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Relationship
Relationship marketing strategy marketing
Policy formulation and curricula development strategy
to enhance quality of care in the health
sector of Ghana 631
Augustine Adomah-Afari and Theophilus Maloreh-Nyamekye
University of Ghana, Accra, Ghana Received 25 May 2017
Revised 19 March 2018
Accepted 27 March 2018

Abstract
Purpose – The purpose of this paper is to explore how strategies are put in place to formulate policies
regarding the introduction and implementation of relationship marketing (RM) in the health sector, and how RM
strategies are designed as part of the curricula for the training of prospective health professionals in Ghana.
Design/methodology/approach – Data were gathered using interviews and documentary review.
A purposive sampling technique was used to recruit policy makers and health educationists in Accra for
in-depth interviews. Qualitative interviews were analysed using framework analysis.
Findings – The findings revealed that, currently, there is no policy framework on RM in the health sector nor
included in the curricula of health training institutions in the country.
Research limitations/implications – Due to limited time and funding constraints, the study could not
include many policy makers, educationists, health providers, facilities and regions outside the Greater Accra
region of Ghana. This means that the authors missed out on useful insights from other relevant policy
makers/educationists who would have added to the knowledge that this study contributes. There were still
some areas that this study could not cover, including the lack of an exploration of the perceptions of health
providers and patients.
Practical implications – Evidence from the current research provides the basis for scaling up of a similar
study to the whole country to address the perennial RM or quality of care/patient satisfaction issues
persisting in health facilities in the country. The outcome of this large-scale study would help to confirm the
findings of the current study on the adoption and incorporation of RM into both policy framework and
curricula of health training institutions in Ghana. The findings would culminate in the preparation and
utilisation of guidelines on RM for client-centred service delivery in the health sector of the country.
Social implications – This paper argues that RM orientation could enable health professionals to improve
upon their healthcare service performance and quality of care so as to enhance patient satisfaction.
Originality/value – The study recommends that RM should be adopted by health policy makers and
designers of curricula for health training institutions.
Keywords Quality healthcare, Policy making, Curricula, Customer service/care,
Relationship marketing orientation/strategies, Training institutions
Paper type Research paper

