as either Very Good or Good (Scale Point 4 or 5) by 42% of patients, while only 6% were not satisfied (Scale Point 1 or 2). Table 3 shows that patients who received ultrasound examinations rated the service at the X-ray Department more highly than those who underwent Barium Meal investigations or X-ray examinations. This aspect was not investigated.

Patients were also invited to express their views on any aspect of the services they had received. Only 12% of the patients had specific comments, while another 44.7% simply called for further improvement in service delivery. The remaining 44.3% made no comments.

Interviews with patients at the Pharmacy

Patients attending the pharmacy had prescriptions for up to seven drugs. The majority of these patients (66.5%) had prescriptions for two or three drugs. Two thirds of the patients (62.1%) did not get all the drugs prescribed for them, mainly because the drugs were out of stock. Only two patients reported that they did not get all the drugs because they could not afford to pay for them. Eighty-two patients (25.8%) made specific comments about the price of drugs at the hospital pharmacy: 8.2% of the patients felt that the price was too high, while 17.6% felt that the price was reasonable.

When asked about how long they had waited for service at the Pharmacy, 68.7% patients said they had waited for up to half an hour, and that this was acceptable to them. Another 27.29% reported that they had to wait for up to an hour or more, and were very unhappy about it.

Most patients (96.2%) reported that the pharmacist who attended them had been of great help, and 11 patients (3.4%) reported that they were not happy with the service rendered by the pharmacist who had attended them.

Overall, many patients were not satisfied with the pharmacy services. Only 37.7% rated the pharmacy service on either Scale Point 4 or 5, indicating that the pharmacy is a problem area in the hospital. Unsurprisingly, this rating was associated with whether or not the patients were able to get all of the drugs prescribed for them and the length of time they waited for service. Patients who received all of the drugs they were prescribed were more likely to express high levels of satisfaction with the pharmacy service. A higher proportion of patients who waited for less than 30 minutes highly appreciated the pharmacy service.

Finally the patients were invited to comment on the services they had received. Over a third of the patients made no comments, while approximately 25% of the patients called for further improvements. Only 26.3% made a number of specific complaints and recommendations, including: a plea for service providers to be gentle and refrain from using bad language when responding to patients’ questions; a suggestion to post information about drugs that are out of stock so that patients do not waste time queuing; and importantly, a suggestion that doctors in the clinics be informed about drugs that are out of stock each day so that they do not prescribe these drugs for their patients.

Interviews with discharged in-patients

These patients had been admitted to the Medical, Surgical, and Obstetrics/Gynaecology wards. The median duration of hospitalisation was four days, with the minimum and maximum duration being one and 98 days. Patients were in different clinical conditions when they were admitted: 45.2% were carried on stretchers or wheeled into the ward; and 4.5% were unconscious. All of the patients who were conscious when they were admitted reported that they were treated well during admission (99.3%).

The patients were asked about the cleanliness of the wards, bathrooms and toilets. Most of the patients (93.6%) reported that the beds (72.8%), wards (88.5%), bathrooms (89.1%), and toilets were clean (67%).

Patients were also asked to indicate the extent to which they were satisfied with the medical/surgical care provided by the doctors, and the nursing care they received while they were in the wards. Table 4 shows that most patients rated their satisfaction with medical and surgical care very highly. It is of particular significance that no patient rated their level of satisfaction on Scale Point 1, and that only six patients (1.9%) rated it on Scale Point 2. The level of satisfaction with nursing care, however, was slightly lower compared to that with medical and surgical care, with one patient rating it on Scale Point 1 and ten patients (3.2%) rating it on Scale Point 2.

It is worth noting that over half (56.9%) of the patients reported that there was a specific doctor who deserved to be commended for providing very satisfactory medical care. A lower proportion of patients (55.8%) indicated that there was a specific nurse to commend for providing very satisfactory nursing care. Conversely, only 5.8% reported that there was a doctor who should be taken to task for giving unacceptable quality of care. The proportion of patients with a nurse in this category was 12.8%.

Patient satisfaction with medical/surgical and nursing care varied with the type of wards in which the patients were admitted. With regard to medical/surgical care, the Medical wards had the highest proportion of patients who scored on either Scale Point 4 or 5. The Surgical wards had the lowest proportion of patients who scored on Scale Point 4 or 5, whereas the Obstetrics/Gynaecology wards fell between the two (Table 5). As for satisfaction with nursing care, the proportion of patients who scored nursing care on Scale Points 4 or 5 was lower.

