ASSESSMENT OF FACTORS INFLUENCING SERVICE DELIVERY

ASSESSMENT OF FACTORS INFLUENCING SERVICE DELIVERY AT SUB-

COUNTY HOSPITALS IN MERU COUNTY, KENYA

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Integrated and people-centred health services are critical for realizing universal health care

coverage. This can only be achieved through provision of efficient and effective health services.

Service delivery is one of the key building blocks of any health system, it is an immediate output

of the inputs into the health system, such as the health workforce, procurement and supplies,

infrastructure and financing. Adequate provision of inputs should lead to enhanced service

delivery and access to services.

Ensuring availability of health services that meet a minimum quality standard and securing

access to them are key functions of a health system. According to World health organisation

[WHO] (2007), good health services are those which deliver effective, safe, quality personal and

non-personal health interventions to those who need them, when and where needed, with

minimum waste of resources.

Services is a process consisting of a series of more or less intangible activities that normally, but

not necessarily always, take place in interactions between the customer and service employee

and/or physical resources or goods and/or systems of the service provider, which are provided as

solutions to customer problems (Grönroos, 2011). Moreover, service is seen as any act or

performance one party can offer to another that is essentially intangible and does not result in the

ownership of anything (Kotler, 2008).

Service delivery as a series of highly localized actions by agents in public agencies or private

enterprises to provide needed goods and services to citizen beneficiaries in a way that meets their

expectations. Service delivery has a life-cycle span (i.e plan, design, operate, maintain, and

monitor) to sustain services such as nutrition or transport or goods such as electricity or water to

citizen beneficiaries (Lockwood & Smits, 2011). Getting (or Delivering) these services or

goods requires access by citizen beneficiaries, and the goods or services should meet the

expectations of the beneficiaries, which implies taking into account their needs and demands

(Fiszbein et al., 2011).

WHO (2010), states that patients’ service delivery includes provision of health services at all

levels as per the standard which include speed of delivery, harmonization at service delivery

point, effectiveness of the services, patient safety, ethics and professionalism in during provision

of service. To better understand the degree of service delivery, there is need to understand

customer satisfaction because the level of service delivery and quality of service are mainly

related to customer satisfaction. Customer satisfaction is a person’s feeling of pleasure or

disappointment resulting from and coverage of health care services.

Most countries in Africa are gaining reputation of poor service delivery, ineffectiveness, and

incompetence and high levels of corruption, although numerous initiatives have been put in place

in order to enhance service delivery, challenges relating to service delivery still abound,

nonetheless poor interdepartmental cooperation and lack of horizontal integration has hampered

effective local development planning and thereby contributed to crippling service deliveries

(Manyaka & Nkuna, 2014).

Service delivery in Africa faces difficult challenges such as shortage of health workers, increased

caseloads for health workers due to migration of skilled health personnel and the double burden

of disease and the HIV/AIDS scourge that affect both the general population and health

personnel, shortage/low motivation of health workers. Moreover, Inappropriate quality of service

delivery results in loss of customer lives, revenue, material resources, time, morale, staff,

recognition, trust and respect and individual and communities' apathy towards health services, all

of which contribute to lowered effectiveness and efficiency of service provider (Mohapatra et al.,

2010).

According to WHO (2013) any country that has unhealthy population bounds to suffer in the

implementation of development program to improve the quality life of its citizens. Each country

needs to offer quality health services and it is important to recognize that a healthy population is

better disposed to achieving the productivity that is needed so as to increase and sustain

continued growth of the country’s economy (Andaleeb, 2015).

Service delivery needs responsiveness by service providers, managers, and policy makers to be

answerable, to provide enforcement, and to make relevant organizational changes in order to

make services “people-centred” (Gonzalez Asis & Woolcock, 2015) . Mcloughlin and Batley

(2012) propose viewing service provision as a two-way process “in which services are formed

by, and formative of, state-society relations and processes of state building,” and placing service

provision in a broad question of control “that is, how and by whom is control exercised over

which services are delivered to whom.”. Improving the level of basic service delivery is partly a

question of resources but it is also a question of governance and allocation.

When an organization tries to offer service to customers, it is time for management to exercise

leadership. Leaders should become the role models for the rest of the staff and manifest behavior

that demonstrate what is expected from employees in relation to the service delivery. In addition,

during a time of service delivery, management needs to send positive messages about the service

itself (Auerbach & Silverstein, 2003). Some sort of reinforcement is necessary to produce

service delivery; Management should be very active in instituting reinforcement tactics even

those that are costless such as verbal reinforcement or altering its structure and policy by simply

writing new rules and procedures.

The Kenyan health service delivery system is organized into 6 levels of care that fits into four

tiers. Each level has specified scope health services that it should provide to its populace. Tier 1

community units, Tier 2 dispensaries and health Centres, Tier 3 County health facilities (Sub

County and County referral hospital) and Tier 4 national referrals (Njuguna, 2015).

Health services are provided through a network of over 4,700 health facilities countrywide, with

the public sector system accounting for about 51 percent of these facilities while 49 percent is

accounted for by the private sector. The public health sector consists of the national referral

hospitals, county referral hospitals, Sub-county hospitals, health centres, and dispensaries. Health

services are integrated as one goes down the hierarchy of health structure from the national level

to the county levels (Chodzaza & Gombachika, 2013).

Since the government cannot fully meet the health needs of its citizens, its effort to offer health

service is supplemented by privately owned and operated hospitals and clinics and faith-based

organizations’ hospitals and clinics, which together provide between 30 and 40 percent of the

hospital beds in Kenya. Depending on their comparative advantage, Non- Governmental

Organizations, Faith Based Organizations and community-based organizations (CBOs)

undertake specific health services.

In most developing countries in Africa, in Kenya, premature deaths and preventable diseases still

inflict a high toll in communities and its people because there inadequacy in access to basic

health services is affecting distinct regions, areas, communities, and social groups in these

countries (Ajayi & Tokon, 2009). Most public hospitals in the recent past have witnessed

employee dissatisfaction presented in terms of refusal to offer services due to failure of payment

of dues, poor working environment, inadequate infrastructure and lack of commitment by the

management to engage with employees. This gap in service delivery in public hospitals has led

to unwarranted suffering by the patients who lay their hopes on the services offered by these

hospitals.

Meru County is one of the Forty Seven (47) counties of Kenya strategically located east of Mt.

Kenya, whose peak cuts through the outskirt of its southern boundary. The county has a total

area of 6,936.2Km2 out of which 972.3Km2 is gazetted forest. The county borders five counties;

to the North it borders Isiolo County, to the East Tharaka/Nithi County, to the South West Nyeri

County and to the West Laikipia County. The County’s population growth rate is estimated at

2.1 per cent per annum. The projected population of the county in 2018 is 1,635,264, consisting

of 808,596 males and 826,668 females (Kenya National Bureau of Statistics [KNBS], 2009).

Health Services provision at the County Level is centred around the tenets described by both the

Kenya Essential Package of Health Services (KEPH) and Schedule IV of the Kenya Constitution

2010. These two key documents define mandates/roles/responsibilities for interventions and

service delivery of the health system. The county has twenty three sub-county hospitals and one

referral hospital (Meru County Data, 2017)

1.2 Statement of the Problem

Health is anchored in Vision 2030 under social pillar in which the country’s aim is to provide an

efficient integrated and high quality affordable health care for all citizens with a priority being

given to preventive care at the community and household levels using a decentralized national

health care system strategy (Government of Kenya [GOK], 2007). The health policy 2014-2030

spells out the organization of health services delivery system and what should be provided at the

specific hospitals, geared towards strengthening the referral mechanism in place (Njuguna,

2015).

The Sub- County Health Facilities (Levels 4) managed by the county is mandated to; offer

comprehensive patient diagnostic, medical, surgical and rehabilitative care, including

reproductive health services; specialized outpatient services; and Facilitate, and manage referrals

from lower levels, and other referral(Ministry of Health , 2014). Despite this, patients still

prefer accessing services from the county referral hospital (level 5) due to several challenges at

the sub county hospitals.

A study done by (Makheti, 2017) reveals that Sub County Hospitals in Meru lack of

equipment and drugs forcing health workers to rely on conventional diagnosis further putting

patients in danger of misdiagnosis. Another report by the ministry of Health done in 2013

on service availability and readiness assessment mapping, showed that the County

Hospitals offered a higher percentage of services delivery e.g. pharmaceuticals ,clinical

laboratory, maternity which accounted for 70%, 85% and 74% respectively (GoK, 2013). This

has caused an increased and continued congestion and strain on the County Referral Hospital

thus hampering quality of care Despite the tremendous efforts by the government to improve

the referral system in Kenya in order to improve efficiency in the health system and health

outcomes, service delivery remain a

big challenges impeding access to equitable, quality and responsive health services by the

populace equity quality services. Should the problem of underutilization health services in the

Sub -County Hospitals continue, the County and the country at large might not be able to achieve

its health goal of attaining the highest standards of health by the year 2030 (Njuguna, 2015).

