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Service quality in healthcare Servicehealthcare

quality in

institutions: establishing the gaps institutions

for policy action
481
Aaron A. Abuosi and Roger A. Atinga
Department of Public Administration and Health Services Management, Received 13 December 2011
University of Ghana Business School, Accra, Ghana Revised 7 February 2012
Accepted 25 February 2012

Abstract
Purpose – The authors seek to examine two key issues: to assess patients’ hospital service quality
perceptions and expectation using SERVQUAL; and to outline the distinct concepts used to assess
patient perceptions.
Design/methodology/approach – Questionnaires were administered to 250 patients on admission
and follow-up visits. The 22 paired SERVQUAL expectation and perception items were adopted.
Repeated t-measures and factor analysis with Varimax rotation were used to analyse data.
Findings – Results showed that patient expectations were not being met during medical treatment.
Perceived service quality was rated lower than expectations for all variables. The mean difference
between perceptions and expectations was statistically significant. Contrary to the SERVQUAL
five-factor model, four service-quality factors were identified in the study.
Practical implications – Findings have practical implications for hospital managers who should
consider stepping up staffing levels backed by client-centred training programmes to help clinicians
deliver care to patients’ expectations.
Originality/value – Limited studies are tailored towards patients’ service-quality perception and
expectation in Ghanaian hospitals. The findings therefore provide valuable information for policy and
practice.
Keywords Service quality, SERVQUAL, Perception, Expectation, Ghana, Health services,
Medical treatment
Paper type Research paper

Introduction
Healthcare consumers in developing countries are increasingly becoming aware of
their right to quality healthcare. Consequently, providing quality services in healthcare
organisations is gaining momentum in the extant literature (Nketiah-Amponsah and
Hiemenz, 2009). Many health sector stakeholders, government agencies/institutions
and healthcare consumers are now emphasising service quality delivery (Lapsley,
2000; Smith et al., 2006) as a mechanism to avoid adverse treatment outcomes and to
meet consumer demand and value for money. Rational healthcare consumers prefer to
use services that provide quality and best-value care (Lee et al., 2006). This suggests
that, unless service users are expediently provided with best value care and adverse
outcomes minimised, healthcare organisations could suffer operational setbacks.
In line with global efforts to provide quality care, Ghana’s health system has gone International Journal of Health Care
through several reforms over the years with the main aim of bringing significant Quality Assurance
Vol. 26 No. 5, 2013
improvements in healthcare delivery. One such reform was the implementation of the pp. 481-492
medium-term health strategy (1997-2001) by the Ministry of Health (MoH) that stressed q Emerald Group Publishing Limited
0952-6862
two important healthcare quality dimensions: improving access to basic health DOI 10.1108/IJHCQA-12-2011-0077
IJHCQA services geographically and strengthening service delivery in health facilities (Atinga,
26,5 2011). The Institutional Care Division was subsequently established as a Ministry of
Health (MoH) body mandated to monitor and periodically evaluate service delivery. In
2003, the health sector witnessed another major turning-point. A financial reform
crystallised the National Health Insurance Scheme (NHIS) with a key objective to
improve health service access and utilisation.
482 Following the NHIS implementation, the country’s health system is currently facing
increasing scrutiny after high profile research revealed that health service quality is
erratic and inadequate in the service users’ opinion (Ministry of Health, 2007; Turkson,
2009; Atinga et al., 2011). Consequently, continuously monitoring and evaluating
clients’ views is necessary for quality improvement purposes and to provide feedback
to health professionals and policy makers. Particularly, after introducing the current
prepayment system, there is the need to adopt practical measures and invest in
hospitals and clinics to provide quality care. Assessing patients’ service-quality
perceptions, expectations and satisfaction is significant since these factors can
considerably influence their health status and treatment outcome (Baker et al., 2008).
With increasing competition between public and private hospitals under the
established social health insurance environment, it becomes more important than ever
for health sector stakeholders to have a deeper and accurate understanding of patient’s
service-quality perceptions and expectations. When these perceptions and expectations
suggest gaps, it becomes critical to remedy the situation with appropriate policies.
Empirical research suggests that considering patients varying needs in the healthcare
delivery process, ignoring their perceptions could be a major setback towards meeting
their demands (Jewett and Hibbard, 1996; Knutson et al., 1998). Patients’ service-quality
perceptions and expectations are a significant driving force that explains the relationship
between health service-quality and utilisation. Studies in developing countries such as
Egypt, China and Bangladesh suggest that patients’ perceptions strongly influence
service utilisation (Andaleeb, 1998; Yip et al., 1998; Mostafa, 2005). But there is little
evidence about this phenomenon in a developing country context like Ghana.
We argue that although several studies examined patients’ service-quality
assessment, many questions remained unanswered. There is a lacuna in the empirical
literature regarding patients’ perception and expectations using established quality
models such as SERVQUAL. Previous publications have either examined healthcare
quality generally (Turkson, 2009; Atinga, 2011) or the relationship between healthcare
quality and patient satisfaction specifically (Atinga et al., 2011). To date there seem to
be no empirical study addressing patients’ perceptions and expectations in their
healthcare encounter. Additionally, the distinct concepts that specifically determine
perceived healthcare quality are rare in the literature.
These gaps provide an important and unique research opportunity. This study
focuses on identifying the gaps between perceived quality and expectation variables to
enhance managerial understanding while at the same time segregating the distinct
concepts of service quality through data reduction techniques. Specifically, the study is
guided by two research questions:
(1) Is there any significant difference between patients’ health service perceptions
and expectations in public hospitals?
(2) What are the salient factors surrounding patient service-quality perceptions in
Ghana?
The multiple healthcare quality instrument adopted for this study will provide Service quality in
valuable information for policy and practice. healthcare
Service quality components
institutions
Several authors have identified various service quality components. Grönroos (1984)
categorised service quality into technical and functional. The former refers to
diagnostic processes and accuracy while the latter describes healthcare delivery 483
methods. Øvretveit (2000) used patient quality (giving patients what they want),
professional quality (giving them what they need) and management quality (using the
least resources without error or delays in giving patients what they want and need).
Cunningham (1991) preferred the terms clinical quality, economic or finance-driven
quality and patient-driven quality. Clinical quality is related to morbidity, mortality
and infection rates, while economic or finance-driven and patient-driven quality
broadly represents service-quality. Several service-quality models have evolved based
on these frameworks.
A modified version of service quality determinants was proposed by Parasuraman
et al. (1988) whose study culminated in SERVQUAL and has since exercised enduring
influence on contemporary writers. Parasuraman et al. (1988) defined service quality as
comparing patients” perceptions and expectations. Expectations are consumer wants;
that is, what they feel an ideal service provider should offer. Perceptions refer to the
consumer’s service evaluation. Service quality is thus, a function of the differences or
gaps between customer perception and expectation. This is called the Gap Model. The
SERVQUAL scale has five dimensions: reliability, responsiveness, assurance, empathy
and tangibles.

