This descriptive cross-sectional study assessed patient satisfaction with healthcare at a tertiary hospital in Northern Malawi. We assessed patient satisfaction in six domains of care (communication, rational conduct, technical competence, personal qualities, availability and accessibility, and sanitation and cleanliness) and calculated overall patient satisfaction with the care they received. We have also reported patient self-rated satisfaction with care and patient suggested areas of improvement for the hospital. To our knowledge this is the first study in Malawi to have taken a multi-pronged approach to assessing patient satisfaction and to have assessed satisfaction holistically and not focussing on a specific service or hospital department.
Patient satisfaction ranged from 4.9% with health workers’ personal qualities to 27.1% with availability and accessibility of health workers and health services while overall satisfaction with medical care was 8.4% and self-rated satisfaction was 8.9%. These results show that patients were not happy with the services across all the domains of care and it is not surprising therefore that overall patient satisfaction was this low – 8.4%, and so was patient self-rated satisfaction at 8.9%. It is reassuring to note, however, that our measured overall satisfaction was not different from patient self-rated satisfaction, giving confidence in the tool that we used to objectively assess patient satisfaction. Therefore, instituting improvements in the domains of care that we assessed may lead to increased satisfaction with care among patients.
Previous studies reported high levels of satisfaction with healthcare services in Malawi. In a study investigating client satisfaction with cervical cancer screening all women (100%) reported that they were satisfied with the services, with 68.3% reporting being very satisfied (17). Creanga and colleagues found patient satisfaction levels of more than 85% with perinatal healthcare (2). Ninety seven percent (97%) of women were satisfied with reproductive health services at Gogo Chatinkha Maternity Unit in Blantyre, Malawi (19) while more than 75% of stroke patients were said to be satisfied by the care they received in four tertiary hospitals in Malawi (20).
All of the above studies have fundamental differences from our study. While we attempted to assess the hospital as a system, encompassing as many dimensions of care that might lead to patient satisfaction (or otherwise) as possible, they focused on a specific service provided by specific staff in a particular unit or department of the hospital. Taking such a narrow and focused approach one is likely to find higher levels of satisfaction. In Nigeria and Uganda studies that assessed only one aspect of care provided by the hospital or clinic, or a particular department or clinic of the hospital reported higher levels of satisfaction (91.6% and 93.8% respectively) (21)(22).
The hospital is, however, a much broader system. In navigating such a system patients may encounter several frustrations along the way. When patients come to seek care they often interact with multiple providers with varying technical competencies and personal manners, and from multiple professional backgrounds and departments, not to mention physical and sanitary facilities. In resource constrained countries like Malawi patients are also faced with limited availability and accessibility of both health workers and essential medicines and diagnostic services. Studying patient experiences with the healthcare system from such a broader perspective one may likely find lower levels of satisfaction. In Ethiopia and Uganda studies that took a similar approach to our own and measured patient satisfaction in a similar manner found lower levels of satisfaction (40.7%, 49.2%, 46.2 and 50.0% respectively) with nursing care among hospitalized patients, inpatient services and outpatient services (23)(24)(25)(26). Even though our results are still far lower than these the trend is visibly apparent and the observed discrepancies could be due differences in study sites. We are, therefore, of the view that when assessing patient satisfaction with hospital care taking a holistic approach is the best way to draw out true hospital ratings from the people it serves and endeavors to serve better.
Further, this study was conducted during the peak of the second surge of COVID-19 in Malawi. COVID-19 has had significant impact on the delivery of other essential health services Sub-Saharan Africa, including Malawi. It led to shortage of human and material resources due to staff and money being redirected to tackle the epidemic (27)(28). COVID-19-related stressors such as physical exhaustion, alarming deaths of COVID-19 patients and the fear of contracting infection and subsequently passing it to family members took a huge toll on mental health of health workers (29)(30), which in turn may have affected how healthcare providers related with the very patients they had sworn to care for. Globally, COVID-19 lockdowns disrupted supply chains and lead to acute shortage of medicines and other essential health commodities in Malawi (31)(32). In addition, the global scramble for essential health commodities such as masks and other protective equipment (PPE) led to severe shortages of these items in third world countries like Malawi (33). Without appropriate and adequate PPE it was hard for health workers to maintain good provider-patient interactions and discharge their duties comfortably. A combination of these factors may have plummeted healthcare provider and hospital ratings in the eyes of the patient.
We examined the association between overall patient satisfaction and independent variables listed in Table 1 using a Chi square or Fishers’s exact test as appropriate. The goal was to identify variables associated with overall patient satisfaction at 5% significance level so that these would be further assessed for the strength and nature of the relationship in a logistic regression. But none of the variables had a significant association with overall patient satisfaction and so we could not proceed with a regression analysis. There are studies which did not find significant associations between satisfaction and variables in the table as much as there are studies which reported significant associations between satisfaction and some of the variable in the table. Maseko et al found no association between client satisfaction with cervical cancer screening and age, education level or marital status(17) while Nabbuye-Sekandi and colleagues reported higher levels of satisfaction among clients with primary or secondary education compared with those that had no formal education (26). They also found greater levels of satisfaction among clients who attended certain specialized clinics (HIV treatment and research clinic) than among those who attended general outpatient clinics (26). Sharew et al reported the opposite of what Nabbuye-Sekandi et al had reported. In their study they found that patients with at least primary education were 80% less satisfied compared with those without any formal education (24). So failure by our study to find any significant associations between satisfaction and demographic variables, visit type and department or clinic consulted could mean that indeed there is no association, or simply a failure by our study to detect these associations owing to few events (only 8.4% of patients were satisfied with the care they received and therefore could not achieve adequate distribution for optimal comparison).
Patients raised various issues that dampened their healthcare seeking expereince at the hospital. Top on the list were health workers reporting late to work, that doctors do not listen to patients’ concerns and that they do not take time to examine patients thoroughly and explain the findings, shortage of medicines and diagnostics, and unprofessional conduct of health workers. Five of the top six items raised by patients were already included in questionnaire we used to objectively assess patient satisfaction, giving reassuarance that the tool we used touched on issues that patients too considered important. A small proportion of patients also raised some important issues that the hospital may have to consider if it is to appeal to its catchment population. Concerns that health workers are favouring or prioritizing their relatives and friends over ordinary patients by aiding them to skip the queue, the revelation that some health workers are soliciting bribes from patients, and the need for adequate physical space so that patients can observe social distance while waiting on the queue during this COVID-19 pandemic must be looked into. None of the issues raised were related to the technical aspects care. Nonetheless, these are the things that patients are able to observe and upon which they base their evaluation of the performance of the hospital. Therefore, while aiming to improve the technical quality of care particular attention must be paid to the nontechnical aspects of it as well.
When asked to mention areas that the hospital should improve on to meet their expectations a substantial proportion of patients (32%) had nothing specific to point a finger at other than to contradict their earlier statements and say they were satisfied with the care they had received. Of these, 98.6% were not satisfied with the care they received by our measured overall satisfaction, and all of them (100%) reported not being satisfied in their self-rated satisfaction. Forty-two (58.3%) of them had completed at least secondary education. This contradictory result is interesting. There could be a couple of plausible explanations why these patients contracted their earlier responses. We suspect that despite many of them having good education they still lacked knowledge on their rights with regard to healthcare, and therefore had no expectations of the quality of services they ought to receive. Without expectations it is difficult to judge the actual care received, and that is why they were not able to point out a single thing that was not right in the services they had received.