A need therefore arises to investigate as to whether the Sub County Hospitals in Meru County

are delivering services commensurate to the concerted effort by the county government to

provide cost-effective priority healthcare interventions and services to ensure affordable,

equitable, accessible and acceptable health services. Therefore, this study sought to assess the

factors influencing service delivery at the Sub County Hospitals in Meru County.

1.3 Purpose of the Study

The purpose of the study was to assess the factors influencing service delivery at Sub-County

Hospitals in Meru County, Kenya.

1.4 Specific Objectives

i. To determine the influence of staff on service delivery in sub-county hospitals in

Meru County.

ii. To assess the influence of facilities on service delivery in sub-county hospitals in

Meru County.

iii. To establish the influence of management practices on service delivery in sub-county

hospitals in Meru County.

iv. To evaluate the influence of Drugs procurement process on service delivery in sub-

county hospitals in Meru County.

1.5 Research Questions

i. What is the influence of staff on service delivery in sub-county hospitals in Meru

County?

ii. How do facilities influence service delivery in sub-county hospitals in Meru County?

iii. What is the influence of management practices on service delivery in sub-county

hospitals in Meru County?

iv. How does Drugs procurement process influence service delivery in sub-county hospitals

in Meru County?

1.6 Justification of the Study

The National and County Government since devolution have put efforts in trying to provide

equitable health services to its population in every corner of this country. This has not been

achieved because of several factors affecting the health sector which touches on all pillars of

health. Meru County is not an exception to this challenge with the fact that the County is still

experiencing mortalities and morbidity from communicable and non-communicable diseases.

Service delivery is a key pillar in ensuring access to safe and quality health services at all levels

of care.

Despite the challenges experienced by the County there is no evidence of studies investigating

the factors in influencing service delivery in Meru County especially at the Sub county

Hospitals. Identifying and addressing the barriers to utilization of services at the level 4

Hospitals is key to increasing access and utilization of services thereby strengthening the referral

system.

Various studies that have been carried out mainly focused on general public health issues, for

instance a study by (Njuguna, 2015) looked at utilization of maternal health services.

Many

other studies investigated aspects of Health information system, Human resources for Health

among others but none has been done on service delivery at the Sub County Hospitals. It is in

this regard that the researcher intended to carry out this study to determine factors influencing

service delivery at the Sub County Hospitals in Meru County.

1.7 Limitations of the Study

During data collection the researcher experienced challenges of accessing the sub-county

hospitals due to their remote location, this caused a delay in collecting data. However, to

overcome this challenge, the researcher prior planned before data collection to ensure easy and

timely access to the hospital this made data collection possible and easy.

Additionally, the researcher experienced a challenge of uncooperative respondents due to their

tight schedules at work and fear of feeling like the hospital is under investigation. The researcher

worked hard to avail more time and was patient in order to access the respondents during their

free time as well as surety of confidentiality and anonymity of the information shared.

1.8 Delimitations of the Study

The researcher experienced challenges of accessing the sub-county hospitals due to their remote

location; this caused a delay in collecting data. Nevertheless, to overcome this challenge, the

researcher prior planned before data collection to ensure easy and timely access to the hospital

this made data collection possible and easy.

Similarly, the researcher experienced a challenge of uncooperative respondents due to their tight

schedules at work and fear of feeling like the hospital is under investigation. The researcher

worked hard to avail more time and was patient in order to access the respondents during their

free time as well as surety of confidentiality and anonymity of the information shared.

1.9 Significance of the Study

The study was to determine which factors influence service delivery in Sub County Hospitals in

Meru County. The research findings were expected to provide current and adequate information

to the national, county government and other stakeholders on the status of service delivery in

public hospitals which would inform policy formulation thereby enabling design of evidence

based, cost effective interventions and strategies to ensure proper and safe services are delivered.

Moreover, the findings are beneficial to other researchers since is expected to provide a basis

upon which other related studies can be done.

1.10 Assumptions of the Study

The study assumes that the respondents were free, honest and gave the right information. It also

assumes that participants had a sincere interest in participating in the research and didn’t have

any other motive for participating in the study. The inclusion criterion of the sample is

appropriate and therefore, assures that the participants had all experienced the same or similar

phenomenon of the study.

1.11 Operational definition of terms.

Staffing factors: These are factors that entail training, experience and

compensation of health workers.

Healthcare facility factors: They include attributes of health care facility such as

equipped laboratories, geographical access and functional

ambulances

Drug supply processes: This is the process used by hospitals in procuring drugs

that include procurement process, procurement policy and

procurement planning.

Management practices: They refer to the activities managers engage in to ensure

the organization runs on a daily basis, these activities

include planning, supervision and staff motivation.

Public Health Hospital: A hospital which is owned by a government and receives

government funding

Health workers: Health workers are people whose job is to protect and

improve the health of their communities.

Experience: Knowledge or skills in a particular activity which one has

gained through having done that activity for a specified

span of time

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This chapter entails the review empirical and theoretical literature. In addition, it also contains

the conceptual framework of this study.

2.2. Service Delivery

2.2.1. Quality service

Quality is one of the things that consumers look for in an offer, which service happens to be one.

Quality can also be defined as the totality of features and characteristics of a product or services

that bear on its ability to satisfy stated or implied needs (Kotler et al., 2019). It is evident that

quality is also related to the value of an offer, which could evoke satisfaction or dissatisfaction

on the part of the user. Service quality in the management and marketing literature is the extent

to which customers' perceptions of service meet and/or exceed their expectations. Thus service

quality can intend to be the way in which customers are served in an organization which could be

good or poor.

Service quality is a multidimensional concept. There are differences between objective quality

and perceived quality. The service quality is derived from customers’ cognitive evaluations of a

service and viewed as a transaction-specific level or a global level (Boonlertvanich,

2019). The service quality is also the result of comparison between the expected services and

perceived services. The service quality as a global judgment or attitude relates to the

superiority of a

service. Service quality and customers’ value have direct effect on customers’ loyalty (Lai et al.,

2009). Providing a high level of service quality is very important for service providers to

compete with other peers (Kemp & Rotmans, 2005).

In India a study was conducted to examine whether the service quality of Indian commercial

banks increases customers’ satisfaction that fosters customers’ loyalty (Lenka et al., 2009). The

unique integration of the resources and capabilities is the essence of overall service innovation

(Kowalkowski & Kindström, 2014). Service innovation can be equated with the creation

of new value propositions by means of developing existing or creating new practices and/or

resources (Skalen et al., 2015).

While studying the link of service quality, customers’ satisfaction and loyalty was investigated in

the context of six casinos in Macau to provide membership to customers. For instance, the chain

effect was investigated in a health setting, but conditional in the casino context (Shi et al., 2014).

In a relevant study in the post office context to investigate the relationship between the service

quality of postal services and customers’ loyalty with customers’ satisfaction as a mediating

variable. In other words, the research mentioned above highlights the existence of causal

relationships among service quality, satisfaction and loyalty (Moez & Gharbi, 2012).

An investigation into the link between service quality, value, satisfaction and behavioural

intentions in a public sector bank in India and one of their results states that “ Service quality was

found to significantly impact on customer satisfaction and value perceptions”.

The good quality of service will convincingly client to repeat the demand of service. It show

customer behavioural towards service provider. The quality of service that fulfils customer

expectation will gain the customer loyalty. This intention will make customers' favourable

inclination a service relative to other firms offering the same service (Kaura et al., 2015).

2.2.2. Accessible Service

As costs and demand for healthcare services rise, access to care is becoming more challenging

globally (Byrne & Callaghan, 2014). Many healthcare systems have also been reported to have

demand versus capacity issues that are extending wait times for care services, and in many cases

deny access. Despite the efforts to improve the systems, numerous healthcare systems around the

globe are faced with huge challenges in accommodating the high demand for healthcare services

as a result of acute workforce shortages, infrastructure limitation, patient locations and cost. In

its submission, proclaim that over one billion population globally lack access to healthcare

systems, from amenities to caregivers (Deloitte, 2014).

Globally, steps have been taken by some countries to address healthcare issues in order to

enhance patient access to care. From workforce shortage perspective, in the United States for

instance, employment in the healthcare sector has risen drastically, and it is expected to increase

to 11.9 percent in 2018. Australia on the other hand has launched a General Practice Training

program to increase the number of trainee general practitioners to 600 by 2014, while numerous

countries have identified the need to invest in healthcare infrastructure as a priority (Byrne &

Callaghan, 2014).

2.2.3. Affordable service

Poverty has been identified as being the greatest threat to health. The poor, who use public

facilities, have less access to healthcare than the more affluent, who are often covered by medical

aid insurance (Swinnerton, 2006). Health services should not only be accessible but should

include physical accessibility and affordable, as substantiated by the United Nations(Yamin et

al., 2003).