Applying the Gap Model to healthcare

The Gap Model has been widely used in different studies and settings. Curry and
Sinclair (2002) applied the SERVQUAL model to study health services. They found
that patients appreciated the services. The gap scores were slightly negative, which
indicated that patients had higher expectations and lower perceptions. Sohail (2003)
measured service quality in Malaysian private hospitals and perceptions exceeded
expectations for all service dimensions. Jabnoun and Chacker (2003) compared UAE
private and public hospital service-quality perceptions. They found reliability,
responsiveness, supporting skills, empathy and tangibles to be the main service
dimensions. Their study also found that private and public hospitals significantly
differed in all dimensions except supporting skills. Boshoff and Gray (2004)
investigated the relationship between service quality, customer satisfaction and
loyalty. They found that nurses’ empathy, assurance and physical facilities influenced
patient loyalty.
Rohini and Mahadevappa (2006) employed the SERVQUAL framework in a
hospital study and found a gap between patient perceptions and expectations. Iyer and
Muncy (2004) used SERVQUAL to compare service quality perceptions among
different patients grouped based on trust. They found reliability and responsiveness to
be the most important attributes among the high-trust groups; whereas, empathy and
tangibles were crucial for the low trust groups. In an Egyptian private and public
hospitals service quality study, Mostafa (2005) discovered gaps between patients’
perceptions and expectations. The authors reduced the SERVQUAL dimensions from
IJHCQA five to three (human performance, human reliability and facility). Herstein and Gamliel
26,5 (2006) studied service-quality perceptions in health maintenance organisations. They
found a sixth SERVQUAL dimension – private branding. Ramsaran-Fowdar (2008), in
a Mauritian private hospitals study, found that reliability, fair and equitable
treatments were the most important service-quality dimension in healthcare.

