Discussion
The study found an overall client satisfaction level of 84.2%. While few studies have been conducted to assess satisfaction levels in Uganda, a study to assess the quality of antenatal care services in Eastern Uganda, reported overall satisfaction rate of 74.6%11. This was attributed to clients having sought care in public facilities with high patient volumes and frequent stock outs of medicines in contrast to private-not-for-profit facilities as in our study. Other studies in Uganda reported much lower satisfaction levels. For example, a study conducted in 10 districts in 2013 found a client satisfaction rate of 47%8. Another study conducted in two facilities providing ART services, a public health facility and a private health facility in Kabale, found that satisfaction was 58% and 64% respectively10. A study on satisfaction among clients attending eye clinics in Masaka, Uganda found a low (40%) satisfaction rate9. Our findings are only comparable to findings in Nigeria where overall satisfaction was found to be 83%1. A much higher rate of overall satisfaction of 94.7% was found in Nigeria2. However, these studies were conducted in a different context. A review on faith-inspired services in African countries including Uganda found that they had significantly higher satisfaction than public services14.
This study also found that marital status, health facility level and dioceses were associated with overall satisfaction. The single/never married were more likely to be dissatisfied with the overall service experience while dissatisfaction among clients at Health centre III was lower showing that the clients interviewed were generally satisfied with the overall service experience at that level. The clients' dissatisfaction experienced at Hospitals and Health centre IVs could be related to a high patient volume in comparison to lower level centres. High patient volumes often lead to long waiting times and a short clinician-patient interaction time. The dioceses of Nebbi, South Rwenzori, Karamoja, Lango and Mukono had higher client dissatisfaction rates suggesting the need to improve on the different client satisfaction dimensions.
The mean satisfaction rating in our study for payments was considerably low at 64.7% as clients complained that payments were not clear. This is similar to the study in Mulago Hospital in Uganda and one in Masaka where cost of health services was associated with low satisfaction5,9. This could be due to the fact that most clients may not be aware of the out-of-pocket payments required for different services and explaining this before hand in informational sessions may improve clarity5. The level of out-of-pocket expenditure in Uganda stood at 33% in 2014 and for health facilities in the UPMB network, user fees contributed to 41% of the income for recurrent operations15,16. Therefore, it is not surprising that there was low satisfaction with the payments and while the goal is to keep charges as low as possible, the decrease in government contribution to the PNFP sector means that there is a growing dependence on user fees for member health facilities. In contrast the study in a teaching hospital in Northern Nigeria found a higher (73%) rate of satisfaction with the payment for services provided among the respondents1.
There was a higher dissatisfaction with payments in hospitals compared with Health Centre IIs and this could indicate higher user fees at hospital level due to more complicated illnesses that require more procedures, high opportunity costs such as transport in order to access health care in hospitals or high costs for procedures due to the need to meet the overall operating costs such as remunerating specialists. The unemployed were significantly dissatisfied with payments and this is not surprising given the lack of income. Interestingly though, the formally employed were also dissatisfied with the payments for services provided indicating that they may perceive that there is low value for money for services rendered5. Additionally, the formally employed might be experiencing a huge burden of paying for the costs of health care for themselves and their dependents thus taking a large share of their household incomes. The study also found that those with post-secondary education were also dissatisfied with payments. Those with post-secondary education are likely to be also formally employed and the same reasons for this might be applicable. Similarly, education level, and estimated expenditure were associated with the mean general satisfaction scores in outpatient clinics in Mulago Hospital in Uganda5. The findings on payment dissatisfaction should inform exemption policies since the unemployed are not satisfied with charges and this could be due to their lack of income.
The dioceses were also associated with high payment dissatisfaction in our study suggesting that there may be different user fee structures across dioceses. Alternatively, the dissatisfaction in the diocese may reflect the variations in incomes across the dioceses and the lack of sensitivity of user fees to these. This may have a negative impact on equity and access to health care. It is important for the different dioceses to consider the socio-economic standing of clients when setting user fees. In addition it may be important for the network to advocate for more budgetary support for facilities in dioceses where clients are unable to afford access to health care.