Statistical relationship between the health status of the poor and that of the wealthy was

established. It was identified that chronic diseases such as asthma, smoking and abuse of alcohol

were more prevalent amongst the poor than the rich; poorer areas are still plagued by a high

burden of disease (Bradshaw & Steyn, 2001). To further substantiate this finding, Stellenberg et

al. (2008) found a statistical relationship between the health status and the socioeconomic level

of the coloured people of the Western Cape. The use of health services may alter, depending on

where the individual lives. Patient factors may be more important than supply factors in

explaining the differential use of health services (Heyden et al., 2003).

2.3 Influence of Management Practices

2.3.1 Staff motivation

Health-care service managers need to have skills, knowledge and expertise required to fulfil day-

to-day responsibilities. Some of these skills and responsibilities include the requirement to

develop and maintain professional standards, procedures, and policies for various institutional

activities (Hamoud et al., 2016). They are also responsible for developing and expanding

programs for scientific research, preventive medicine, medical & vocational rehabilitation, and

community health welfare. Excellent, assertive communication skills, both verbal and written,

are paramount to a leader's ability to carry out an effective healthcare operation. Information

Communication Technology skills are also essential as healthcare machinery and information

systems continue to evolve (Harrison et al., 2010).

2.3.2 Planning

The motivating concept underlying employees’ incentives is to foster employees to put in more

effort to improve organisations performance, (Imberman, 2015). Motivation is one of the

factors influencing the work attitude of any establishment. To learn how to motivate employees

to execute assigned duties and responsibilities in the organisation is the objective of work

motivation. Motivation is a set of courses concerned with a kind of strength that boosts

performance and directs towards accomplishing some definite targets (Shoraj & Llaci, 2015).

These explanations show that to achieve positive goal, employees must be adequately active and

their objective clearly stated. Organisational growth, rest on identification factor analysis that

ascertains the success of the organization (Kennedy & Chew-Graham, 2014).

In a study to investigate managers’ perception of customer expectations in hotel industry in

Kenya. The results revealed that assurance, empathy and tangibles were regarded as the most

important factors affecting service quality (Kiange, 2011). Moreover, the findings established

that customers have the highest expectations on promptness of service, accuracy of transactions

and security issues. The researcher advised managers to prioritize on attention to details and

promptness in addressing customer complaints. The researcher noted that customers‟

expectations and perceptions are subjective and the findings can only be generalized to a pre-

defined market and economic scenarios (Rungtusanatham et al., 2010).

The study on motivational factors affecting professional conduct in the workplace, evinced that

poor professional conduct has been put forward as a precursor to low morale and is said to lead

to poor work performance. The low state of the spirits of a person or group as exhibited by

confidence, cheerfulness, discipline, and willingness to perform assigned tasks emanate from

lack of motivation and failure by Employers to address employee needs, drives and capabilities,

(Buhr et al., 2020). Financial incentives are preferred by the junior staff, because they perceived

non-financial incentives as not a motivational technique.

Although not denying the strength of financial incentives per se, their limited ability to resolve

complex problems in areas have seen support from complementary non-financial incentives

(Iyke et al., 2014). Consequently, they may not be effective if they are the only method used in

the public sector (Chaix et al., 2000).

It has been documented by many that the motivation approach has helped to improve efficiency

and employee motivation and their collective capabilities enhances employee performance

(Iqbal & Waseem, 2012). These lead to maximum productivity, but how best to get

employees committed to their work in accomplishing organisational goal has been the main

concern of managers (Iyoke et al., 2014). Intrinsic factors are considered to be those rewards (or

outcomes) that derive directly from or are inherently connected to the job/task, such as

recognition, degree of autonomy and responsibility, sense of accomplishment and growth,

demanding and challenging job. Consequently, the individual receives the intrinsic rewards by

the very act of performance (Tetteh, 2015).

Reward influences positively on employee performance (Hameed et al., 2014). The obligation to

assess the impact of compensation meant that attracting and motivating employees for effective

performance has been a challenged. Compensation attracts, retain and help increase employee’s

performance. In a research to determine the motivational factors affecting employee motivation

and their relationship with the resulted employee performance outcome in Pakistan, and

disclosed that access to quality experience, good environmental working condition, positive,

alignment of employee skills and job need as well as incentive packages have a notable influence

on job performance (Javed & Javed, 2014).

CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Introduction

This chapter describes the study methodology and materials that were used. It explains the study

design, study population, sampling procedures and sample size determination, data collection,

data management and analysis, lastly describes the ethical considerations for the study.

3.2 Research Design

The researcher adopted a descriptive cross-sectional study design. In a cross sectional study the

researcher gathers data just once (Sekaran & Bougie, 2010). This design is appropriate

for this study because it provides quantitative and qualitative description of facts, attitudes, or

opinions of a population by studying a sample of that population. From sample results, the

researcher has generalized or drawed inferences to the population (Creswell, 2003).

3.3 Study Site

The Study was conducted in Sub-County Hospitals in Meru County. Meru County is one of the

Forty Seven (47) counties of Kenya strategically located east of Mt. Kenya. The county has a

total area of 6,936.2Km2. The county borders five counties; to the North it borders Isiolo

County, to the East Tharaka/Nithi County, to the South West Nyeri County and to the West

Laikipia County. It spans the equator lying 0 0 6’ North and 0 01’ South and between latitudes 370

West and 380 East (Meru County, 2018). According to the Kenya National Bureau of Statistics,

the population in the county is 1,365,301 people (male-670,656, females-685,645) (KNBS,

2015). The county’s’ administrative structure comprises of nine recognised (9) sub-counties. The

9 sub-counties include: Imenti South, Meru Central, Imenti North, Buuri, Tigania East, Tigania

West, Igembe Central, Igembe South and Igembe North. There are a total of 498 facilities

covering all levels of health and out of this number, Sub County hospitals are 23. The county

also has 1872 health care workers distributed evenly across the county (Meru County, 2018).

3.4 Target population

Target population refers to the entire group of individuals, elements or groups studied (Orodho,

2009). Meru County has a total of 23sub-county hospitals that were involved in this study.

In each sub-county hospital there are five officers in the management of the facility. These

officers include In-charge of the sub-county hospital, head of Pharmacy, head of Nursing, head

of laboratory and head of Clinical services. Therefore the total target population for this study

consisted of one hundred and fifteen staff in all the sub-county hospitals. These officers oversee

service delivery in these sub county hospitals.

3.5 Sample Size Determination and Sampling Procedure

3.5.1 Sample Size Determination

Meru County has a total of 23 sub-county hospitals that were involved in this study. Every sub-

county hospital has five officers who are at the helm of running and managing them. These

officers include the In-charge of the sub-county hospital, head of Pharmacy, head of Nursing,

head of laboratory and head of Clinical services. These officers oversee service delivery in all the

sub county hospitals and are well versed with knowledge about service delivery. Therefore the

sample size of this study was 115 employees of the 23 sub county hospitals.

3.5.2 Sampling Procedure

These officers were purposively selected to participate in the study due to their positions,

specialist knowledge, capacity and understanding of health matters and variables under this

study. Purposive sampling is a form of non-probability sampling in which decision concerning

the individuals to be included in the sample are taken by the researcher, based upon a variety of

criteria which may include specialist knowledge of the research issue, or capacity and

willingness to participate in the research (Oliver, 2006). The sample size of the study will consist

of all the one hundred and fifteen officers from the twenty three sub-county hospitals.

3.6 Instrumentation.

In this study, the researcher collected data using a self-administered structured questionnaire.

The questionnaire was made up of questions formulated using a 5 point likert scale (SA-

Strongly Agree; A-Agreed; U-Undecided; SD-Strongly Disagree; D-Disagreed) where the

respondent chose the answer that suited their response. The questionnaire consisted of sections

that measured staff, facilities, drug procurement; management practices factors that influence

service delivery in the facilities.

To ensure reliability and validity of the instrument, the researcher pre-tested the questionnaire to

ensure that it was measuring what it was supposed to measure and that the wording was clear for

the respondents. Pre-testing of the questionnaires was done in the neighbouring isiolo county and

involved 10% of the sample size which was 12 respondents from the sub county hospitals.

3.6.1 Validity

Validity is often defined as the extent to which an instrument measures what it asserts to measure

(Cooper, 2005). Validity of a research instrument assesses the extent to which the instrument

measures what it is designed to measure (Robson, 2011). It is the degree to which the

results are truthful. So that it requires research instrument (questionnaire) to correctly measure

the concepts under the study (Pallant, 2011). It encompasses the entire experimental concept,

and establishes whether the results obtained meet all of the requirements of the scientific

research method. Qualitative research is based on the fact that validity is a matter of

trustworthiness, utility, and dependability (Zohrabi, 2013).Validity of research is an extent

at which

requirements of scientific research method have been followed during the process of generating

research findings. It is a compulsory requirement for all types of studies (Oliver, 2010).

