University of Medical Sciences and Technology

Graduate College
M.Sc. in Public and Tropical Health programme

Project Title

Patients satisfaction with primary health care services in

Khartoum state, Sudan, 2013

Student name: Imran Ahmed Abdikadir

Batch number and year of admission: Batch 11, Year of Admission 2012
Student index number: PHT11-2011-039
Telephone number: 0923511161
E-mail: imraan09@hotmail.com

Project Supervisor:
Name: Dr. Muna Hassan Mustafa
Position:
Telephone number: 0912257378
E-mail: mhmhs67@hotmail.com

Date of Submission: ..

Project Number: ..........

2013

Table of Contents

NO

Contents

Page
number

I.

Title page...... 1

II.

Table of Contents.....

III.

Lists of Abbreviations..... 3

1.

Introduction..... 4

2.

Statement of the problem .......

3.

Objectives..... 6

3.1.

General Objectives....... 6

3.2.

Specific Objectives......

4.

Material and Methods..............

4.1.

Study design......... 6

4.2.

Study area .... 6

4.3.

Study population .................................

4.4.

Sample size and technique ..............

4.5.

Data collection tools .... 7

4.6.

Data analysis ...

4.7.

Data presentation ..... 8

4.8.

Ethical considerations......................

4.9.

Time plan (Gantt chart) ............... 9

4.10. Budget .........

10

5.

References.... 11

6.

Appendix 1: Consent Form..

13

7.

Appendix 2: Questionnaire..

14

8.

Appendix 3: Questionnaire in Arabic language... 19

Lists of Abbreviations

1. WHO: World Health Organization

2. PHC: Primary Health Care
3. NGOs: Non-governmental organizations
4. SPSS: Statistical Package For Social Sciences
5. UMST: University of Medical Sciences and Technology
6. MOH: Ministry of Health
7. UNICEF: United Nations International Children's Emergency Fund
8. KAP: Knowledge, Attitudes and Practices
9. USSR: Union of Soviet Socialist Republics
10. HIC: Health Insurance Corporation
11. PPS: Probability Proportionate to Size
12. SPSS : Statistical Package for Social Sciences SPSS
13. SIRB: SUMASRI Institutional Review Board SIRB

Introduction:
Primary health care is defined by the WHOs Alma Ata declaration (1978) as follows:
The essential health care based on practical, scientifically sound and socially
acceptable methods and technologies made universally accessible to individuals and
families in the communities through their full participation and at a cost they can
afford. (1)
The government of Sudan was a signatory to Alma Atas declaration and committed
to providing quality primary health care services to achieve health for all by the year
2000. (2)Primary health care centers have an important role in improving the basic
health services and if they fail to provide satisfactory services to patients, this will
lead to adverse patients attitudes towards health care system at all. (3) Community
participation is one of the key principles on which primary health care is established
others being equitable distribution, inter sectoral coordination and appropriate
technology. (1)
In the way of providing primary health care services the government of Sudan has
made impressive growth in term of the establishment of primary health care
institutions across urban and rural areas hard to reach sectors. (2) However,
shortcomings in the delivery of primary health care services have resulted in lesser
utilization rates and more dependence on private health care services providers.(4) The
delivery of health services for the poor people in urban and rural areas remains a
challenge in Sudan. (5)Information about community perception with a thorough
understanding of the needs and expectations of the community about the health care
services can help in better delivery and higher utilization of health services. (5)
Patient satisfaction is generally considered as the extent to which the patients feel that
their needs and expectations are being met by the services provided. (6)
Patient satisfaction is an important tool to measure the performance of providers,
managed care organizations and health care systems. (7) Also patient satisfaction is an
important aspect of health care quality and can be used for monitoring of some
aspects of quality. (8)

The determinants of patient satisfaction include demographic factors, socioeconomic

