Received date: March 19, 2019; Accepted date: April 5, 2019; Published date: April 12, 2019
Citation:Garedew MG, Kerie MW, Walle AA (2019) Choice of Healthcare Providing Facility and Associated Factors among Government Employees in Nekemte Town, Western Part of Ethiopia. Health Syst Policy Res Vol. 6 No.2:81
Background: A growing body of literature on health care demand has pointed out that individuals are not passive recipients of health services; rather they make active choices about whether or not to make use of particular health care providing facilities. Objective: To assess level of choice for public or private healthcare providing facility and associated factors among government employees in Nekemte town, 2015. Methods: A cross-sectional study was conducted from March 09-30, 2015 among government employees. Simple random sampling technique was employed to select 361 study participants and data were collected using a semi-structured interviewer administered questionnaire. Data were coded and entered into Epi-data version 3.1 and transported into SPSS version 20 for analysis. Both descriptive and inferential statistics were performed. Binary Logistic regression by using backward stepwise method was done to determine presence of statistically significant association between independent variables and the outcome variable at p value <0.05, with 95% CI. Results: Three hundred and forty six employees participated in the study which provided the response rate of 95.8%. Government healthcare facilities were preferred by 57.2% of the study participants while the remaining 42.8% preferred private providers. In this study quality of patient-provider interaction (AOR=3.19), cleanliness of facility (AOR=1.84), satisfaction with usual healthcare providing facility (AOR=2.30), and expenditure at health facility (AOR=1.98) were significantly associated with choice of health facilities. Conclusion: More than half of government employees choose public health facilities as their usual health care provider. Preference to public health facilities could be even higher if the quality of care in the public facilities improves in terms of patient-provider interaction, cleanliness of facility and other factors contributing for patient satisfaction which are widely implied in the literature.
Government employees’ health facility choice; Factors affecting choice of health facility
A growing literature on health care demand has pointed out that individuals are not passive recipients of health services; rather they make active choices about whether or not to use of provided health care services . Choice of healthcare providing facility by the user is defined as the process of determining which healthcare facilities are available and then choosing the most preferred one according to consistent criteria to maximize utility or solving a health problem .
The health care systems in many low and low-middle income countries have a composite of public and private health care providers. For outpatient services, more than half of the utilization was at public health facilities in these countries. For some countries, over 80% of services were delivered at public facilities. For inpatient services, public facilities are even more dominant and their share topped that of the private facilities in all countries except Pakistan and India [3,4]. Demand-side barriers play a crucial role as the supply side factors in deterring patients from obtaining treatment. However, relatively little attention is given by policy makers and researchers to ways of minimizing their effect. Early policy and research initiatives focused on the need to improve physical access through an expansion of the network of facilities .
Over the past decade, Ethiopia has recorded notable progress in a number of population health outcomes [6-8]. These changes have been supplemented by a rapid expansion of healthcare infrastructure at all levels . Primary health service coverage reached 92% with 122 public hospitals and 2660 health centers and 15,095 health posts and more than 4000 private for profit and not for profit clinics . Despite these increases in the supply of healthcare and increases in the utilization of some specific services, overall outpatient healthcare utilization rates remain low and have increased only marginally from 0.27 visits in 2000 to 0.3 visits in 2011 [11-13].
In areas where health care services are readily available, the factors that determine the utilization of the services ranges from lack of awareness to low level of education, distance to health care, bureaucracy in the medical practice and mismanagement of facilities and equipment. Those who can’t afford the cost of care in the hospitals, opt for traditional healers and other spiritual and homes remedies [14,15]. Many factors influence the selection of a healthcare providing facility once the decision to seek care has been made . The choice of health facilities for healthcare by an individual is largely determined by his/her taste, satisfaction with service and the perceived quality of care provided [17-19].
Usually, choice of health care providing facility is influenced by quality of service provided, access to providers, out-ofpocket costs, health provider communication skills, courtesy, and administrative burden. However, patients’ perceptions of the quality of services provided are a key factor (along with cost effectiveness) in determining the use of the health care facility .
Although, utilization of health services and determinants of use have been largely studied, there is paucity of literature specifically on factors that determine preference for the type (public or private) and the facilities visited first when ill especially when there are many options. As a consequence, there is now greater emphasis on the encouragement of individual choice and the opportunity to exercise it freely . Unlike in developed and few developing countries, choice of healthcare facilities and factors affecting patient’s choice has not been sufficiently explored in Ethiopia. It is not very clear what influences the customer’s choice of one or the other within a health system with many healthcare providing facilities.