Validity determines whether the research truly measures that which it was intended to measure or

how truthful the research results are (Golafshani, 2003).

3.6.2 Reliability

Reliability refers to whether an assessment instrument gives the same results each time it is used

in the same setting with the same type of subjects (Sullivan, 2011). It refers to a measurement

that supplies consistent results with equal values (Cooper, 2005). It measures consistency,

precision, repeatability, and trustworthiness of a research (Chakrabartty, 2013). It indicates

the extent to which it is without bias (error free), and hence insures consistent measurement cross

time and across the various items in the instruments (the observed scores). Reliability is used to

evaluate the stability of measures administered at different times to the same individuals and the

equivalence of sets of items from the same test (Kimberlin & Winterstein, 2008). The

better the reliability is perform, the more accurate the results; which increases the chance of

making correct decision in research. Reliability is a necessary, but not a sufficient condition for

the validity of research. In this study, the researcher will use Cronbach’s alpha to test the

reliability of the instrument. Cronbach’s alpha measures how consistently participants respond to

one set of items. Cronbach’s alpha is thought of as a sort of average of the correlations between

items. Cronbach’s alpha ranges from 0.0 to 1.0 (a negative alpha means probably there is need to

reverse some items). Since the late 1960s, the minimally acceptable measure of reliability has

been 0.70; in practice, though, for high-stakes questionnaires, aim for greater than 0.90.

A questionnaire is reliable and valid, if both α and β are greater than 0.77. Once the pre- test

study has been done, necessary amendments will be made to the questionnaire. The researcher

did not use the pre-test sample in the actual study since the pre-test was carried out among

participants who did not form part of the main study.

3.7 Methods of Data Collection.

Data was collected by use of a questionnaire which was administered by the researcher on the

basis of drop and pick once the respondent has finished filling it. To be allowed for data

collection, the researcher applied for research permit from national commission for science

technology and innovation. Moreover, Heads of departments (In charge of the sub-county

hospital, head of Pharmacy, head of Nursing, head of laboratory and head of Clinical services) in

the sub-county Hospitals was approached and recruited into the study. The purpose of the

research and procedure will be explained to them and those who will consent to participate will

be interviewed by the researcher and the assistants. Confidentiality will be assured by ensuring

that the names of the respondent do not appear anywhere in the questionnaire. The researcher

will ensure that no respondent will be issued with a questionnaire more than once by asking if

they had previously been issued with one.

3.7.1 Ethical Considerations

The researcher obtained an introduction letter from Kenya Methodist University that was used to

apply for research permit from National commission for science technology and innovation. This

research permit enabled the researcher to collect data from the various respondents.

The researcher also obtained Ethical clearance from the Ethics and Research Committee of

Kenya Methodist University and permission sought from the respective hospital administrations

before the study was conducted. The researcher explained the purpose of the research and those

who volunteered were given the responses after informed consent and voluntary participation.

The names of the officers were not be recorded and the officers s’ identities were not included

anywhere in the data collection sheets to maintain confidentially. All data collected was

protected during the study. During the entire process of carrying out this research, all ethical

considerations were made to ensure high levels of confidentiality, anonymity, respect for other

people’s property and objects as well as convenience of the respondents.

3.8 Operational measure of Variables

Operationalization refers to the process of developing indicators or items for measuring

constructs (Bhattacherjee, 2012). Operationalization of variables is shown in Table 3.1.

Objective Type

Variables

of Indicator Measuring of

Indicators

Scale Type of Analysis

To determine the

influence of staff on

service delivery

Independent Staff Training

Experience

Compensation

Interval

ordinal

Descriptive

Pearson’s r

stats,

To assess the influence

facilities on service

delivery

Independent Facilities Wards

Ambulances

Geographical

access.

Interval Descriptive

Pearson’s r

stats,

To establish the

influence of

management practices

on service delivery

To evaluate the influence

of Drugs procurement

process on service

delivery

Independent

Dependent

Manage

ment

practices

Drugs

procure

ment

process

Service

Planning

Supervision

Staff motivation

Procurement

process.

Procurement

policy

Procurement

planning

Quality

interval

Interval

Nomin

Descriptive

Pearson’s r

Descriptive

Pearson’s r

Descriptive

stats,

Delivery Accountability

and efficiency

Accessibility

al Regression

analysis.

Table 3.1

Operational measure of variable

3.9 Methods of data analysis.

To ensure confidentiality and anonymity, the data collection tools will not bear a participant’s

name or ethnicity and will be identified by the study code numbers. Once the data has been

transferred from the instrument to the computers, the instrument will be kept safe in a secure

lockable cabinet for future reference. The completed instruments will not be destroyed or thrown

away for at least 3 years after the completion of the research. Access to data about individual

participants will be restricted to the researcher, supervisors and any research assistants on a need-

to-know basis.

The data will be checked for consistency, coded appropriately, and entered into SPSS software

package version 21 for analysis. Preliminary analyses will be conducted and any inconsistency in

the data will identified and corrected. The data will be explored and general features displayed to

identify problem areas before commencing data analyses. Descriptive and inferential statistical

tests will be used in the analysis. The output will be presented in tables and charts.

CHAPTER FOUR

RESULTS AND DISCUSSION

4.1 Introduction

This chapter presents study findings of the analysed data as per research variables. This research

study sought to determine factors influencing service delivery at Sub-County Hospitals in Meru

County, Kenya. Specific objectives included: i) to determine the influence of staff, ii) to assess

the influence of facilities, iii) to establish the influence of management practices, and iv) to

evaluate the influence of drugs procurement process on service delivery in Sub-county Hospitals

in Meru County

4.2 Response Rate

In this study, the number of questionnaires administered were 115 and 84 were successfully

completed and returned making the response rate of 73%. See Table 4.1. Response rate of 50% is

fit for analysis and publishing, 60% is good while 70% is very good (Babbie, 2014).

Table 4.1

Study Response Rate

Response Frequency Percentage %

Respondents 84 73

Non-respondents 31 27

Total 115 100

4.3 Reliability Test Results

The reliability of the instrument is the ability to give clear and stable measurement. In this study

research, the reliability was carried out using Cronbach’s coefficient test alpha. Coefficient alpha

is normally used during a scale development with items that have several items. A Cronbach’s α

≥ 0.7 implies that the tool delivers a moderately decent measurement tool and therefore is

consistent (Flick, 2015). The reliability results shown in Table 4.2 confirmed the reliability of

the instrument with a least Cronbach’s alpha of >0.704.

Table 4.2

Reliability Test Results

Scale Cronbach’s Alpha Number of items

Service delivery 0.736 9

Staff 0.704 9

Facilities 0.804 9

Management Practices 0.763 9

Drugs Procurement Process 0.765 9

4.4 Demographic Characteristics of the respondent

The demographic characteristics of the respondents were collected. It was necessary to

investigate the relevance of age, level of education, gender and years worked and their influence

service delivery in Sub-County hospitals in Meru County, Kenya.

4.4.1 Gender of the respondents

It was necessary to investigate the relevance of age and their influence service delivery in Sub-

County hospitals in Meru County, Kenya. There were 84 respondents who participated in the

survey. All the respondents indicated their gender, most of the respondents (n=49, 58.3%) were

female while (n=35, 41.7%) were male as shown in figure 4.1

Figure 4.1

Gender of respondents

4.4.2 Age of the respondents

Similarly it was necessary to investigate the relevance of age and their influence service delivery

in Sub-County hospitals in Meru County, Kenya. Among the 84 respondents who participated in

the survey, 77 of the respondents indicated their age-group. From figure 4.2 it is clear that most

of the respondents (n=35, 41.2%) were between age 31-40; (n=19, 22.4%) were between age 21-

30; (n=13, 15.4%) were between the age of 41-50; (n=10, 11.9%) were between age 51-60.

41.70%

58.30% Male

Female

Figure 4.2

Age of the respondents

4.4.3 Education level of the respondents

As shown in Figure 4.3 most of the respondents (n=46, 59.0%) indicated that they had gone up

to the Diploma level; (n=23, 29.5%) of the respondents had attained a Bachelor’s degree; (n=5,

6.4%) of the respondents had gone up to the certificate level ; (n=1, 1.3%) of the respondents had

attained a master degree and (n=1, 1.3%) of the respondents had gone to an extent of attaining a

PhD and (n=2, 2.6%) had other level of education, that is Hospitality Nutrition & Diatec.