Introduction
There is the need to develop a suitable and more humane approach to healthcare service
delivery to enhance quality care and patient satisfaction (Alrubaiee and Alkaa’ida, 2011).
Some analysts anticipate that paying attention to the perspectives of clients, improving the
competencies and skills of providers, working environment and motivating staff among
others could help improve quality of care (Bannerman et al., 2002; Turkson, 2009). The lack
of these attributes is why there is perceived poor delivery of healthcare services in hospitals
and clinics in Ghana. Even under the current National Health Insurance Scheme
dispensation, healthcare providers are perceived to be rude, uncaring, disrespectful and
unfriendly (Turkson, 2009). These, coupled with other factors, have created the assumption
International Journal of Health
Care Quality Assurance
Vol. 31 No. 6, 2018
This research was funded by the Office of Research, Innovation and Development (ORID), pp. 631-645
University of Ghana, with Project Reference Number: URF/8/Sf-018/2014/2015. The authors appreciate © Emerald Publishing Limited
0952-6862
this financial support. DOI 10.1108/IJHCQA-05-2017-0086
IJHCQA that healthcare providers are not customer friendly, giving rise to self-medication and other
31,6 unethical means of healthcare service consumption (Gyasi et al., 2011).
Relationship marketing (RM) strategy on the part of healthcare providers can resolve
some of these problems (Berry, 1983; Sorce, 2002). The primary goal of RM is to build
and maintain a base of committed customers who are profitable for the organisation.
The concerns include attracting, developing and retaining customer relationships (Berry
632 and Parasuraman, 1991). RM is within the framework of services marketing (Gronroos,
2000), a branch of the marketing discipline (Kotler, 2000). Kotler (2000) argued that
marketing deals with profitably identifying and meeting human and social needs. That is,
marketing people are involved in marketing ten types of entities: goods, services,
experiences, events, persons, places, properties, organisations, information and ideas.
“Service” has been defined as the application of specialised competencies (skills and
knowledge) through deeds, processes and performances for the benefit of another entity or
the entity itself (self-service) (Gronroos, 2000). However, “services marketing” has been
defined differently including the fact that it is the marketing of activities and processes
(rather than objects) (Solomon et al., 1985) and as a process or performance (rather than a
thing) (Lovelock, 1991). In addition to the traditional four “Ps” of marketing (product, price,
place and promotion (distribution)), Rust et al. (1996) identified another three “Ps” of services
marketing – people, physical evidence and process.
RM, which is the focus of this study, takes a cue from services marketing (Rust et al., 1996;
Rohrer et al., 1999; Rohrer, 2000). Thus, Berry (1995) explains that RM is an old idea with a
new focus. It has taken the forefront of services marketing practice and academic research.
The impetus for its development has come from the maturing of services marketing with
emphasis on quality, increased recognition of potential benefits for the firm and customer and
technological advances. Undeniably, the notion of RM sub-sits on long-term relationships
(MacNeil, 1981). Thus, the firm/hospital will have to focus on the attraction, retention and
enhancement of customer relationships (Berry, 1983). In doing this, Khurana et al. (1993)
proposed 18 novel ways to get more patients. Berry (1995) argues that RM aims to target
profitable customers using the strongest possible strategies for customer bonding, marketing
to employees and other stakeholders and building trust as a marketing tool.
Without a doubt, RM strategy has become important in the delivery of health services
due to the introduction of cost and risk sharing policies in Ghana (Badasu, 2004). Naidu et al.
(1999) contend that RM has been gaining momentum as business entities realise that
short-term sales/transaction orientation has several pitfalls for building customer loyalty
and continued patronage. The reason is that RM has the potential to improve marketing
productivity (Sheth and Parvatiyar, 1995).
Naidu et al. (1999, p. 207) examined the nature of RM practices adopted by hospitals in the
USA and how they correlated with the performance of such hospitals. These researchers
concluded that development and implementation of customer retention programmes,
partnering with customers, suppliers and competitors and other RM practices had become a
way of life. Hasan et al. (2014) recognised that customer loyalty is important for many
competitive organisations and that retail firms will need to make investments (in RM) towards
building and maintaining loyal relationships with their existing and potential customers.
In spite of the benefits derived from an RM strategy, there are certain impediments to its
implementation (Grönroos, 1995). Grönroos (1995, p. 252) observe that as service firms like
banks, insurance firms, transportation companies and retailers have grown, the masses of
customers have made the establishment of true relationship more difficult. What seemed to
have happened was that, in growing service businesses, the customer turned from a
relationship partner into market share statistics. This analyst provides two obvious reasons
for this. First, there is a difficulty to administer a relationship-oriented customer contact
when the number of customers is increasing. Second, there is a growing influence from
popular consumer goods-based, non-relational marketing approaches. Of particular mention Relationship
was when the marketing mix management paradigm and its flagship (the 4Ps model) marketing
established itself as the dominating marketing paradigm. strategy
Supporting this perspective, Hibbard et al. (2001) suggested that though building trust,
commitment and the other components of RM continue to have a positive effect on the
performance of business partners, the positive effect could diminish over time. The authors
suggest that managers need to identify the true cost of building relationships so as to judge 633
whether the diminishing returns justify the effort; and to vary their handling of each
relationship because standardized RM practices are unlikely to be effective (Hibbard et al.,
2001, p. 29). Confirming this, Leverin and Liljander (2006) observed no significant differences
between the segments on customers’ evaluations of the service relationship or their loyalty to
the bank. Thus, managers should invest resources to stimulate customer gratitude in order to
build strong customer–seller relationships (Hasan et al., 2014). Indeed, firms can do this by
organising what is termed as a service-influenced marketing so as to create a customer focus
among all employees beyond conventional marketing (Grönroos and Gummerus, 2014).
Recognising the deficiencies, Berry (1995) indicates that although RM is developing,
more research is needed before it reaches maturity. To do this, Gummerus et al. (2017)
suggest that there is the need to look for a common ground in RM thinking, assessing the
extent to which the different literature streams add to marketing research and when they do
not, testing/deploying the learnings in new settings. In spite of its applicability, no study
using qualitative interviews has yet explored how strategies were being put in place to
formulate policies regarding the introduction and implementation of RM in the health
sector or has examined how RM strategies were designed as part of the curricula for the
training of prospective health professionals in Ghana (Derbile and van der Geest, 2012).
This paper provides more understanding and argues that the introduction of RM strategy
into the policy framework and curricula of health training institutions could help to address
the perennial RM issues persisting in the health facilities in the country.