status and general health status. Satisfaction is also influenced by the manner in which
health care is delivered, the type of health care setting and characteristics of medical
provider such as experience, age and gender. Finally continuity of care is another
important determinant of patient satisfaction. (8)
Problem statement:
Sudan health system is based on the district health system approach, which
emphasizes the principles of primary health care (PHC). Nevertheless, the
decentralization of the public sector resulted in more deterioration of the PHC system
particularly in rural and peripheral areas due to lack of financial resources and
managerial capacities. The local health system act gave the responsibility of
management of PHC level to the localities while, this wasnt accompanied by
ensuring availability of sufficient financing resources to localities to run this function.
This condition is worsened by the focus of government spending on hospitals leading
to an unbalanced health system. For instance, 36% of the total health expenditure goes
to the secondary and tertiary hospitals. Moreover, over 90% of the government health
expenditure is directed to the secondary and tertiary hospitals. (9) However, when it
comes to crucial issues such as finance, budget planning and allocation is usually
skewed towards curative and tertiary care. For example, in 2004, about 82% of the
total health expenditure was devoted to curative care in the secondary and tertiary
levels. (4) This problem manifested in terms of the very low access to PHC in Sudan.
One quarter of the population has no access to health facilities with considerable
inter-state, urban and rural disparity. Many rural areas are underserved by the health
system in terms of functional facilities, in particular health centres and hospitals,
which are found to be clustered in towns and cities. It should be noted that 33.2% of
the population live in urban areas. Furthermore, the minimum PHC package is
provided by 19% of PHC facilities which hamper the adequacy and quality of PHC
services. Therefore, one of the major problems of Sudans health system delivery is
the lack of optimal access to high quality PHC services. (9) Although some evidence
indicates that the perception of the general public regarding quality of care is more to
the side of institutions. (4)

Objectives
General objectives:

To assess the levels of Patient satisfaction with the services and to identify
factors relating to the patient satisfaction.

Specific objectives:
1. To assess the patient satisfaction with primary health care services in
Khartoum state
2. To determine the effect of socio demographic factors of patient on the level of
satisfaction of primary health care services in Khartoum states
Material and Methods
Study design: Cross-sectional descriptive facility-based study design.
Study area: The study will be was carried out in Health Centers in Khartoum state.
Khartoum state is the national capital of the country with an area of about 28,000
square kilometers and is administratively divided into 7 Localities: Khartoum,
Omdurman, Khartoum North, Jabal Owlia, Karari, Um Badda, and Eastern Nile. (10)
Its health facilities include 43 hospitals, (11) 195 health centers, (12) 185 NGO centers, 235
dispensaries, 365 primary health care units. (11)

The total population is about Five million citizens; the state climate is semi-desert due
to its geographical position. (10)
Most of the population of Khartoum state is working in the work offices in
governmental and private institutions.
Study population: The study population will consist of as all adult patients (more
than 18 years) seeking health care in health centers in Khartoum state.

Sample size and technique: A sample of 450 patients will be was calculated selected
by the following equation:
n=

* pq * deff

n = sample size
= the value which corresponds to the level of confidence 95% and is 1.96.
p = the proportion of the phenomenon under study and will be taken 73%.
(The study conducted in the first half of 2010 by Health Insurance Corporation (HIC)
showed that 73% of the insured patients feel that the level of service provided by the
health insurance is very good).
q=1-p
d = the desired margin of error and will be taking the value of 5%.
deff = design effect of cluster sample and will be taking the value 1.5.
This gave a sample size of 450 patients.
The sampling technique that to be used in this study is Multi Stage Cluster Stratified
Systematic technique.
The health centers are classified into 3 levels, each level represent a stratum: the
primary level (PHC), the secondary level (multi specialists' centers) and the third level
(hospitals). The secondary level (multi specialists' centers) and the third level
(hospitals) will be excluded in this study.
The sample will be distributed over the primary level according to the load of users at
each level.
The total number of centers chosen will be 30 centers. The centers were chosen in
each stratum by the Probability Proportionate to Size (PPS) method, and the sample
will be distributed over the localities of Khartoum State.
From each center, 15 patients will be selected after receiving the service. Patients in
each center will be chosen by systematic sampling technique.

Data collection tools:

Interviews based on structured questionnaire, information will be obtained from the
patients on background information (gender, age, marital status, education,
occupation, religion, and residence), distance of the health center from house, travel

time, means of arrival to the health center, waiting time for services, Information
received, level of satisfaction with health care services. The interviews were
conducted with patients after the consultation but before departure.
Data analysis:
Data will be reviewed, edited and entered into computer and to be analyzed by
software program Statistical Package for Social Sciences (SPSS) and Excel program.
Factor analysis procedure will be used to group intercorrelated items load (cluster)
onto one factor which then formed a scale (dimension).
The effect of each factor on general satisfaction was tested using Chi square test with
p<0.05 considered significant.
Data presentation:
Data will be presented in the simple frequency statistical tables and figures.
Ethical considerations:

The written ethical approval and clearance will be obtained

from the

SUMASRI Institutional Review Board (SIRB) in University of Medical

Sciences and Technology

Participation is voluntary.