50.00%

50%

45%

40%

35%

30%

25%

20%

15%

10%

22.60%

15.50%

11.90%

21-30 Years31-40 Years41-50 Years51-60 Years

Figure 4.3

Education level of the respondents

4.4.4 Years worked of the respondents

The number of respondents that participated in the survey was 84. Figure 4.4 indicate that most

of the respondents (n=55, 64.9%) indicated they had worked at the hospitals for 5 years and

below; (n=17, 20.1%) of the respondents indicated that they had worked at the hospitals for 6-11

years; three (3.6%) of the respondents indicated that for 11-20 years they had been working at

the hospital and (n=2, 2.4%) of the respondents had been at the hospital for 21 years and above.

70%

60%

59.00%

50%

40%

30%

29.50%

20%

10% 6.40%

1.30% 1.30% 2.60%

Certificate DiplomaBachelorMasters PhD Other

Figure 4.4

Number of years worked by the respondents

4.5 Responses on Staff Issues in Sub-county Hospitals in Meru County

The first objective of the study was to determine the influence of staff on service delivery in sub-

county hospitals in Meru County. See results in Table 4.3.

Table 4.3

Responses on Staff Issues

Statements N Mean Std. Dev.

We always get an opportunity to advance our skills through 84 3.63 .875

CME/CPD

The hospital has a policy to support staff financially to 84 3.39 .761

further their education

The hospital always gives staff enough time for their training 84 3.55 .856

Most of the staff have many years of experience 84 2.71 .505

Staff are rotated in hospital sections to acquire experience 84 3.83 1.128

Staff are taken for benchmarking to build on their experience 84 3.98 .931

There is adequate compensation package for staff 84 2.74 .604

Compensation is always given in good time to staff 84 3.76 1.158

Compensation packages for all staff is competitive enough 84 3.90 1.001

2.40%9.00%

3.60%

20.10%

64.90%

0-5 Years

6-11 Years

11-15 Years

16-20 Years

21-30 Years

The respondents agreed that ccompensation package for all staff is competitive enough mean of

3.90, that they always get an opportunity to advance their skills through CME/CPD mean of

3.63, that staff are rotated in hospital sections to acquire experience mean of 3.83, and staff are

taken for benchmarking to build on their experience mean of 3.98. The respondents disagreed

that the hospital has a policy to support staff financially to further their education mean of 3.39,

most of the staff have many years of experience mean of 2.71, and that there is adequate

compensation package for staff 2.74.

This study found that there was great extent of agreements on staffing issues in all sub-county

hospitals in Meru County. Moreover, “Staff are taken for benchmarking to build on their

experience” is the attribute of staff that received the highest mean (M=3.98, SD= 0.931). This

means that management of these sub-county Hospitals was keen in taking their staff for

benchmarking since it was an important ingredient in service delivery compared to other

attributes such as “Most of the staff have many years of experience” which attained the lowest

mean (M=2.71, SD= 0.505) implying that many years of experience was not very key in service

delivery. This means that staffing issues like training and compensation package are critical in

delivery of healthcare services. These results are supported by the findings of a study conducted

by (Mwaniki & Dulo, 2008), in their study "Migration of Health Workers in Kenya: The

Impact on Health Service Delivery", training influences the capacity of health workers. High

quality and accessible health services cannot be delivered without sufficient numbers of well-

skilled, well distributed and well-managed health workers. In their study "Decentralizing

Kenya’s Health Management System: An Evaluation" observed that patient satisfaction is a

critical component in health care service delivery (Ndavi et al., 2009).

4.6 Responses on Hospital Facilities in Sub-county Hospitals in Meru County

The second objective of the study was to determine the influence of facilities on service delivery

in sub-county hospitals in Meru County. The results in Table 4.4 present the responses on state

of hospital facilities in sub-county hospitals in Meru County.

Table 4.4

State of Facilities in Sub-county Hospitals of Meru County

Statements N Mean Std. Dev.

The hospital has functional laboratories that serve patients 84 4.17 1.051

The hospital has state of the art laboratories 84 3.80 1.170

The hospital laboratories are always open to offer services 84 3.39 .761

The hospital is always accessible by road 84 3.58 .853

The proximity to the hospital is near to my home 84 2.75 .557

Hospitals are strategically located 84 3.85 1.135

Hospitals have functional ambulances 84 3.51 .898

Ambulances are well equipped 84 2.70 .555

Use of ambulances is affordable 84 3.79 1.162

The respondents agreed that the hospital has functional laboratories that serve patients scoring a

mean of 4.17, the hospital has state of the art laboratories scoring a mean of 3.80, hospitals are

strategically located 3.85, hospitals have functional ambulances 3.51, and the hospital is always

accessible by road 3.58. However the respondents disagreed that the hospital laboratories are

always open to offer services mean of 3.39, the proximity to the hospitals is near to their homes,

mean of 2.75, and that ambulances are well equipped mean of 2.70.

From the findings of this study, it was evident that the respondents agreed that the sub-county

hospitals had laboratory facilities. Aspects of facilities such as “the hospital has functional

laboratories that serve patients” had the highest mean (Mean=4.17; SD=1.051) implying that

functional laboratories were key in delivery services to patients. However, some aspects of

facilities such as “ambulances are well equipped” had the least mean (M=2.70; SD=0.557). This

meant that overall ambulances in sub-county hospitals were not well equipped which affects

service delivery. Overall, most respondents agreed that the hospital have laboratory facilities to

provide health services to all the patients. This implies that these laboratories in in usable state

and can meet the expectations of patients when they are receiving the services in the Hospital.

Results revealed that the hospitals are strategically located ad that hospitals are accessible by

road (Mean=3.85; SD=1.135 and Mean 3.58; SD=0.853) respectively. These results are

supported by Hall et al., (2006) who conducted a study in the Eastern Cape province of South

Africa with a view to understanding the impacts of transport to healthcare service delivery. Their

findings demonstrated not only the need for improved transport services in the delivery of health,

but also the importance of using the right type of vehicles. Their study also revealed that during

the rainy season, it was exceedingly difficult for delivery vehicles laden with drug supplies to

access health facilities largely because of poor road infrastructure running along hilly, often

broken and generally difficult terrain that characterize the province. In wet weather, these roads

become muddy and slippery. In fact, health transport problems are indeed most severe in the wet

season for most rural areas not only in South Africa but also in other developing countries (Gray

& Suleman, 1999). In a study done by Mobility and Health (2008) in Namibia, it was

demonstrated that transport for emergency cases comes at a higher cost for people living in rural

and largely marginalized areas. Very often, patients get too exhausted or die while waiting for

Ambulances, which take over three hours on average to report at the scene after a callout.

Lack of adequate and affordable transport services particularly in remote rural and marginalized

areas, under-girded by sound transportation infrastructure, are obstacles to achieving meaningful

service delivery. Clearly, without proper transport infrastructure and services, healthcare

facilities in these areas will remain under-serviced in terms of maintaining adequate levels of

medical supplies and retaining medical staff as well as eliciting confidence and therefore regular

utilization of the facilities by locals (Mashiri et al., 2016) .

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.1 Introduction

This chapter presents the summary of the findings and it gives the conclusions and

recommendation of the study based on the objectives of the study. Specific objectives included

determining the influence of staff on service delivery in sub-county hospitals in Meru County,

assess the influence of facilities on service delivery in sub-county hospitals in Meru County,

establish the influence of management practices on service delivery in sub-county hospitals in

Meru County and evaluate the influence of Drugs procurement process on service delivery in

sub-county hospitals in Meru County.

5.2 Summary of the findings

This research study sought to determine factors influencing service delivery at Sub-County

Hospitals in Meru County, Kenya. In this study, the number of questionnaires administered

amounted to 115 out of which 84 were successfully completed and returned making the response

rate of 73%. To collect the data, the researcher used closed structured questionnaires that were

personally administered to all the sampled respondents. The target population for undertaking

this study included all Meru County 23 sub-county hospitals that were involved in this study. In

this study, data was analyzed using SPSS and findings were presented in the form of mean std

deviation, correlation and regression analysis. Findings revealed that majority of the respondents

were aged between 21-30 years and over. In addition this demographic result reveals that all of

the respondents have at least gone to school with over 50% having attained diploma.

5.2.1 Influence of staff on service delivery

The results confirmed that, on average the respondents agreed that staff have influence on

service delivery in sub-county hospitals in Meru County. Among the aspect agreed upon

included we always get an opportunity to advance our skills through CME/CPD, the hospital has

a policy to support staff financially to further their education, the hospital always gives staff

enough time for their training, most of the staff have many years of experience, staff are rotated

in hospital sections to acquire experience, staff are taken for benchmarking to build on their

experience, there is adequate compensation package for staff, Compensation is always given in

good time to staff and Compensation packages for all staff is competitive enough.

5.2.2 Influence of facilities on service delivery

The findings confirm that, on average the respondents agreed that facilities have influence on

service delivery in sub-county hospitals in Meru County. Among the aspect agreed upon

included hospital has functional laboratories that serve patients scoring, the hospital has state of

the art laboratories, the hospital laboratories are always open to offer service, the hospital is

always accessible by road, the proximity to the hospital is near to my home, Hospitals are

strategically locate, hospitals have functional ambulances, ambulances are well equipped while

use of ambulances is affordable.