484 Service quality and customer satisfaction

Evidence abounds in the literature that service quality leads to patient satisfaction.
Good customer care, which takes into consideration customer communication,
employee demeanour, helping and attending to patients can influence customer
satisfaction with services. Atinga et al. (2011) established that patient satisfaction is
dependent upon supporting patients, reducing waiting time and improving the health
facility’s environment. Taylor and Baker (1994) showed that the moderating effect of
customer satisfaction on service quality and purchase intentions was significant in
several services such as communication, travel, recreation except healthcare. de Ruyter
et al. (1998) concluded that the relationship between service quality and service loyalty
differed, based on industry type. In an industry characterised by heavy switching costs
(e.g. healthcare setting), customers would be loyal. Tucker and Adams (2001), in their
public hospital patient satisfaction study, found that service quality was positively
related to customer satisfaction. Rhodes et al. (2008) noted that US family members
were satisfied if they were regularly informed about their patient’s conditions.

Methods
The study was conducted in five public hospitals in one of Ghana’s ten regions.
Selecting only one region was based on geographical accessibility since we were
interested in exploring service quality perception and expectations to inform further
research in this subject matter. The five hospitals experienced high outpatient
attendance largely because they provided care to patients with different health
conditions. Letters introducing the research team and explaining the study’s purpose
were mailed directly to hospital managers to obtain their consent. The researchers
subsequently visited each hospital to get final endorsements and to arrange a start
date. On obtaining managers’ consent, the first questionnaire containing the
expectation dimensions was administered to patients on admission and follow-up
visit. The patients were randomly selected using hospital admission and follow-up
records. This random selection method guarded against bias. The final questionnaire
containing the perception questions was administered to the same patients after their
discharge or final follow-up visits. In all, 250 patients (50 in each hospital) participated
in the study.

Questionnaire design
We applied the SERVQUAL instrument, widely used in contemporary research
(Sohail, 2003; Mostafa, 2005; Wiesniewski and Wiesniewski, 2005), in our study. The
questionnaire had 22 paired questions designed to examine customer perception and
service-quality expectations. We adopted all the original SERVQUAL questions
without modification. The perception and expectation variables were measured on a
five-point Likert scale ranging from 1 ¼ “strongly disagree” to 5 ¼ “strongly agree”.
The following summarises the SERVQUAL instrument:
 .
Tangibles: physical-environment, medical equipment and staff appearance. Service quality in
.
Reliability: capacity to deliver services accurately and in line with promises. healthcare
.
Responsiveness: providing prompt services and helping patients. institutions
. Assurance: patient safety and health provider demeanour.
.
Empathy: convenient opening hours and providing individual attention to
patients. 485
Apart from the healthcare industry, SERVQUAL has yielded insightful results in
several service organisations such as the hospitality business (Saleh and Ryan, 1991),
information systems (Kettinger and Lee, 1995), airline services (Frost and Kumar, 2001)
and the judiciary (Witt and Steward, 1996). Generally, SERVQUAL’s benefits are
enormous. It is a standardised instrument for assessing service quality in different
settings. It is reliable and has a standard analysis procedure that makes interpretation
easy (Rohini and Mahadevappa, 2006).

Results
Cronbach’s a coefficients were computed to determine the level of reliability of the
SERVQUAL constructs under analysis (Table I). All the constructs had alpha values
exceeding the 0.70 threshold value (Hair et al., 1995).
To answer the first research question, repeated t-measures were conducted to
examine service-quality differences. This is illustrated as Service Quality ðSQÞ ¼
Perception ðPÞ 2 Expectation (E). Addressing the second research question, we
factor-analysed the perception elements to determine the distinct concepts used to
measure patients” service quality perception. Perception and expectation descriptive
statistics are captured in Table II. Among the expectation constructs, almost all items
recorded high mean scores above 4.0. The response pattern demonstrates that patients
have higher expectations about service quality when they are about to report for
medical care. The service-quality areas that attracted lower expectations were the
hospital staff’s ability to get things done the first time (m ¼ 3:80; SD ¼ 1:15) and
convenient hospital opening hours (3.98; SD ¼ 1.01). The perception scores ranged
from 3.12 to 3.81. The least mean scores were found under:
(1) Reliability:
.
“The hospital staff provide promised services” (m ¼ 3:12; SD ¼ 1:24).
.
“The hospital staff get things done the first time” (m ¼ 3:29; SD ¼ 1:09).
(2) Responsiveness. “The hospital staff provides prompt services” (m ¼ 3.29;
SD ¼ 1:14).