Literature review
RM orientation can enhance patients’ satisfaction with the reception they receive from
health personnel (Palmatier, 2008). RM strategy provides the basis for a business entity to
realise that any attempt to underestimate the supremacy of the customer (patient) will lead
to other competitors having competitive advantage (Palmatier, 2008). In the healthcare
environment, patients consider the time spent with the doctor/health personnel as very
crucial due to consumerism (Fang et al., 2008). RM strategy to healthcare service delivery
will ensure the appreciation of the exchange relationships that must exist between
healthcare providers and clients/patients of healthcare services (Enyeart and Weaver, 2005).
Patients take into account the attitude of staff in assessing quality of care. Hence, RM
skills will enable staff to appreciate the urgent need to be customer friendly (Ngo-Metzger
et al., 2006). Patients are satisfied with less waiting time at the various departments of a
healthcare institution ( Jennings et al., 2015). Designing an RM strategy in this direction must
consist of the health sector as a whole (MacAdam, 2008). This will create new opportunities,
customer friendly health service environment and engender competition (Debono and
Travaglia, 2009). Greer (1985) noted that the media could influence people’s perception of
medical technology as well as reflect community perception of the local hospitals. Such
perceptions play an important part in determining whether local community members
would support a hospital financially as well as use its services (Asadi-Lari et al., 2004).
The key gaps identified in the literature include the reality that even though RM is
considered a paradigm change in both academic and practitioner literature, it has yet to
evolve into becoming a discipline in the health training institutions in Ghana (Thoreli, 1986;
Sheth and Parvatiyar, 2000). This justifies the reason RM must be considered as a strategic
IJHCQA policy framework and included in the training curricula to be taught by health training
31,6 institutions (Zeithaml and Bitner, 1996). This will arouse the interest of student health
professionals to accept RM as an integral part of the delivery of quality healthcare service
(Morgan, 1998; Yoon and Lee, 2005).

Conceptual analysis
634 The study sub-sits on the framework of relationship, trust, collaboration, commitment,
quality of care and satisfaction (Morgan and Hunt, 1994). These are important elements for
effective and efficient management and delivery of quality healthcare services. Commitment
is a variable believed to be central in distinguishing social from economic exchange, and
commitment and trust lead directly to cooperative behaviours that are conducive to RM
success (Moorman et al., 1993). A few analysts argue that collaborative efforts between the
private health sector, public health sector and community members could enhance social
relationships (Molinari et al., 1998). These can promote the health of residents as there is a
positive relationship between community health service, quality and health status (House
et al., 1988; Sturchio and Goel, 2012).
Wright (1994) points out that human evolution depends on relationships that enable
reciprocal altruism. RM has a positive relationship with commitment and trust – successful
RM requires relationship, commitment and trust (Rotter, 1967). Invariably, the efficiency,
adjustment and even survival of any social group depend upon the presence or absence of
trust (Fu, 2004). This is why true marketing companies are held by means of norms of sharing
and commitment based on trust (Morgan and Hunt, 1994; Kozlowski and Ilgen, 2006).
Walt and Gilson (1994) develop a policy analysis framework specifically for health but its
relevance extends beyond this sector. These researchers note that health policy research
focusses largely on the content of the policy, neglecting actors, context and processes.
The content of the policy looks at the following factors: educational qualification, knowledge
and experience, skills and abilities. The process factors include: legal framework,
institutional influences and external influences. The contextual factors include: situational/
political, socio-cultural and economic. This framework was used to assess the policy makers’
knowledge and readiness to institute and implement RM strategy as a new policy direction
in the health sector under the health sector reforms.
Donabedian (1988) discusses three phases of quality of care measures in healthcare
institutions: structure, process and outcome. The structure indicates characteristics of the
resources in the health delivery system. For example, number of qualified staff and policy
guidelines and management systems including RM strategies. The process involves an
examination of care in terms of what is actually done to and for the patient. Process measures
include factors such as waiting time, examining patients properly and appropriateness of
treatment. The outcome measured includes patient satisfaction, coverage and attendance
levels (Donabedian, 1988). The three phases of quality of care measures were used to measure
heads of health training institutions’ level of knowledge of the contribution of RM orientation
towards achieving quality of care for patients in health institutions.