Written informed voluntary consent will be taken from each patient after
explaining the benefits of the study in improving the quality of health services.

Doctors in the health centers will be informed verbally and approvals were
obtained from them.

Confidentiality of the data obtained will be assured.

The information obtained will be reported back to the ministry of health and
doctors.

Time plan (Gantt chart):

Gantts Chart
Task

Jun.

Jul.

Aug.

1.Proposal writing and

approval
1.1- preparation of the
protocol
1.2-Informed consent
development
1.3 Ethical approval
(MOH and UMST )
2- writing and Literature
review
3-study site preparation
3-1 Recruitment of the
field staff
3-2 Training
3-3 Provision of the
supplies
4. Field studies
4.1 pre test of the
materials
4-2 data collection
5-Data management
5-1 Data cleaning
5-2 Data entry
5-3 Data analysis
5-4 Report writing
Final report

Month
Sep.

Oct.

Nov.

Dec.

Budget:
Activity

No

Budget in unit cost(SDG)

Budget
(SDG)

Personnel

1.1

Training of evaluation team

5person x20 SDGx1day

100

1.2

Field visit (pre-test )

5person x 15 SDGx1day

75

1.3

Reviewer of medical records

5person x 20 SDGx20day

2000

1.4

Incentives of data collectors

5person x 50 SDG

250

Supplies and equipment

2.1

Papers

2backeta A4 x25

50

2.2

Internet fees

6 Month x100SDG

600

2.3

Printing

---------------------------

300

2.4

Stationary

---------------------------

200

Transportation

3.1

Local travel

4
4.1

5person x10SDGx20day

1000

5person x 10SDGx20day

1000

Accommodation
breakfast , cold water for team work

Running cost during study

5.1

Data analysis

--------------------------

500

Actual Total

---------------------------

6075
SDG

GRAND TOTAL(Unforeseen)

607

PLUS TEN PERCENT

6682
SDG

10

References:
1. WHO. Primary health care: International Conference on Primary Health Care,
Alma Ata, USSR. Geneva: WHO/UNICEF; 1978.
2. Republic of Sudan, Federal Ministry of Health, Knowledge, Attitudes and
Practices (KAP) in the Sudanese communities for their health seeking
behaviour, Nov. 2011.
3. Sabry A.Salem. Patient Satisfaction with Primary Health Care Services in
Qassim Province, Saudia Arabia, Faculty of Medicine, Benha University,
October 2010
4. Habbani, Samia, Elsheikh Badr and Walid A. Abubaker. Good Governance for
Improving Health Systems Performance. Khartoum- Sudan, 2006
5. WHO. Health services: concepts and information for national planning and
management. Geneva: 1977
6. Al-Eisa, Ibrahim, et al, Manal S Al-Mutar, Maged M Radwan, Adel M AlTerkit. Patients' Satisfaction with Primary Health Care Services at Capital
Health Region, Kuwait. Middle East Journal of Family Medicine, Vol. 3. 3
(2005): 10-12.
7. Murante, Anna M. Patient satisfaction: a strategic tool for health services
management, The Class of Social Sciences for the degree of Doctor of
Philosophy in the subject of Management, competitiveness and development,
2009-2010
8. Said, Randa. Assessment of Patient Satisfaction in Primary Health Care
Facilities, Sharkia Governorate, Master degree in Family Medicine thesis,
Faculty of Medicine, Zagazig University, 2009.
9. WHO. Promoting access to high quality primary health care services in Sudan.
Khartoum: 2012.
10. http://www.krt.gov.sd/khartoumen.php, 27-08-2013.
11. Sahal, Nagla. Assessment of Communicable Diseases Surveillance System in
Khartoum State, Sudan. Ph.D. Thesis, Publications of the Unit for Health
Promotion Research, 2011.

11

12. MOH, Khartoum State, Local health system, statistical department. Health
centers in localities in Khartoum state: classification 2013 by (location - rural urban) 2013.

12

Appendix 1: Consent Form

University of Medical Science and Technology,
Graduate College
M.Sc. in Public and Tropical Health
Dear Participant
I am Imran Ahmed Abdikadir studying towards a Masters Degree in Public and
Tropical Health. The course requires me to conduct a study. The study is on your
satisfaction with services in relation to primary health care services, accessibility and
socio demographic factors of the services. The letter serves as a consent asking you to
paI1icipate in the study after random selection.
You have been chosen to participate in the study through the attendance register but
you are free to participate and not to participate. Your decision to participate or not to
participate will not have any negative consequences on you. You are free to withdraw
if you decide so. Your identity will be protected so that no one can link it with you.
The information obtained will be available to the researcher and will be destroyed
after use. The purpose of the study is to find out your perceptions as far as satisfaction
is concerned with regard to participation in health programmes and accessibility of
this health centre. The results will be for academic purposes and may be used for
future planning for this health centre. There will be no rewards following
participation. You will be asked to fill in a questionnaire and some will be asked to
have group discussions that will be chaired by the researcher.
Thank you so much for your decision.