Expectation Perception
Construct Mean Cronbach a mean Cronbach a

Tangibles 4.21 0.85 3.47 0.80

Reliability 4.14 0.78 3.31 0.84
Responsiveness 4.11 0.83 3.36 0.83 Table I.
Assurance 4.12 0.79 3.49 0.83 Cronbach alpha
Empathy 4.16 0.80 3.47 0.84 coefficients
IJHCQA
Expectation Perception
26,5 Item-total Item-total
Dimension Mean SD correlation Mean SD correlation

Tangibles
Modern equipment in the hospital 4.29 1.10 0.664 3.34 1.22 0.587
486 Hospital attractiveness 4.13 1.01 0.660 3.36 1.11 0.654
Medical staff appearance 4.31 0.99 0.699 3.81 1.04 0.625
Attractiveness of medical materials 4.09 0.96 0.674 3.37 1.12 0.673
Reliability
The hospital staff provide promised services 4.27 0.85 0.621 3.12 1.24 0.694
Hospital staff are interested in solving patient’s
problem 4.33 0.90 0.650 3.43 1.12 0.708
The hospital staff get things done the first time 3.80 1.15 0.559 3.29 1.09 0.616
Providing timely services 4.22 0.91 0.637 3.31 1.13 0.684
The hospital staff insist on error free records 4.09 1.04 0.619 3.38 1.08 0.624
Responsiveness
The hospital staff communicate to patients about
service provision 4.10 1.08 0.728 3.44 1.19 0.676
The hospital staff provide prompt services 4.08 1.015 0.746 3.29 1.14 0.697
Medical staff willingness to help patients 4.25 0.93 0.695 3.43 1.13 0.770
Medical staff never too busy to respond to
patients request 4.10 1.12 0.685 3.31 1.15 0.696
Assurance
Hospital staff demeanour instils confidence 4.17 0.99 0.654 3.37 1.23 0.730
Patients feel safe in the hospital 4.27 0.95 0.715 3.57 1.04 0.712
Hospital staff are always courteous towards
patients 4.21 0.90 0.667 3.42 1.13 0.751
Medical staff are knowledgeable enough 4.12 0.94 0.705 3.60 0.98 0.637
Empathy
Hospital staff give patients individual attention 4.19 0.94 0.697 3.47 1.11 0.724
Hospital has convenient opening hours 3.98 1.01 0.597 3.33 1.15 0.603
Hospital staff give patients personal attention 4.16 0.91 0.655 3.43 1.12 0.635
Table II. Staff have patients interest at heart 4.31 0.87 0.667 3.58 1.01 0.670
Service quality dimension Medical staff understand clearly patients’ specific
mean scores needs 4.18 0.94 0.676 3.53 1.13 0.752