Table 1: Observed waiting time and service delivery time at different service stations

Table 2: Patient satisfaction with the perceived length of waiting time before laboratory investigations (%)

Table 3: Variation in satisfaction levels for different services received by patients interviewed at the X-ray Department.(%)

Table 4: Variation in satisfaction levels with medical/surgical care and nursing care received by inpatients.

Table 5: Variation in satisfaction levels with medical/surgical care and nursing care received by inpatients in different wards.

Discussion

The results of this study indicate that most of the patients interviewed were satisfied with the services they received at MNH. This is in line with findings of patient satisfaction surveys elsewhere (8). A very low proportion of patients expressed dissatisfaction with various aspects of the services, especially with what they perceived as long waiting times. However, the high satisfaction must be put into the context of MNH being a referral hospital, which receives patients who have often been shunted around between lower level health facilities and attended by auxiliaries and general practitioners.

Measuring patient satisfaction has many purposes, but there are three prominent reasons to do so (8). Such interviews help to evaluate health care services from the patient’s point of view, facilitate the identification of problem areas, and help generate ideas towards resolving these problems. For MNH, which is undergoing reform, the findings of this survey describe the health services provided by MNH from the patient’s point of view. Despite the overall high level of patient satisfaction, a small, but by no means insignificant, proportion of patients expressed dissatisfaction with the attitudes and behaviours of health personnel, including doctors. The fact that some patients expressed dissatisfaction with the services indicates that MNH needs to do more in the drive towards improving services.

Patient dissatisfaction with the attitudes of health personnel is an important weakness that needs to be addressed by the reform process. For MNH personnel, the association of the concept of the patient with little or no power against the health establishment, and hence as passive and dependent remains strong. They are yet to view the patient as a consumer who has legitimate expectations and concerns, let alone as a customer who can assess the delivery of health care services and make valid conclusions about the quality of care rendered to themselves. They must recognise that quality assurance and quality management programmes need to impact on patient satisfaction in addition to improving professionally determined technical aspects of quality of health care.

The nonchalant attitudes and behaviours of health personnel are not unique to MNH. Two studies describing patient satisfaction in Bangladesh both decry the negative attitudes and behaviours of health personnel in government hospitals. Aldana and his colleagues (9) report that the most powerful predictor for client satisfaction with government health services was the providers’ behaviour towards patients, particularly respect and politeness. Andaleeb (10) in turn, reported that a general sense of apathy and unconcern is reflected by health care providers towards patients in a number of hospitals. Andaleeb suggested that patients are denied the elements of responsiveness and personal attention because of their perceived subordinate status compared to that of providers. The factor explaining the poor attitudes and behaviour of health personnel is similar to that reported by Juntunen and Nikkonen (11) in their study of professional nursing in a Mission hospital in rural Tanzania. They found that nurses treated patients and relatives of hospitalised patients as very inferior to them. Andaleeb (10) reports that patients in Bangladesh who can afford to are seeking health services in other countries. In Tanzania, those who can afford to choose to go to private health facilities instead of seeking care at public health facilities (12) 

Taking these results into account, it is worth pondering the observations made by James Shaw that: “Six out of seven customers, who should complain, do not complain. They silently take their business elsewhere and you may never know it. The one in seven customers who do complain are saying, if only you could correct the situation, they would like to continue doing business with you” (13).

Recommendations

The overall recommendation is that MNH should strive to maintain the high standard it has in order to keep patients satisfied with the services they receive. As a national referral hospital, MNH is the final destination for most patients. Very few are referred to hospitals outside the country. MNH is equipped to provide the best medical care and has the most highly trained health professionals to provide it. The patients who come to MNH should be able to experience it as such.

A specific recommendation relates to the need to encourage the staff to treat patients with courtesy and respect in line with the Health Sector Reforms and patient-centred quality assurance. Patients should not be expected to be grateful for whatever is done to/for them. They are customers whose concerns need to be taken into account, the indigent status of some of them being irrelevant.

Another specific recommendation is for MNH to review the working arrangements and procedures at the different service delivery stations. The fact that some patients expressed dissatisfaction with the services indicates that MNH needs to do more in the drive towards improving service stations in order to improve efficiency, minimise patient waiting times and provide for patient comfort.

Acknowledgements

We are very grateful to the patients who were willing to be interviewed. Although they were made to understand that they would not benefit personally from participating in this study, they were convinced that their views were valuable in the drive towards making health care satisfactory to patients attending MNH. We also thank our research assistants who collected the data.

The baseline study as a whole could not have been conducted without the permission and support of the MNH authorities. We are grateful to them. Above all we are grateful to the Abbott Fund for the financial support through the Axios Foundation that enabled us to do the study and to Axios for technical review and guidance.

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