Methods
Data were gathered using qualitative and documentary reviews between June and
September 2015.

Study design and strategies

Ghana is located on the west coast of Africa with a population of 24,658,823. There are ten
administrative regions (GSS, 2011). The health sector in Ghana has been decentralised to the
district level (Ministry of Health, 1996). The study was conducted in Greater Accra which
had a population of 4,010,054 in 2010 (GSS, 2011). Using the interpretivist approach Relationship
(Schwandt, 1998), purposive sampling strategy (Creswell and Clark, 2007) was used in marketing
selecting ten participants based in Accra, the capital city of Ghana. Creswell (1998) suggests strategy
a sample size between 5 and 25. This sample size was determined based on saturation.
This was explained by Polite and Beck (2008) as the point in data collection when new data
no longer brought additional insight to the research questions.
635
Interviews
The ten policy makers and educationists interviewed were selected from the Ministry of
Health, Ghana Health Service, health regulatory bodies and health training institutions.
They had varied years of experience in their respective positions. Using a semi-structured
interview guide, the following questions were addressed:
(1) What are the strategies put in place to formulate policies regarding the introduction
and implementation of RM in the health sector?
(2) How can RM strategies be designed as part of the curricula for the training of
prospective health professionals?
The interviews, which were conducted in the English language, were held in their respective
offices during working hours. Attempts were made to minimise interruptions and
interferences. Each interview lasted between 15 and 30 minutes, and was tape recorded
using a digital voice recorder.

Data analysis
The interviews were transcribed and analysed using suitable theories and techniques
including framework analysis and Nvivo software. The interpretative perspective was used
in the data analysis because there was the need for thematic emphasis on understanding
and interpretation (Bernstein, 1983; Lincoln, 1990). The interview transcripts were read over
and over, developing patterns and themes based on frequently occurring issues raised by
the participants. Codes were used to identify respondents of each organisation: PM means
policy maker; HTIP means health training institution personnel.

Ethics, access and quality assurance

A pre-test of the semi-structured interview was done with some officials with similar
characteristics within the health sector. Ethical clearance was granted by the Ethics
Committee for Humanities (ECH), University of Ghana-Legon, under certificate number:
ECH 074/14-15. Another ethical clearance was granted by the Ethics Review Committee,
Ghana Health Service under Ethics Approval ID No. GHS-ERC 01/09/15. Introductory
letters were sent to appropriate authorities/institutions. Participants’ consent was
sought using an approved participant’s consent form. Confidentiality and anonymity of
participants was guaranteed.

Analysis of findings
The analyses of the findings based on the themes that emerged from the interview data in
respect to the objectives of the study are presented in the next subsections.

Strategies towards formulating policies regarding the introduction and implementation of