The perception scores suggest that patients were fairly convinced about hospital
service provision. Thus the manner in which patients wished to be treated when they
visit the hospital did not compare favourably with actual services rendered. Each
service quality dimension was highly correlated with the total computed variables,
suggesting how patient attach importance to these dimensions when evaluating
service quality.
Differences between perception and expectation scores were computed using
repeated t-measures since we were only interested in estimating the mean difference for
the variables (Pallant, 2007). This approach has been used in previous studies
(Mostafa, 2005; Sohail, 2003). All perception and expectations items were statistically
significant (p , 0:001) (Table III). The negative mean difference scores suggest that
patient service expectations in their healthcare encounter are not being met. This gap
 Service quality in
Gap Std. error
P – E SD mean t healthcare
Tangibles
institutions
Modern equipment in the hospital 20.95 1.28 0.081 2 11.71 *
Hospital attractiveness 20.78 1.24 0.079 2 9.86 *
Medical staff appearance 20.50 1.15 0.073 2 3.87 * 487
Attractiveness of medical materials 20.72 1.37 0.087 2 8.32 *
Reliability
The hospital staff provide promised services 21.14 1.53 0.097 2 11.73 *
Hospital staff are interested in solving patient’s problem 20.90 1.45 0.092 2 9.81 *
The hospital staff get things done the first time 20.51 1.36 0.086 2 5.92 *
Providing timely services 20.92 1.38 0.088 2 10.44 *
The hospital staff insist on error free records 20.71 1.33 0.084 2 8.43 *
Responsiveness
The hospital staff communicate to patients about service provision 20.66 1.25 0.079 2 8.34 *
The hospital staff provide prompt services 20.79 1.39 0.088 2 8.96 *
Medical staff willingness to help patients 20.82 1.26 0.080 2 10.30 *
Medical staff never too busy to respond to patients request 20.69 1.40 0.089 2 7.76 *
Assurance
Hospital staff demeanour instils confidence 20.80 1.51 0.096 2 8.38 *
Patients feel safe in the hospital 20.69 1.26 0.080 2 8.64 *
Hospital staff are always courteous towards patients 20.78 1.45 0.092 2 8.47 *
Medical staff are knowledgeable enough 20.52 1.18 0.075 2 6.99 *
Empathy
Hospital staff give patients individual attention 20.72 1.31 0.08 2 8.63 *
Hospital has convenient opening hours 20.65 1.52 0.10 2 6.81 *
Hospital staff give patients personal attention 20.73 1.42 0.09 2 8.14 *
Staff have patients interest at heart 20.72 1.13 0.07 2 10.14 *
Medical staff understand clearly patients’ specific needs 20.65 1.22 0.08 2 8.45 * Table III.
Repeated t-measures –
Notes: *Paired mean difference significant at 0.001(two-tailed test) results

signals that policy actions are required to remove the bottlenecks. To examine the
distinct service-quality concepts, we used factor analysis with Varimax rotation
(Table IV). Factor analysis is able to group variables that are not correlated
appropriately. The model’s strength in explaining the factors extracted was strongly
supported by the Kaiser-Meyer-Olkin (KMO) sampling adequacy measure (0.932) and
Bartlett’s Sphericity Test (x 2 ¼ 31:263; df ¼ 231, p , 0:001). Using minimum
Eigenvalues of 1.0 (Child, 1990), the model produced four factors contrary to the
SERVQUAL model’s original five factors (Table IV). The first factor collapsed
SERVQUAL model’s responsiveness and assurance, which we termed “prompt
attention”. The second and fourth factors produced similar service dimensions in the
original model and so they were labelled “tangibles” and “reliability” respectively. The
third factor items can be appropriately described as access to the hospital and
clinicians. This factor was therefore termed “access”. Our study therefore identified
four distinct service-quality perceptions in Ghana.
IJHCQA
Component
26,5 Items 1 2 3 4

Tangibles
(% of variance explained ¼ 46:245; Cronbach a ¼ 0:80)
Modern equipment of the hospital 0.833
488 Attractiveness of the hospital 0.734
Neat appearance of medical staff 0.676
Reliability
(% of variance explained ¼ 52:55; Cronbach a ¼ 0:84)
Hospital staff provide promised services 0.674
Staff are interested in solving patient’s problem 0.680
Hospital staff gets thing done the first time 0.721
Timely services 0.630
Hospital staff insist on error free records 0.670
Prompt attention
(% of variance explained ¼ 58:19; Cronbach a ¼ 0:89)
Hospital staff communicates service provision to patients 0.596
Hospital staff provide prompt services 0.717
Medical staff willingness to help patients 0.657
Medical staff never get busy to respond to patients’ request 0.642
Hospital staff demeanour instil confidence 0.570
Patients feel safe in the hospital 0.678
Hospital staff are always courteous towards patients 0.506
Medical staff are knowledgeable enough 0.516
Access
(% of variance explained ¼ 62:85; Cronbach a ¼ 0:77)
Hospital staff give patients individual attention 0.650
Hospital has convenient opening hours 0.741
Hospital staff give patients personal attention 0.726
Table IV. Notes: Kaiser-Meyer-Olkin Measure of Sampling ¼ 0:932; Bartlett’s Test of Sphericity
Factor analysis (x 2 ðdfÞ ¼ 31:263ð231Þ; p , 0:001)