Name of the participant:

..........................................................................................................................................
Date:
..........................................................................................................................................
Signature:
..........................................................................................................................................

13

Appendix 2: Questionnaire
This questionnaire prepared for thesis writing purpose of MPH (Master of Public
Health) course and evaluating level of patient satisfaction with primary health care
services in Khartoum state. Your response will be kept secret and will not be exposed
to any other purpose. Your cooperation in completing the questionnaire is greatly
appreciated.
Date of interview:........../........../2013
Please mark into (

) or fill in the blank as appropriate answer according to you.

Section One Socio Demographic factors

Please tick where appropriate.
1. Gender
a) Male (

b) Female (

2. Age
1) 18-30

2) 30-40

3) 40-50

4) 50- 60

5) Above 60 (

3. What is your marital status?

1) Single

2) Married (

3) Widow/ Widower

4) Divorced/ Separated (

4. What is your Educational and qualification?

1) No education/ Illiterate (

2) Primary school

3) Secondary school

4) College/University

14

5) Other, specify:
..................................................................................................................
..................................................................................................................

5. What is your current Occupation?

1) Housewife

2) Government service (

3) Farmer

4) Self employee

5) Soldier

6) Student

7) Unemployed

8) Other specify
..................................................................................................................
..................................................................................................................
6. What is your Religion?
1) Muslim (

2) Christian (

Section Two accessibility to health centre

Distance
7. How far from your Residence to health centre?
1) 0-5km

2) 5-10km

3) 10-15km

4) Above 15km (

8. Distance from your residence to health centre is easy to reach

1) Yes

2) To some extent (

3) No

9. How long (in travel time)?

1) 15 minutes

2) 30 minutes

)
15

3) One hour

4) Two hours

5) More than two hours (

10. What is your mean or transportation to come to this health centre?

1) Own car (

2) Hired car (

3) Minibus (

4) Bicycle

5) On foot

6) Other:
..................................................................................................................
.................................................................................................................
11. Health centre location is convenience to come to your residence
1) Yes

2) To some extent (

3) No

Waiting time for services

12. The waiting time for registration is not very long
1) Yes

2) To some extent (

3) No

13. The waiting time for physicians examination is not very long
1) Yes

2) To some extent (

3) No

Information received
14. Received enough information about steps of receive procedure
1) Yes

2) To some extent (

3) No

16

15. Received enough information about health regulation

1) Yes

2) To some extent (

3) No

16. Received enough information about types of examination

1) Yes

2) To some extent (

3) No

17. Received enough information about health promotion and prevention

1) Yes

2) To some extent (

3) No

Section Three satisfaction with health care services in Khartoum state health
centres
For the following statement, please mark () the answer relevant to your perception
Statements

Level of satisfaction
Good

Convenience
18. It's convenient to access the registration
19. There are enough seats at the waiting room before you
get the physical examination
20. Services hours is convenience
21. Convenience at the waiting room at the pharmacy
section
Courtesy
22. Doctor at the health centre treats the patient with
respect and friendly
23. Nurses at the health centre treat the patients with
respect and friendly

17

Fair

Poor

24. Pharmacist at the health centre treat the patients with

respect and friendly
25. Registration staff at health centre treat the patients
with respect and friendly
26. Courtesy of other staff
Quality of care
27. The doctors are very competent and well trained
28. Doctor at health centre is good about explaining the
reason for medical test
29. Nurse skill is using medical equipment and very
cooperative
30. Pharmacists explain clearly and accurately on drug
prescription
31. Registration services are skilful and systematic careful
Physical examination
32. The location of services is clean and enough space to
use
33. The atmosphere of this health centre is good
34. Facilities and equipment at health centre tidy and clean

35. Other comments or suggestions to improve the quality of services

1)
2)
3)
36. Would you visit the health centre service again in case of sickness?
1) No
2) Not sure
3) Yes

Thank you very much

18

Appendix 3:
Questionnaire in Arabic language
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23

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