RM in the health sector
The first objective, which focussed on the policy makers, was achieved by using the
framework for policy analysis to assess the policy makers’ knowledge and readiness to
institute and implement RM strategy as a new policy direction in the health sector.
IJHCQA Content
31,6 The analysis revealed that although health professionals are somewhat trained in different
aspects of customer services and that there was the existence of “work-in-progress manual”
on “customer services” for the health sector, there was no specific policy framework,
training manual or inclusion of RM in the curricula:
[…] I think that we have some modules on staff-patient relationship but I wouldn’t call that one RM
636 because marketing is another terminology for a new concept […] […]. PM-3
The absence of strong emphasis on marketing and RM in the health sector could also be related
to the orientation of health providers. Sometimes, quality of healthcare measures is adopted:
[…] Clearly, we recognise the technical perspective in terms of “quality”, and we recognise the user
“satisfaction” as another important dimension […] […]. PM-4
Processes. The perspective of policy makers was that all stakeholders in the health sector
should encourage, coordinate, collaborate and support the institution and training of health
personnel in the health sector in RM:
[…] So one way to actually carry out the process is advocacy with the professional regulatory
bodies so that they see the need for incorporating RM into the course syllabus of the training
institutions […]. PM-2
Participants discussed the seeming absence of accountability in terms of performance to
demonstrate invested resources in the public health sector compared with the private health
sector. This could account for the lack of a good customer/patient relationship.
Context. Participants believed that introduction of RM would give the public health
sector a new look within the context of the health sector reform:
[…] After your research findings come out in a positive direction and based on what the findings
are, we’ll be making a presentation and we will adopt that (RM) and then quickly put them in a form
as a policy […] Now, we are moving away from just putting policies in a vacuum […] […]. PM-1
The policy processes and procedures that RM would need to go through before it could
become a national policy were discussed. There are, however, attitudinal issues and certain
cultural behaviours of health providers that should be addressed:
[…] We all know that people complain about attitude of health workers – it is the culture of
Ghanaians […] RM will help change the mindset of people […] […]. PM-1
Introducing RM will require some financial commitment from both government and other
stakeholders in the healthcare environment.

Designing RM strategies as part of the curricula for the training of prospective health
professionals
The three phases of quality of care measures were used to measure heads of health training
institutions’ level of knowledge of the contribution of RM orientation towards achieving
quality of care for patients in healthcare institutions.
Structure. The health training institutions make enormous efforts to inculcate in trainees
different good attitudes so as to encourage good relationship between them and their clients
on completion of their courses. However, there is no specific topic on the concept of RM:
[…] In our training, we teach some courses like behaviour change under health promotion - we
expect them to learn some things about change of attitude […] […]. HTIP-2
Efforts are also made outside the curriculum, to introduce courses that help trainees to
understand relationship-specific issues.
 Process. It is important that healthcare training institutions inculcate into students the Relationship
habit of establishing a long-term stable relationship with their stakeholders. Participants marketing
revealed the areas serving as the basis of such an orientation while in training.
Training on the relationship with clients. The health training schools ensure that
strategy
students develop the idea of how health personnel provide quality relationship between
them and their patients/clients by even instilling discipline:
[…] When they’re coming in at first with their admission letter, we have an undertaking – academic 637
work and behaviour […] […]. HTIP-4
They teach the students how to even do community entry, how to meet the chiefs, how to
pay homage among others.
Training on the relationship with government. Respondents described how they talk to
students about how to improve relationship between health institutions and government:
[…] During administration, we teach them a lot about the pillars of government: the Ministry of
Health and the Ghana Health Service where we work basically […] […]. HTIP-2
Training on the relationship with competitors. The training institutions introduce students
to the idea of improving the relationship between their institutions and the competitors in
the competitive healthcare environment:
[…] We tell them “when you finish and you’re in the hospitals, you should be ambassadors of your
school” […] “You should work hard, learn and be singled out among the lot” […] […]. HTIP-3
Training on the relationship with media. Educating nurse trainees on their relationship with
the media upon completion is approached from a point where they have to establish cordial
working relationships; to ensure continuous public education:
[…] We encourage them to work hand in hand […] Most of them even do TV programmes – they
are called upon to talk to the public on health education […] […]. HTIP-2
Outcome. Respondents recommended training in RM for tutors of health training institutions
to achieve the most desirable patient-provider related outcomes in the health sector:
[…] I will also approve of the training of the tutors […] A curriculum needs to be developed, then
the tutors can be taken through RM, and they will in turn teach the students both the theory and
practicals […] […]. HTIP-2
Despite the few challenges such as attitude of health providers and financial constraints
likely to confront the introduction of RM into the policy framework and curricula of health
training institutions, there was overwhelming support from all participants.

Discussion
The study argues that there is a difference between customer service/care and RM.
Customer care/service is a temporary interaction with patients; the current “work in
progress” concept being promoted in the public health sector. RM is a long-term/sustained
relationship. The difference can be seen in the ability of RM to attract, establish, maintain
and enhance a long-term relationship between healthcare providers and patients in the
health sector (Berry, 1983). Using this premise, the key findings of the study are discussed in
relation to the concepts of collaboration and commitment; and relationship and trust.