Therefore, this study intended to find out which healthcare providing facilities (private/public) were preferred by government employees in Nekemte town, Western Ethiopia. We also aimed to identify socio-demographic, economic and health facility related factors affecting the choice of usual healthcare providing facility in the study participants.
This study was conducted in Nekemte town, East Wollega zone, which is located 334 km west of Addis Ababa. There are total of 23 governmental organizations in Nekemte town administration with 2229 employees. There are three public (two health centers and one referral hospital) and thirty two private for profits (3 higher, 4 medium and 25 small clinics) and non-profit privates (4 clinics) health institutions found in the town according to health office report in 2014.
This institutional based cross-sectional study was conducted from March 09-30, 2015 G.C. The source included all employees in governmental organizations of Nekemte town administration. Sample of government employees in Nekemte town who utilized services at a health facility (public or private) during a period of 18 months preceding this survey were studied. Contract workers in the government organization were excluded from the study.
The sample size was determined by using single population proportion formula with the following assumptions: proportion of choosing to visit public health facilities when they got sick was taken as=50% (p=0.5), 95% confidence interval (Z=1.96) and margin of error (d=0.05). The sample size was 384; by using finite population correction formula and adding 10% for potential non-response, the final sample size was calculated to be 361 permanent (full time) government employees.
Prior to actual data collection census was conducted to identify employees who used healthcare providing facilities in the town in the preceding one and half year. According to this out of 2229 employees, 975 who utilized public or private facilities were identified and the final sample was drawn from this sample frame. A simple random sampling technique was employed to select study participants by using computer generated random numbers in Excel spreadsheet (Microsoft Corporation, 2013).
Public health facilities were defined as those run by the government (public hospital and health centers) and all other non-state health facilities were classified as private. And also usual healthcare providing facilities for the purpose of this study is the health facilities (public or private orthodox medical facility) where the respondents go to first to access health care for their illness. The primary data used for this study was collected using a semi-structured interviewer administered questionnaire for the study to obtain information on sociodemographic and economic data, usual health care provider, perceived quality and their satisfaction on the health services.
The data collection tool was adapted from different published literatures and modified according to the local context. The patient satisfaction and quality of care questionnaire was a modified version of SEVQUAL model [11,12] and from study done in Nigeria on choice of health care providing facility among government workers . Perceived quality of health care was assessed using 29 items of 5 point Likert scale (strongly disagree, disagree, indifferent, agree and strongly agree). Patients satisfaction was also measured using four items of a 5-point Likert scale (very dissatisfied, dissatisfied, indifferent, satisfied and very satisfied).
Face to face interview was conducted by trained six diploma holders’ data collectors and one bachelor degree supervisor who assigned to monitor quality of collected data. The questionnaire for survey was first prepared in English language, then translated into Afan Oromo and back translated into English to check for consistency.
The questionnaire was pre-tested before the actual data collection on 5% of the total sample size of government employees in the Ambo town. Supervision was conducted on the sites of data collection and the completeness of filled questionnaires was checked on the daily basis. Data were coded and entered into Epi-data version 3.1 and transported into SPSS (IBM Corporation, version 20.0). After cleaning data for inconsistencies and missing values in SPSS descriptive statistics such as median, frequency and proportion were done.
After data collection, to reduce a large number of variables into a smaller and more manageable number of factors, as well as to transform data to meet the assumptions of logistic regression (i.e., predictors are statistically unrelated) the perceived quality of healthcare services and satisfaction data was subjected to exploratory factor analysis. PCA reduced 29 items under six domains to 16 items of perceived quality under three components and each component was renamed according to their items. The total variance explained by perceived quality and satisfaction items was 63.96% and 70.56% respectively.
Reliability of the items were checked for the perceived quality and satisfaction, which had Cronbach's Alpha value 0.916 and 0.855 respectively, both were above 0.7 recommended alpha value. Based on the factor scores of each scale, the responses were ranked using compute and rank cases command into two groups (good and poor). Satisfaction component also dichotomized into satisfied and dissatisfied through the same procedure. This facilitated the comparison of respondents with different characteristics. Bivariate analysis using binary logistic regression was done and all independent variables which had association with the outcome variable at p value of 0.25 were selected for multivariate analysis.
Then multivariate analysis using backward stepwise method was done to determine presence of statistically significant association between independent variables and the outcome variable at p value <0.05 and OR with 95% CI.