The overall satisfaction rate with the dimension of rights in our study was 63% and this is similar to a study conducted in Portugal which also found a 63% rate of satisfaction with rights awareness17. This signaled dissatisfaction of clients in the way health providers engaged with them in informing them of their entitlements and in the decision-making process. In this study, marital status and dioceses were significantly associated with higher dissatisfaction and those who were divorced or separated where more likely to be dissatisfied with respect for their rights as patients. Similarly, marital status has been linked to consciousness of client rights18. Client rights are aimed at protecting their autonomy and while health providers may have an understanding of this, client rights are not always upheld. Information on rights and entitlements is not always fully given leading to dissatisfaction17. This is so in spite of the need to give personalized information that allows patients to make informed choices that suit them in their circumstances and improve their quality of life. Health providers need to recognize that the client-provider relationship has evolved over the years from one of paternalism where the provider knows it all to one where there is a strong focus on human rights and individual autonomy and curiosity is encouraged enabling effective participation in decision-making19.
Client satisfaction improves a health facility's image and can result in high service uptake18. Furthermore, when patients are kept aware of their care using simple language that is easy to understand, this alleviates anxiety and increases satisfaction. Client rights refers to the operationalization of human rights in health care enabling clients to get appropriate and respectable care according to need based on the premise of preserving human dignity20. In Uganda, there is a patients' charter which spells the client rights and responsibilities as well as the responsibilities of the health workers and is aimed at increasing clients' awareness of their rights and encourage them to demand good quality health services21. This charter was introduced against the backdrop of limited capacity to demand health rights by patients in the country.
In this study, 46% of clients had a health facility that was closer to their home than the one they visited on the day they were interviewed. While clients' physical proximity to their preferred health facility could indicate the level of access to health care, this study revealed that for close to half of the clients, the nearest health facility was not necessarily the one they used for different reasons. The quality of services, availability of drugs and availability of staff were found to be key determinants of clients' choice of health care sources. This conforms to other findings where the same factors were also found to influence access to health care14,22. It is therefore not sufficient to guarantee physical proximity only, as clients will leave nearer facilities to look for those with better care, even if far away. All efforts should therefore be made to improve the quality of care available at all health facilities particularly those in dioceses with greater dissatisfaction rates. Most importantly, the dioceses' that had high dissatisfaction across all the satisfaction dimensions (overall satisfaction, payment, rights) namely South Rwenzori, Mukono and Lango need urgent attention to be able to improve the service experiences of clients.
Our study was conducted in a heterogeneous population spread geographically across all the different regions of the country and at different health facility levels. The study was conducted only in the private-not-for-profit protestant faith-based network therefore may not be generalizable to the public sector health facilities. Due to the cross-sectional nature of this study, it is important to interpret the findings with caution as satisfaction may vary with different service encounters and is subject to extrinsic and peculiar factors unrelated to the service experience23. In addition clients' satisfaction assessments may be subjective.
This study indicates a high level of satisfaction with services in the UPMB faith-based network in Uganda. The study has also highlighted significant dissatisfaction with the payment and rights dimensions. This has some implications for service delivery within the network. The findings suggest the need to develop service improvement plans to address concerns around overall client satisfaction, payments and rights. There is need to standardize and explain the different charges levied on clients. To reduce out-of-pocket expenditure, there is need to implement community health insurance schemes. Health facility managers should ensure that the number of health workers match patient volumes especially at higher level centres. Health workers should take more time to explain rights and entitlement to clients as part of health education talks. All member health facilities should be encouraged to conduct routine client satisfaction surveys and implement continuous quality improvement strategies. Training of health workers on the patient charter and provision of job aids is necessary to promote patient-centered care in UPMB facilities.