Promoting policy formulation and implementation of RM in the health sector –

collaboration and commitment to enhance quality of care and patient satisfaction
Studies show that RM emerged from dissatisfaction with existing paradigms – many
marketing theories tend to focus on exchange as ad hoc transactions based on conflict
IJHCQA (Cannon and Sheth, 1994). The study argues that quality of care and health status of people
31,6 would be improved when partners in the healthcare market environment coordinate,
cooperate and collaborate with each other. This can promote the health of residents as there
is a positive relationship between community health service, quality and health status
(House et al., 1988; Sturchio and Goel, 2012).

638 Policy adoption pathways for RM

Morgan (2012) argues that academics and managers have struggled for many years to
understand and delineate the role of marketing in explaining business performance
differences between firms. This study shows the view that the process towards the adoption
and implementation of RM is based on some assumptions shown in Figure 1:
(1) the content, processes and context are crucial regarding policy implementation;
(2) the three dimensions are intertwined; and
(3) each dimension may operate in isolation in certain instances.
Walt and Gilson (1994) note that health policy research focus largely on the content of
policy, neglecting actors, context and processes. However, the findings of this study show
that when RM is implemented with the requisite regulatory framework, it will be adopted
for implementation by healthcare providers. This supports Eiriz and Wilson’s (2006)
suggestion that future research into RM should focus on the rationale, processes and
structures involved.

Promoting strategies towards curricula development in RM for health training

institutions – relationship and trust to enhance quality of care and patient satisfaction
Rotter (1967) notes that a successful RM requires relationship, commitment and trust.
The study found that this was a prerequisite since participants agreed on the need to
include RM strategy in the curricula of health training institutions. The fact is that RM
reflects a strategy and process that integrates customers, suppliers and other partners/
stakeholders into the company’s design, development, manufacturing and sales processes
(Sheth and Parvatiyar, 1993; Cannon and Sheth, 1994). Thus, the study revealed
the interrelationship between the structure, process and outcome in Figure 2. The figure
shows that training is a key aspect of education that ensures that students receive
knowledge of RM strategies as part of curricula for prospective health professionals.
However, this process can only be successful in an enabling environment where structures
and systems such as the readiness of the health ministry to institutionalise RM strategies
as part of the students’ curricula are available. Hopefully, when the process is supported
by the appropriate structures, health professionals’ knowledge of RM would be enhanced.
This would lead to enhanced quality healthcare.
Storey and Hughes (2013) observe that there are different pathways to new service
development performance depending on existing organisational conditions. Thus, the
study argues that there is the need to inculcate the tenets of RM into prospective students
before they graduate to join the healthcare delivery institutions. The relevance of RM in
the curricula of health training institutions is paramount because academics and
practitioners have become increasingly dissatisfied with traditional marketing theory and
practice (Cannon and Sheth, 1994). However, this study found that marketing/RM as a
discipline was not included in the curricula of health training institutions. Thus, managers
require faculty to provide them with knowledge that is relevant and able to guide their
decisions. The need for collaboration between the health training institutions and
healthcare industry is also paramount.
 Processes Relationship
marketing
strategy
B