Ethical clearance was obtained from the Institution Review Broad (IRB) of the College of Health Sciences of Jimma University. Permission letter was obtained from Oromia Regional Health Bureau and Nekemte town health office. Verbal consent of the study participants were obtained prior to interview by explaining purpose of the study. Confidentiality of their information was assured by using coding system and by removing any personal identifiers. The right of respondents to refuse to answer for few or all of the questions was respected.
Description of study subjects
From 361 sampled government employees, 346 participated in the study which provided the response rate of 95.8%. The median age of respondents was 33, ranging from 20-60 years. Out of total respondents, 191 (55.2%) were male, 218 (63%) were degree holders and above in terms of educational background and 252 (72.8%) were married.
Majority of participants 321 (92.8%) were Oromo in ethnicity and 238 (68.8%) were protestant Christians. The median number of family members of the employees was 4, ranging from 1-9. The median monthly income of the respondents was 3000 ETB ($150 USD), ranging between 520-10,500 ETB ($26-525 USD) and annual health care expenditure was 200 ETB ($10 USD), within range of 20-3600 ETB ($1-180 USD) (Table 1).
|Characteristics (n=346)||Frequency||Percent (%)|
|Sex of respondent|
|Age (in year)|
|Degree and above||218||63|
|Four or less||211||61|
|Greater than four||135||39|
|Income/salary per month (in ETB)|
|Expenditure on health per year|
|Low (≤ 400ETB or $20 US)||256||74|
|High (>400ETB or $20US)||90||26|
|ETB= Ethiopian Birr (20ETB= $1 USA)|
|*=Tigre and Gurage|
|**=Catholic and Wakefata|
Table 1: Demographic and socio-economic characteristics of the government employees in Nekemte town administration, 2015.
Descriptive analysis of perceived quality of health service and overall satisfaction
Regarding to perceived quality, majority of the respondents 134 (38.27%) were rated patient-provider as poor at public health facilities while higher proportion of respondents 109 (31.5%) were rated it as good at private health facilities.
On the overall satisfaction, a higher proportion of respondents 127 (36.7%) were not satisfied at public health facilities. Whereas, majority of study participants 105 (30.35%) were satisfied by their usual healthcare providing facility at private health facilities (Table 2).
|Variables (n=346)||Quality Perceived||Usual Health Care Facility|
|Public No. (%)||Private No. (%)|
|Patient-provider interaction||Poor quality||134 (38.27)||39 (11.27)|
|Good quality||64 (18.5)||109 (31.5)|
|Communication skill||Poor quality||111 (32.08)||62 (35.17.92)|
|Good quality||87 (25.14)||86 (24.86)|
|Cleanliness/tangibility of Facility||Poor quality||116 (33.53)||57 (16.47)|
|Good quality||82 (23.7)||91 (26.3)|
|Satisfaction||Dissatisfied||127 (36.7)||43 (12.43)|
|Satisfied||71 (20.52)||105 (30.35)|
Table 2: Percentage responses on the perceived quality and satisfaction of usual healthcare providing facilities by government employees in Nekemte town administration, 2015 G.C.
Choice of healthcare providing facilities
More than half of the respondents (198, 57.2%) obtained health services from government owned health facilities as their usual healthcare provider. Whereas 148 (42.8%) of the respondents preferred the services from private for profit or non-profit health facility (Figure 1).
Figure 1: Choice of healthcare facilities by government employees in Nekemte town administration, 2015 G.C.
Choice of usual healthcare providing facility by type of health facilities
From government owned health facilities, public hospital and health center were chosen as usual healthcare providing facilities by 162 (46.82%) and 36 (10.4%) respondents respectively. While, private for profit clinic was opted by 70 (20.2%) of study participants (Table 3).
|Usual healthcare providing facilities||Number||Percent (%)|
|Public health center||36||10.4|
|Private for non-profit clinic||14||4|
|Private for profit higher clinic||70||20.2|
|Private for profit medium clinic||54||15.6|
|Private for profit small clinic||10||2.89|
Table 3: Choice of usual healthcare providing facility by type of health facilities among government employees in Nekemte town administration, 2015 G.C.
Reasons for choice of usual healthcare providing facility
In seeking reasons for their preference and what they considered in choosing a facility for health care, cost of health care was the commonest reason given by 124 (62.6%) and this was followed by availability qualified personnel’s vowed by 107 (54%) of all respondents among who opt public facilities.