Discussion and policy implication

Our findings show that patients generally have high hospital-service expectations.
They expect hospital staff and the hospital environment to appear attractive. After
their service encounter however, patients felt that availability of modern medical
equipment, hospital attractiveness, medical materials and medical staff appearance
were fairly good. This calls for hospital managers to pay attention to regular
maintenance while at the same time maintaining environmental quality. A good
physical outlook helps improve patient mood and morale (Fottler et al., 2002).
Additionally, hospital managers need to encourage medical staff to improve upon their
appearance. The Ghana Health Service (GHS) Code of Ethics mandates clinical staff to
appear in a specified uniform, but in practice this appears not to be strictly followed.
The code of ethics should therefore be reinforced while educating clinicians about how
personal attractiveness can meet or exceed patient expectations.
Consistent with previous studies (Sohail, 2003), patients’ expectation about reliable
services also diminished after their service encounter. There was some consensus
among patients that hospital staff should provide services to the public in-line with the Service quality in
promises captured in their mission and vision statements. The patients conceived an healthcare
ideal hospital to be one where staff solve patients’ problems, provides timely services
and do not incur medical errors. Their expectations however contrasted sharply with institutions
what they perceived during the actual medical treatment process. The mean scores
demonstrate that hospital staff’s ability to provide services they promised were
somewhat good. Similar episodes were reported for other reliability dimensions. A 489
critical policy measure is to streamline services in congruent with the hospital’s
purpose. Hospital staff needs to be driven by a focus to render services akin to banks,
insurance and telecommunication companies. Vision and mission statements therefore
should be constantly communicated to staff to help them understand the hospital’s core
values. Constantly emphasising reliable services under the established health
insurance regime could be profitable because it encourages patient loyalty.
We found that hospital staff do not provide responsive services that meet patient
expectations (Mostafa, 2005; Wiesniewski and Wiesniewski, 2005). Patients with
different health situations, especially those with critical conditions, expect prompt
services and support from clinicians. However, this did not materialise, thus prompting
them to give lower ratings on the perception items. All four perceived responsiveness
dimensions were rated lower than the expectation variables. Understandably, low
staffing levels in a developing healthcare system like Ghana is likely to thwart
responsive care. The poor health-worker to population ratio no doubt places stress on
health professionals and constrains their efforts to provide prompt care. The large gap
scores found in all responsiveness items require prioritisation (Anderson and Zwelling,
1996) to achieve significant results. Health professionals should be encouraged to
prioritise responsive care. In particular, “medical staff willingness to help patients”,
which recorded the largest gap score, demands health managers’ attention.
Enthusiasm to provide help and support to patients during the treatment process
communicates to them that hospital staff respect their dignity and identity.
The assurance dimensions, which relate to health professionals’ demeanour, also
received low perception scores. The knowledge gap between patients and providers
enables the latter to act in ways that are not in the former’s best interest. Patients in
Ghana are still not enlightened under the patient charter to hold medical staff
responsible for their demeanour (Abekah-Nkrumah et al., 2010). Apart from the
knowledge gap, healthcare quality studies have generally reported poor service
delivery with respect to long waiting time and health providers’ poor attitude
(Turkson, 2009; Atinga et al., 2011). To engineer behavioural changes, continuously
educating health professionals about relationship building with patients is important.
Such training programmes should centre on customer management and treating
patients as guests, comparable to private organisations. Hospital managers
implementing service oriented programmes and effectively training health
professionals to make patients feel at ease can reap enormous benefits. Nonetheless,
patients must also be made aware of the problems existing in hospitals and how to
cope with pressure from the few health workers handling numerous cases at a time.
We also discovered that contrary to the five-factor model proposed by Parasuraman’s
et al. (1988), there are four distinct patient service-quality determinants in Ghanaian
hospitals. These include tangibles, reliability, prompt attention and access. Access to
health facilities and health providers therefore need to be improved. Hospital opening
IJHCQA hours need reviewing. Perhaps reveille clinics should be established to respond to
26,5 patients reporting much earlier for medical treatment. This can reduce waiting time and
ensure that every patient who turns-out for medical care gets treatment.

Conclusion
Every rational customer expects to be treated with dignity and respect in any service
490 organisation. This expectation is likely to be more in the healthcare industry where illness
temporarily reduces patient autonomy and creates disaffection. Our findings suggest that
patients do not get the medical treatment services they want. Therefore health managers
can use these findings and recommendations to improve service delivery.

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Corresponding author
Roger A. Atinga can be contacted at: ayimbillah@yahoo.com

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