5.2.3 Influence of management practices on service delivery

The study confirms that, on average the respondents agreed that the management practices have

influence on service delivery in sub-county hospitals in Meru County. Among the aspect agreed

upon included with the aspect of adequate resources are budgeted for implementing plans,

resources are availed for implementing plan, management follows and adhere to hospital,

management supervises staff adequately, there is sound relationship between staff and

supervisors, supervisors lead by examples to staff, hospital has a motivation policy for staff,

hospital management follows and adheres to motivation policy and management has various

reward systems for motivating employees.

5.2.4 Influence of drugs procurement process on service delivery

The results confirm that, on average the respondents agreed that the drugs have influence on

service delivery in sub-county hospitals in Meru County. Among the aspect agreed upon

included the aspect of drugs procurement process is flexible scoring, there is minimum lead time

during drugs procurement, there are adequate resources for drugs procurement, there is a hospital

policy for drugs procurement, procurement policies are adhered to during procurement, staff

understand and are familiar with procurement policy, hospital plans for procurement of drugs ,

hospitals adhere to procurement plans and procurement pans are flexible.

5.3 Conclusion

This study makes the following conclusion;

Staffs working in sub-county Hospitals in Meru County have an influence on service delivery in

these Hospitals and there was a strong and positive relationship between staff and service

delivery in sub-county Hospitals in Meru County. Moreover, Facilities in all sub-county

Hospitals in Meru County have an influence on service delivery. In addition, facilities have a

strong positive relationship with service delivery. Management practices influences service

delivery in all sub-county Hospitals in Meru County. Additionally, management practices were

found to have a strong and positive relationship with service delivery in all sub-county hospitals

in Meru County. Consequently, Drugs procurement process influences service delivery in all

sub-county Hospitals in Meru County. Moreover there was found a strong positive relationship

between drugs procurement process and service delivery in sub-county Hospitals in Meru

County.

5.4 Recommendations

This study recommends the following:

i. Management of Meru sub-county hospitals should provide adequate financial support

to their staff to enable them further their education in order to acquire more skills that

can empower them in delivering services to patients.

ii. Management of Meru sub-county hospitals should ensure that all sub-county hospitals

have adequate facilities that are in usable state to facilitate smooth service delivery to

all the patients.

iii. Management should follow and adhere to hospital plans, motivation policy and lead

by example to ensure smooth service delivery to the patients.

iv. Procurement department as well as Hospital administrator should always use and

adhere to drugs procurement plans to ensure there are drugs of right quality and

quantity in the Hospital at all given times to facilitate seamless service delivery.

5.5 Suggestions for further research

Carry out research study to widen the current knowledge on factors influencing service delivery

at Sub-County Hospitals in the neighbouring counties such as Tharaka Nithi so that the result is

obtained and used as a benchmark.

References

Ajayi, O. T. (2009). The advantage Project: Utilizing SMS to support evidence based medicine for

health practitioners in complex settings. John Hopkins University.

Ali, R. and Ahmed, M.S. (2009). The Impact of Reward & Recognition Programs on Employees

Motivation & satisfaction. An Empirical Study. International Review of Business Research

Papers, 5(4), 270-279. https://www.researchgate.net/publication/242422190

Auerbach, J. N. (2003). Police Accountability in Kenya; Seize the moment police as a service

Organization. African Human Rights Law Journal (AHRLJ), 3(2), 275-313.

https://www.ahrlj.up.ac.za/auerbach-j-n

Badaso, C. J. (2014). Challenges of Implementing Procurement Policy in States Corporations in Kenya.

European Journal of Business and Management,6(3), 56-61.

https://iiste.org/Journals/index.php/EJBM/article/view/10527

Basheka, B. (2004). Procurement planning and local governance in Uganda: A factor analysis approach.

Organisation. International Journal of Procurement Management,2(2), 191-209.

http://www.inderscience.com/link.php?id=23407

Bashuna, A. (2013). Factors affecting effective management of the procurement function at Nakuru

North Sub-County. World Academic Journal of Business & Applied Sciences (WAJBAS),1(7),

250-291. https://www.academia.edu/4683113/

Boonlertvanich, K. (2011). Effect of customer perceived value on satisfaction and customer loyalty in

bankingservice: The moderating effect of main bank status. International Journal of Business

Research, 11(6), 40-54. http://connection.ebscohost.com/c/articles/70065874/

Bradshaw, M., & Steyn, K. (2001). Poverty and chronic diseases in South Africa: Technical Report,

Cape Town and World Health Organization. Scandinavian Journal of Public Health, 37(2), 176–

186.https://doi.org/10.1177/1403494808100272Geneva: Medical Research Council.

Brown, C.A., Sohani, S.B., Khan, K. (2008). Antenatal care and perinatal outcomes in Kwale district,

Kenya. BioMed Central (BMC) Pregnancy Childbirth Journal, 8(2), 1-11.

https://doi.org/10.1186/1471-2393-8-2

Byrne, D., & Callaghan, G. (2014). Complexity theory and the social sciences. Routledge.

https://doi.org/10.4324/9780203519585

Chaix-Couturier, C., Durand-Zaleski, I., Jolly, D., & Durieux, P. (2000). Effects of financial incentives

on medical practice: results from a systematic review of the literature and methodological

issues. International journal for quality in health care : Journal of the International Society for

Quality in Health Care, 12(2), 133–142. https://doi.org/10.1093/intqhc/12.2.133

Chebat, J-C., & Kollias, P. (2000). The Impact of Empowerment on Customer Contact Employees’

Roles in Service Organizations. Journal of Service Research,3(1), 66-81.

https://doi.org/10.1177/109467050031005

Chodzaza, G. E. & Gombachika, H. S. H. (2013). Service quality, customer satisfaction and loyalty

among industrial customers of a public electricity utility in Malawi. International Journal of

Energy Sector Management, 7(2), 269-282. https://doi.org/10.1108/IJESM-02-2013-0003

Cromley, R. G., & Cromley, E. K. (2009). Choropleth map legend design for visualizing community

health disparities. International journal of health geographics, 8(52), 1-11.

https://doi.org/10.1186/1476-072X-8-52

Dacha, V. W., & Juma, D. (2018). Effect of stakeholder participation on the efficiency of the

procurement process in the public sector: a case of Jomo Kenyatta University of Agriculture And

Technology.strategic journal of business and change management,5(2), 1206-1230.

http://www.strategicjournals.com/index.php/journal/article/view/718/733

Delamater, P. L. (2013). Spatial accessibility in suboptimally configured health care systems: a modified

two-step floating catchment area (M2SFCA) metric. Health & place, 24(2013), 30–43.

https://doi.org/10.1016/j.healthplace.2013.07.012

Deloitte. (2014). 2014 Global health care outlook: shared challenges, shared opportunities.

https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/

dttl-lshc-2014-global-health-care-sector-report.pdf

Demirbag, Sahadev, & Akgul, K. (2012). Modeling quality commitment in service organizations: an

empirical study. European Journal of Marketing, 46(6), 790-810.

https://www.emerald.com/insight/content/doi/10.1108/03090561211214609/full/html

Duberg, C., & Mollén, M. (2010). Reward systems within the health and geriatric care sector.

Medicine, 3(2), 1-59. https://gupea.ub.gu.se/bitstream/2077/21844/1/gupea_2077_21844_1.pdf

Ellinger, Ellinger, & Bachrach, W. (2011). Measurement of organizational investments in social capital:

The service employee perspective. Journal of Business Research ,64(6), 572-578.

https://doi.org/10.1016/j.jbusres.2010.06.008

Finkle, L. (2011, January 4). Motivating Employee Performance Through Year-End

Bonuses. http://ezinearticles.com/?Motivating-Employee-Performance-Through-Year-End--

Bonuses&id=5658825

Fiszbein, A. D. (2011). Making Services Work. Indicators, Assessments, and Benchmarking of the

Quality and Governance of Public Service Delivery in the Human Development Sector. Policy

Research Working Paper. World Bank. https://doi.org/10.1596/1813-9450-5690

Furuta, M., & Salway, S. (2006). Women's position within the household as a determinant of maternal

health care use in Nepal. International family planning perspectives, 32(1), 17–27.

https://doi.org/10.1363/3201706

Gatrell, A. C. (2005). Complexity theory and geographies of health: a critical assessment. Social science

& medicine, 60(12), 2661–2671. https://doi.org/10.1016/j.socscimed.2004.11.002

Gittel, & Weiss. (2004). Coordination Networks Within and Across Organizations: A Multi-level

Framework. Journal of Management Studies, 41(1), 127- 153. https://doi.org/10.1111/j.1467-

6486.2004.00424.x

Gonzalez Asis, M. & Woolock, M. (2015).Operationalizing the Science of Delivery Agenda to Enhance

Development Results. World Bank. https://openknowledge.worldbank.org/handle/10986/23226?

locale-attribute=fr

Grönroos, C. &. (2011). Service as business logic: implications for value creation and marketing.