While 77 (52%) and 76 (51.4%) of participants were choose private facilities for availability of qualified personnel’s and time saving respectively. Other reasons were availability of equipment and laboratory service (40.5%), quality of service provided (33.1%) among private facility utilizers, whereas availability of equipment and laboratory service (23.7%) and effectiveness of treatment (16.2%) among public facility choosers (Table 4).
|Reasons||Healthcare providing Facility|
|Availability of qualified personnel’s||107 (54)||77 (52)|
|Price of health service||124 (62.6)||18 (12.2)|
|Friendly staffs||24 (12.1)||28 (18.9)|
|Time saving||21 (10.6)||76 (51.4)|
|Effectiveness of treatment||32 (16.2)||38 (25.7)|
|Equipment and laboratory service||47 (23.7)||60 (40.5)|
|Drug availability||28 (14.1)||18 (12.2)|
|Proximity to home||31 (15.7)||9 (6.1)|
|Privacy||3 (1.5)||4 (2.7)|
|Reputation of health care facility||3 (1.5)||1 (0.7)|
|Quality of service provided||28 (14.1)||49 (33.1)|
Table 4: Reasons of government employees’ for choice of their usual health care providing facility in Nekemte town administration, 2015 G.C.
Final predictors of choice of healthcare providing facility
Multivariate analysis was done by using binary logistic regression of backward stepwise method to identify for the factors associated with choice usual health care providing facility of government employees as displayed in Table 3 below.
Final variables or predictors entered into model include health care expenditure, patient-provider interaction, communication skill of providers, cleanliness of facility and satisfaction of clients, which were shown association at bivariate analysis.
Whereas variables from demographic and socio-economic characteristics were not associated with the usual choice of health care provider in the bivariate logistic regression analysis were excluded. Respondents who described the quality of patient-provider interaction as being good were 3 times more likely to choose private health facilities as their usual health care providing facility than those who stated it as poor (AOR=3.19, 95% CI: 1.87, 5.43).
Those who reported that cleanliness of facility as being good, were 1.84 times more likely to use private health facility as compared to public facility (AOR=1.84, 95% CI: 1.12, 3.03). Government employees who used private facilities as their usual care providing facilities were 2.3 times more likely to be satisfied than public facilities choosers (AOR=2.30, 95% CI: 1.33, 3.98). Among participants who had high health care expenditure (greater than four hundred birr per year or $20 USD) were 2 times more likely to choose private facility as their usual health care providing facility than those who had low healthcare expenditure (≤ 400 ETB per year or $20 US ) (AOR=1.98, 95% CI: 1.14, 3.44) (Table 5).
|Variables (n=346)||Usual Health Care Facility||COR(95%CI)||p-value||AOR (95%CI)||p-value|
|Public no. (%)||Private no. (%)|
|Poor quality âÃÂ°||134(38.27)||39(11.27)||5.85 (3.65, 9.38)||0.001||3.19 (1.87, 5.43)||0.0001|
|Cleanliness of Facility|
|Poor quality âÃÂ°||116(33.53)||57(16.47)||2.26 (1.46, 3.49)||0.001||1.84 (1.12, 3.03)||0.016|
|Good quality||82(23.7)||91 (24.86)|
|Dissatisfied âÃÂ°||127(36.7)||43(12.43)||4.33 (2.74, 6.86)||0.001||2.30 (1.33, 0.98)||0.003|
|Healthcare expenditures per year|
|Low (≤ 400ETB âÃÂ° or $20 US)||159(45.95)||97(28.03)||0.47 (0.29, 0.76)||0.002||1.98(1.14, 3.44)||0.015|
|High (>400ETB or $20US)||39(11.27)||51(14.74)|
|Note: * reference category COR: Crude Odds Ratio AOR: Adjusted Odds Ratio 95%CI: 95% Confidence Interval ETB= Ethiopian Birr|
Table 5: Logistic regression for factors associated with choice of health care providing facility among government employees Nekemte town, 2015 G.C.
This study assessed choice healthcare facilities and factors determining it among government employees. Choice of health care facilities depends on both the features of the providers and the characteristics of consumers of health care . Quality of care, especially perceived quality based on patients’ evaluations and opinions, is an important deciding factor in choosing a health facility .
In this study government healthcare facilities were chosen by more than half of (57.2%) the study participants. This is comparable with finding of Ethiopia’s household health service utilization & expenditure survey by Federal Ministry of Health which stated that government health facilities were used by 59% of individuals residing in urban areas .