E G 639
D

A F C

Content Context
Notes: A represents that aspect of policy content that may never be implemented
because it has no bearing on or with contextual factors; B represents that aspect of
policy process which cannot be implemented unless it is based on policy content
and context; C stands for policy context, which involves the contextual factors
related to realities on the ground, but meaningless unless it is linked up with policy
content and process; D shows that for an effective implementation of a policy on
RM in the health sector, the content, context and process factors must interact
concurrently. For example, RM processes in public health sector institutions can
only survive if policy making led by political leaders (of the day) are ready to
embrace the concept. On the other hand, there has to be a policy in place to guide
the implementation process. The context of such a policy must be clearly understood
by health educational institutions whose role it is to impact knowledge of RM
orientation. However, this policy, if established, is only relevant when it has the
backing of political leaders and embraced by technocrats at all levels. This leads us
to the process dimension, which essentially focuses on actual implementation of
RM orientation in health care institutions. For instance, lecturers and tutors in
training institutions must have the required knowledge, skills and readiness to teach
the concept and the passion to use students to effect change in healthcare delivery
following completion of studies; E shows that policy content is embraced by those
involved in policy implementation. These include such implementers as health
service managers, lecturers, principals and tutors of health training institutions.
However, without contextual factors such as health care providers’ belief in patients
as valued customers, health care practitioners’ readiness to be customer-focus and
the understanding that health care institutions only exist because of patients, no
headway can be made; F shows an interaction between policy content and context. Figure 1.
Strategies towards
It means that aspect of the policy content has a link with reality. However, this is formulating policies
not enough because without it being embraced by political authorities and regarding the
technocrats at the helm of affairs, implementation is meaningless; G represents a introduction and
situation where process factors intersect with contextual factors in the absence of implementation of
policy content. Contextual and process factors are meaningless if policy content is relationships
marketing in the
absent. Thus, the best scenario is D, which provides an ideal platform for policy health sector
implementation success

Additionally, students desire that the pedagogy will help them to develop skills and provide
them with hands-on experience. The curricula for the training of students in RM should be
designed taking cognisance of the socio-cultural parameters of the country.
This will sit with the observation that RM has emerged as a big new idea for many
Western companies– there is emphasis on relational as opposed to transactional exchange
IJHCQA (Palmer, 1997). Notably, attitudinal/behavioural changes are necessary to engender
31,6 confidence and trust of the patients in the healthcare providers as documented (Zeithaml
and Bitner, 1996).

Conclusion
This study explored how strategies were put in place to formulate policies regarding the
640 introduction and implementation of RM as a policy in the health sector; and how RM
strategies were designed as part of the curricula for the training of prospective health
professionals. Generally, the findings showed that there was no policy framework on RM in
the health sector nor was it included in the curricula of health training institutions. Although
a large body of research theoretically asserts a positive association between RM orientation
and business performance, a valid measure of RM orientation has not yet been proposed and
systematic analysis of its effect on business performance has thus far not been possible as
indicated (Sin et al., 2002). Nonetheless, attempts were being made to introduce “customer
service” in the health sector. This could be used as a basis to develop the policy and
curricula frameworks for RM towards improving quality of care, patient satisfaction and
performance in the health sector.
Evidently, RM orientation was positively and significantly associated with overall
performance in other studies (Sin et al., 2002). The process of adopting RM strategy as
a policy framework may be seen as developing an understanding of the communicator’s
intentions and qualities (ethos) and the communication climate (pathos), both of which are
necessary for engaging in constructive dialogues with customers (logos) (Houman, 2001,
p. 167). Equally, participants agreed on the crucial need to include RM strategy in the
curricula of health training institutions (Achrol, 1991). This would help inculcate into
prospective students the tenets of RM before they graduate to join the healthcare delivery
institutions. Patient satisfaction would be enhanced with the service received in hospitals
through RM orientation as indicated (Morgan and Hunt, 1994).

Implications for policy, practice and management

Ravald and Grönroos (1996) suggest that it is possible to establish and maintain mutually
profitable customer relationships which are of prime concern in RM. Consequently, the
suggestion is that option “D” in Figure 1 should be adopted. For an effective implementation
of a policy on RM in the health sector of Ghana and elsewhere, the content, context and
process factors must interact concurrently. A similar result led to the acceptance of a model
which indicated that change context mediated the relationship between individual
differences and change process and content (Walker et al., 2007). Indeed, RM processes in
public health sector institutions can only survive if policy makers, led by political leaders