Journal of Service Management, 22(1), 5-22. https://doi.org/10.1108/09564231111106893.

Harrison, Bosse, & Phillips. (2010). Managing for stakeholders, stakeholder utility functions, and

competitive advantage. Strategic Management Journal,31(1), 58-74.

https://ssrn.com/abstract=1501885

Hatch, N., & Dyer, J. (2004). Human capital and learning as a source of sustainable competitive

advantage. Strategic Management Journal, 25(12). 1155 - 1178. https://doi.org/10.1002/smj.421

Heider, F. (1958). The Psychology of Interpersonal Relations. Psychology Press,

https://doi.org/10.4324/9780203781159

Heyden, V. d., Tafforeau, & Oyen, V. (2003). Socio-economic differences in the utilisation of health

services in Belgium . Health Policy , 65(2), 153–165. https://doi.org/10.1016/s0168-

8510(02)00213-0

Holmes, W., & Kennedy, E. (2010). Reaching emergency obstetric care: Overcoming the ‘second delay.

The Women’s and Children’s Knowledge Hub. 1(1), 1-4.

https://www.burnet.edu.au/publications/3465_reaching_emergency_obstetric_care_overcoming_

the_second_delay

Imberman, S. (2015). How effective are financial incentives for teachers” Linking teacher pay to student

performance has become popular, but evidence on its effectiveness is mixed. IZA World of

Labor, 2015(158), 1-6. https://wol.iza.org/articles/how-effective-are-financial-incentives-for-

teachers/long

Iqbal, J., (2012). Employee motivation in modern organization. Journal of contemporary research in

business, 4(3), 7-14. http://strategicjournals.com/index.php/journal/article/view/426/0

James, U. (2004). Public Policy and the African Environment: An Examination of the Theory and

practice of the planning process of the continent. In K. Kalu, (Ed.). (2004). Agenda Setting and

Public Policy in Africa. Routledge, https://doi.org/10.4324/9781315263151.

Javed, L., & Javed, N. (2013). An Empirical Study on the Factors That Affect Employee Motivation and

Their Relationship with Job Performance. International Journal of Management Sciences, 1(4),

114-124. https://ideas.repec.org/a/rss/jnljms/v1i4p2.html

Kaura, V., Durga Prasad, C.S. & Sharma, S. (2015). Service quality, service convenience, price and

fairness, customer loyalty, and the mediating role of customer satisfaction. International Journal

of Bank Marketing, 33(4), 404-422. https://doi.org/10.1108/IJBM-04-2014-0048

Kemp R., Rotmans J. (2005) The Management of the Co-Evolution of Technical, Environmental and

Social Systems. In: M., Weber, J. Hemmelskamp (eds) (33-35) Towards Environmental

Innovation Systems. Springer. https://doi.org/10.1007/3-540-27298-4_3

Kennedy, A., Rogers, A., Chew-Graham, C., Blakeman, T., Bowen, R., Gardner, C., Lee, V., Morris, R.,

& Protheroe, J. (2014). Implementation of a self-management support approach (WISE) across a

health system: a process evaluation explaining what did and did not work for organisations,

clinicians and patients. Implementation science, 9(129), 1-16. https://doi.org/10.1186/s13012-

014-0129-5

Ministry of Health (2010). Health managemnet information sysstem, Report for the 1996-1999 period.

Republic of Kenya.

Kiange, M. (2011). The relationship between service quality and customer satisfaction in the

telecommunication industry: Evidence from Nigeria. Broad Research in Accounting,

Negotiation, and Distribution,1(1), 88-100.

http://www.edusoft.ro/brand/RePEc/bra/journl/brand_1_ojo.pdf

Kotler, P. (2008). Principle of Marketing, (3rd ed). Pretence Hall .

Kotler, P., Keller, K. L., Goodman,G.,Brady, M., & Hansen, T. (2019). Marketing Management.

Pearson Education Limited.

Ladhari, R., Ladhari, I., & Morales, M. (2011). Bank service quality: comparing Canadian and Tunisian

customer perceptions. International Journal of Bank Marketing,29(3), 224-246.

https://doi.org/10.1108/02652321111117502.

Lai, F., Griffin, M., & Babin, B. J. (2009). How quality, value, image, and satisfaction create loyalty at a

Chinese telecom. Journal of Business Research,62(10), 980-986.

https://doi.org/10.1016/j.jbusres.2008.10.015

Lenka, U. Suar, D. & Mohapatra, P. K. (2009). Service quality, customer satisfaction, and customer

loyalty in Indian commercial banks. Journal of Entrepreneurship,18(1), 47-64.

https://doi.org/10.1177/097135570801800103

Lockwood, H. & Smits, S. (2011). Supporting Rural Water Supply. Moving toward a Service Delivery

Approach. Practical Action Publishing. https://www.jstor.org/stable/j.ctt1hj597s

Mamiro, R. (2010). Value for Money, The Limping Pillar in Public Procurement. Tanzania Procurement

Journal, 1(1), 4 -5.

http://ippa.org/images/PROCEEDINGS/IPPC4/01ComparativeProcurement /Paper1-2.pdf

Maund, L. (2001). An Introduction to Human Resource Management Theory & Practice. Macmillan.

Mburu, P.N., Zyl, H.V., & Cullen, M. (2013). Determinants of Customer Satisfaction in the Kenyan

Banking Industry. European Journal of Business and Management, 5(2), 155-161.

https://www.iiste.org/Journals/index.php/EJBM/article/view/3938

Mcloughlin, C. & Batley, R. (2012). The Effects of Sector Characteristics on Accountability

Relationships in Service Delivery (Working Paper No. 350). Overseas Development Institute.

https://ssrn.com/abstract=2209074 or http://dx.doi.org/10.2139/ssrn.2209074

Morçöl, G. (2012). A complexity theory for public policy. Routledge.

Mukucha, P. (2013). The Mediation Effects of Perceived Service Quality in The Relationship between

Employee Satisfaction and Customer Satisfaction. Journal of Studies in Accounts and

Economics, 1(3), 9-16. http://ijecm.co.uk/wp-content/uploads/2019/03/7314.pdf

Nichols, P. (2002). Regulating transnational bribery in times of globalization and fragmentation. The

Yale Journal of Internal law,24(1), 257-304.

https://digitalcommons.law.yale.edu/yjil/vol24/iss1/6/

Nyaboke, J., Arasa, R.., & Ombui, K. (2013). Effects of public procurement policies on organizational

performance: A case of Water Services Regulatory Board. International Journal of Social

Sciences and Entrepreneurship,1(5), 89-103.

https://www.ijsse.org/articles/ijsse_v1_i5_89_103.pdf

Obiero. (2008). The challenges in the implementation of the 2005 procurement act on the Kenyan

Ministry of Higher Education, Science and Technology. [Master's thesis University of Nairobi]

http://erepository.uonbi.ac.ke/handle/11295/63996

Oduor, C. (2013). Integrity in the Public Health Sector Service Delivery in Busia County. Institute of

Economic Affairs. https://media.africaportal.org/documents/Busia-Final-1.pdf

Pathmanathan, I., Liljestrand, J., Martins, J. M., de Silva, A., Lissner,C., Selvaraju, S., & Singh, P.

(2003). Investing in maternal health: Learning from Malaysia and Sri Lanka. The world bank

group. https://openknowledge.worldbank.org/handle/10986/14754

Ployhart, R. E. & Moliterno,T. P. (2011). Emergence of the human capital resource: A multilevel model.