While it is lower than study done in Nigeria and Nepal that reported 72.3% and 68% were opt public health facilities at the first instance for their health problems respectively [22,24]. The difference might be due to difference in perceived quality and satisfaction of respondents at these health facilities and difference in the study area.
Public facilities were chosen by respondents mainly because of financial reasons. Similarly, study from Nigeria and Kenya reported that respondents who utilized public health facilities attributing their choice to the low cost of services [22,25]. Study from Nepal also revealed that people were chose public health facilities, not because of better health personnel conduct and practices and health care delivery, but mainly because of financial and physical accessibility . Perceived quality of services was used in this study to determine preference and by extension choice. Accordingly, two dimensions of perceived quality of care were found to determine choice of a health care providing facility.
Good quality of patient-provider interaction was found to be strong predictor of choice of usual healthcare providing facility. Respondents who experienced quality of patientprovider interaction as being good were 3 times more likely to choose private health facilities as their usual health care providing facility. Study done in Vietnam revealed that quality of patient-provider interaction (assurance and empathy) was affecting the service quality of hospital care .
This finding is also in line with study from other low income countries indicated that perceived quality play an vital role in determining health facility of their choice . The possible explanation might be participants of the study aware that providing good quality of healthcare is an ethical obligation of all health care professionals and major responsibility of health care facilities as well as receiving good quality care is a right of all clients/patients. In this study good cleanliness of facility was also predictor of choice of usual healthcare provider. Similarly, Study done in Jordan also stated that cleanliness of facility and other variables of quality had impact on choice of healthcare provider .
This might be due to overcrowding, poorly ventilated and unhygienic environments has discouraged study participants from the use of public facilities thereby opt for private facilities, since educated people are more aware of effect of unhygienic environments& their possible consequences.
We also found that users of private facilities were more satisfied with the health services they received. Similarly, study from Ghana found that utilizers of private health care are more satisfied as compared to their counterpart . However, our finding is in contrast to study done in Nigeria, which reported that respondents who are satisfied with their usual care providing facilities were more likely to utilize public facilities than private facilities . This might be due to difference in availability of various health resources, health-care delivery system and patient-provider interaction in the study areas.
On the other hand, this study indicated that in-terms of health care expenditure participants prefer to use the public health facilities than at private facilities. A similar study done in Nigeria reported that cost/payment for services were predictive for the choice of public facilities . As well as study from Jordan asserted that an increase in out-of-pocket expenditure was negatively associated with choosing public facilities compared to private facilities .
This finding is also comparable with study done in Eretria explained that majority of patients who sought treatment in private for profit health facilities had difficult to afford the user fees than government health care facilities utilizers . The possible explanations might be due to health care financing system that supported by government finance at public facilities and primary health care approaches policy followed by the countries to avail health services at affordable cost for the community.
Interpretation of the findings in this study should take note of some limitations. First, choice of facilities often depends on types of health services needed or on severity of illness which we did not take into consideration in this study. Second, level of satisfaction and quality of service questions may have been biased since respondents are more likely to remember unpleasant experiences or there may be recall bias. Finally, the information on health care expenditure for health may have been over or under estimated since it was primarily based on estimation made by the respondents.
In this study, more than half of the study participants choose public health facilities as the usual source of healthcare, despite that these facilities were perceived to offer lower quality of services than private facilities. Public health facilities were chosen mainly because of cost/payment for health service and availability of qualified personnel’s, whereas availability of qualified personnel’s and time saving were main reasons to opt private facilities. Perceived quality of care, satisfaction with services at usual healthcare providing facility and cost of health care are important determinants for choice of usual healthcare provider. Good quality of patientprovider interaction and cleanliness of facility and satisfaction were associated with choice of private facilities, whereas respondents chose public facilities to obtain services at lower cost. Therefore this finding has important policy implication since changes in cost of health service and perceived quality would mean changes in client satisfaction as well as their choice.
We would like to express our grateful thanks to Jimma University for sponsoring this research. We would like to also to extend our thanks to Nekemte town government employees for their willingness and participation on this study. We would like to thank Nekemte town Health office for providing us necessary information on healthcare providing facility in the town. We would like to acknowledge Civil Service office for providing us necessary information on study participants.
We all the authors declare that this is an original article that is not published or submitted to other journal and there is no financial or other conflict of interest.
This researcher was done for partial fulfillment of Master Degree of public health in Health service Management, and its fund was total covered by Jimma University Postgraduate Research fund project office.