Process Outcome
• Training on relationship with • Implementing
Structure clients quality outcomes
Institutionalising • Training on relationship with in the training of
RM in the stakeholders healthcare
recognition of providers
Figure 2. • Training on relationship with
schemes/
Designing relationship government • Delivery of
enabling
marketing strategies • Training on relationship with
environment patient
as part of the competitors
curricula for the centred/customer
training of prospective • Training on relationship with focused care
health professionals media
(of the day), are ready to embrace the concept. There has to be a policy in place to guide the Relationship
implementation process. The context of such a policy must be clearly understood by health marketing
educational institutions whose role is to impact knowledge of RM orientation. However, this strategy
policy, if established, will be only relevant when it has the backing of political leaders and
embraced by technocrats at all levels.
Walker et al. (2007, p. 761) reported that even though an organisation’s prior change
history (i.e. context) has the potential to negatively influence change success, change agents 641
should concentrate on clearly communicating the change details (i.e. process) to employees
in order to counteract these effects. Similarly, the study argues that the extent to which
employees perceive an organisational change as justified will be influenced by their
perceived organisational support (an organisational context variable) (Self et al., 2007).
Ravald and Grönroos (1996) suggest that the ability to provide superior value to
customers is a prerequisite when trying to establish and maintain long-term customer
relationships. This study observes that since the process dimension essentially focusses on
actual implementation of RM orientation in healthcare institutions, participants suggested
that lecturers and tutors in training institutions must have the required knowledge, skills
and readiness to teach the concept and passion to use students to effect change in healthcare
delivery following completion of studies – the value concept is a basic constituent of RM as
indicated in other studies (Ravald and Grönroos, 1996). This is because organisational
change (an employee outcome variable) is strongly related to the impact of the change on
employees (a content variable) and organisational communication media (a process variable)
(Self et al., 2007).

Limitations and future research

There were few challenges in the overall success of the study. Due to funding constraints,
it was not possible to include many policy makers, educationists, health providers, facilities
and regions outside the Greater Accra region of Ghana. This study could not explore the
perceptions of health providers and patients. Therefore, attempts should be made by future
researchers to mitigate similar challenges. Crucially, the evidence from the current research
provides the basis for scaling up a similar study to the whole country to address the
perennial RM or quality of care/patient satisfaction issues persisting in health facilities in
the country (Wall et al., 2009). The outcome of this large-scale study would help to confirm
the findings of the current study on the adoption and incorporation of RM into both policy
framework and curricula of health training institutions. The findings would culminate in the
preparation and utilisation of guidelines on RM for client-centred service delivery in the
health sector of Ghana and beyond.

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About the authors

Dr Augustine Adomah-Afari, is currently, Lecturer in Health Policy, Planning and Management,
School of Public Health, College of Health Sciences, University of Ghana. He received both MA and PhD
degrees from the Sheffield Business School, Sheffield Hallam University, UK. He had also graduated
from the University of Ghana Business School with both BSc (Admin) and MBA. He worked as Health
Services Administrator (District and Regional Hospitals, Ghana), Senior Health Services Administrator
(HASS/GHS), Consultant (PHRplus, Ghana) and Administrator (Manor & Castle Development Trust
Ltd, UK). His research interests include health system reforms; health financing, policy, planning and
management; quality of healthcare; relationship marketing; human resources management; and
community-based organisations. Dr Augustine Adomah-Afari is the corresponding author and can be
contacted at: augustineafari@yahoo.co.uk
Dr Theophilus Maloreh-Nyamekye, is currently, Lecturer in Public Administration & Health Services
Management, University of Ghana Business School, University of Ghana. He obtained his PhD, MSc and
PG Certification from the Robert Gordon University, Aberdeen, Scotland, UK. He has a PG Diploma in
Marketing (CIM, Ghana). He had also graduated from the University of Ghana with both MBA and BA
(Nursing with Psychology). His work experiences include: Part-Time Lecturer (Ghana Telecom University),
Lecturer (Catholic Institute of Business and Technology), Consultant/Lecturer (GIMPA), Management
Consultant (Ghana, Mali and Mozambique) and Health Services Administrator (Effia-Nkwanta Regional
Hospital and Tarkwa Government Hospital). He has also served as Member at Staff Recruitment and
Promotion Panel, Catholic Institute of Business and Technology (CIBT); Head at Department of
Procurement and Supply Chain Management, CIBT; and Review Panellist (CIMG). His research interests
include: health service marketing, impact of information, education and communication strategies related
to malaria prevention and control during pregnancy, health systems evaluation, including management
and mechanisms of malaria control programmes in Africa, poverty reduction, procurement and supply
chain management and quality management, including customer satisfaction surveys in hospitals, and
systematic review of evidence related to community health and healthcare.

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