Academy of Management Review, 36(1),127–150. https://www.jstor.org/stable/29765018

Rungtusanatham, M., Filippini, R. B. & Anderson, J. C. (2010). A replication study of a theory of

quality management underlying the Deming management method: insights from an Italian

context. Journal of Operations Management, 17(1), 77-95. https://doi.org/10.1016/S0272-

6963(98)00032-1

Rosann, S., & Barton, W. (2014). Adaptive Selling: Conceptualization, Measurement and Nomological

Validity. Journal of Marketing Research, 27(1),61-69. https://www.jstor.org/stable/3172551

Sarvadi, P. (2010, October ). The Best Ways to Reward Employees. Entrepreneur Magazine.

https://www.entrepreneur.com/article/75340

Schooner, & Whiteman. (2000). Purchase Cards and Micro Purchases. Public Procurement Law Review,

9(4), 148-170. https://doi.org/10.1108/JOPP-08-03 2008-B003

Singh, J. (2000). Performance productivity and quality of frontline employees in service

organizations. Journal of Marketing, 64(2), 15–34. https://doi.org/10.1509/jmkg.64.2.15.17998

Skålén, P., Gummerus, J., von Koskull, C., & Magnusson, P. (2015). Exploring value propositions and

service innovation: a service-dominant logic study. Journal of the Academy of Marketing

Science, 43(2), 137-158. https://doi.org/10.1007/s11747-013-0365-2

Sony, M. & Mekoth, N. (2012). A typology for frontline employee adaptability to gain insights in

service customisation: a viewpoint. International Journal of Services and Operations

Management, 12(4), 490-508. https://doi.org/10.1504/IJSOM.2012.047955

Stellenberg, E. L., Welmann, E. B., & Groenewald, J. C. (2008). Investigation into the relationship

between the socio-economic and health status of the coloured people of the Western Cape in an

urban setting. Curationis, 31(2), 50–59. https://doi.org/10.4102/curationis.v31i2.981

Swinnerton S. (2006). Living in poverty and its effects on health. Contemporary nurse, 22(1), 75–80.

https://doi.org/10.5172/conu.2006.22.1.75

Tetteh, K. I. (2015). The relationship between employees’ incentives and performance at Ghana oil

company limited in the southern zone of Ghana. Advances in Social Sciences Research Journal,

2(2), 1-5. https://doi.org/10.14738/assrj.22.952

Thomas, A., Spencer, J., & Perin, J. (2005). The effect of geographical and spatial behaviour on

healthcare utilization among the residents of a rural region. Health Service Research, 40(1),135-

155. https://doi.org/10.1111/j.1475-6773.2005.00346.x

Thompson,C. & Rampton, L. (2003). Human Resource Management. NewYork: Melbourne Press.

Torrington, D. & Stephen, L.H. (2008). Human Resource Management (7th ed.). Pearson Education

Limited.

World Health Organisation. (2014). The health of the people: what works: the African Regional Health

Report.https://www.afro.who.int/publications/african-regional-health-report-2014-health-people-

what-works

Wimonphan, P., & Nuttawuth, M. (2012). Is There a Link? Employee Satisfaction and Service Quality.

World Journal of Management,4(1), 82-92.

https://www.cscjournals.org/manuscript/Journals/IJBRM/Volume6/Issue3/IJBRM-187.pdf

Yamin. (2003). Not just a tragedy: Access to medications as a right under international law. Boston

University International Law Journal ,21(2), 325–371.

https://pubmed.ncbi.nlm.nih.gov/16514750/

Appendices

Appendix i: Letter of Introduction

Kenya Methodist University

P. 0 Box 267- 60200

MERU, Kenya

SUBJECT: INFORMED CONSENT

Dear Respondent,

My names are Jason Maingi Anampiu, I am an MSc student from Kenya Methodist University.

I am conducting a study titled: Factors influencing efficiency of service delivery in public

hospitals in Kenya: a case study of Meru County. The findings will be utilized to strengthen the

health systems in Kenya and other Low-in- come countries in Africa. As a result, countries,

communities and individuals will benefit from improved quality of healthcare services. This

research thesis is critical to strengthening health systems as it will generate new knowledge in

this area that will inform decision makers to make decisions that are research based.

Procedure followed

Participation in this study will require that I ask you some questions and also access all the

hospital’s department to address the six pillars of the health system. I will record the information

from you in a questionnaire check list. You have the right to refuse participation in this study.

You will not be penalized nor victimized for not joining the study and your decision will not be

used against you nor affect you at your place of employment. Please remember that participation

in the study is voluntary. You may ask questions related to the study at any time. You may refuse

to respond to any questions and you may stop an interview at any time. You may also stop being

in the study at any time without any consequences to the services you are rendering.

Discomforts and risks

Some of the questions you will be asked are on intimate subject and may be embarrassing or

make you uncomfortable. If this happens; you may refuse to answer if you choose. You may also

stop the interview at any time. The interview may take about 40 minutes to complete.

Benefits

If you participate in this study you will help us to strengthen the health systems in Kenya and

other Low-in- come countries in Africa. As a result, countries, communities and individuals will

benefit from improved quality of healthcare services. This field attachment is critical to

strengthening the health systems as it will generate new knowledge in this area that will inform

decision makers to make decisions that are research based.

Rewards

There is no reward for anyone who chooses to participate in the study.

Confidentiality

The interviews will be conducted in a private setting within the hospital. Your name will not be

recorded on the questionnaire and the questionnaires will be kept in a safe place at the

University.

Contact Information

If you have any questions you may contact the following supervisors:

i. Ms. Roselyn Kinyamu, Department of Health Systems Management – Riara

University.

ii. Dr. Wanja,Mwaura Tenambergen Chair of Department of Health Systems

Management - Kenya Methodist University, Nairobi Campus.

Participant’s Statement

The above statement regarding my participation in the study is clear to me. I have been given a

chance to ask questions and my questions have been answered to my satisfaction. My

participation in this study is entirely voluntary. I understand that my records will be kept private

and that I can leave the study at any time. I understand that I will not be victimized at my place

of work whether I decide to leave the study or not and my decision will not affect the way I am

treated at my work place.

Name of Participant…………………………………. Date…………………………..

Signature……………………………………….

Investigator’s Statement

I, the undersigned, have explained to the volunteer in a language s/he understands the procedures

to be followed in the study and the risks and the benefits involved.

Name of Interviewer………………………………………………Date…………………….

Interviewer Signature…………………………………………

Appendix ii: Research Questionaire

Section A: General Information:

(Please tick in the box provided)

1. Gender: Male [ ] Female [ ]

2. What is your age? ……………………………………....

3. Name of the hospital (Optional) ……………………………………..

4. Level of education

Certificate [ ] Diploma [ ] Bachelors [ ]

Masters [ ] PhD [ ] others (specify)……………..

5. How many years have you worked in this hospital? ……………………………………………..

Section B. Staff

Rate the following statements on staffing issues and how they influence service delivery.

Statement SA A U SD D

Training

We always get an opportunity to advance our skills through

CME/CPD

The hospital has a policy to support staff financially to further their

education

The hospital always gives staff enough time for their training

Experience

Most of the staff have many years of experience

Staff are rotated in hospital sections to acquire experience

Staff are taken for benchmarking to build on their experience

Compensation

There is adequate compensation package for staff

Compensation is always given in good time to staff

Compensation packages for all staff is competitive enough

SA- Strongly Agree; A-Agreed; U-Undecided; SD-Strongly Disagree; D-Disagreed

Section C. Facilities

Rate the following statements on facilities issues and how they influence service delivery.

Statement SA A U SD D

Equipped laboratories

The hospital has functional laboratories that serve patients

The hospital has state of the art laboratories

The hospital laboratories are always open to offer services

Geographical access

The hospital is always accessible by road

The proximity to the hospital is near to my home

Hospitals are strategically located

Ambulances

Hospitals have functional ambulances

Ambulances are well equipped

Use of ambulances is affordable

SA- Strongly Agree; A-Agreed; U-Undecided; SD-Strongly Disagree; D-Disagreed

Section D. Management practices

Rate the following statements on management practices issues and how they influence service

delivery.

Statement SA A U SD D

planning

Adequate resources are budgeted for implementing plans

Resources are availed for implementing plans

Management follows and adhere to hospital plans

Supervision

Management supervises staff adequately

There is sound relationship between staff and supervisors

Supervisors lead by examples to staff

Staff motivation

Hospital has a motivation policy for staff

Hospital management follows and adheres to motivation policy

Management has various reward systems for motivating employees

SA- Strongly Agree; A-Agreed; U-Undecided; SD-Strongly Disagree; D-Disagreed

Section D. Drugs procurement process

Rate the following statements on drugs procurement process and how they influence service

delivery.

Statement SA A U SD D

Procurement process

Drugs procurement process is flexible

There is minimum lead time during drugs procurement

There are adequate resources for drugs procurement

Procurement policy

There is a hospital policy for drugs procurement

Procurement policies are adhered to during procurement

Staff understand and are familiar with procurement policy

Procurement planning

Hospital plans for procurement of drugs

Hospitals adhere to procurement plans

Procurement pans are flexible

SA- Strongly Agree; A-Agreed; U-Undecided; SD-Strongly Disagree; D-Disagreed

Section E. services delivery

Rate the following statements on service delivery as a result of staff, facilities, management

practices and drugs procurement process

Statement SA A U SD D

Quality

Hospital services are effective in serving patients’ needs

Services offered in this hospital are safe to the patients

Services offered here are centered on the patient’s needs

Accountability and efficiency

Health services are well managed so as to achieve the core

elements described above with a minimum wastage of resources

Managers are allocated the necessary authority to achieve

planned objectives and held accountable for overall performance

and results

Health services are delivered in a timely manner to the patients

Accessibility

Services are directly and permanently accessible with no undue

barriers of cost, language, culture, or geography

Health services are close to the people, with a routine point of

entry to the service network at primary care level

Services may be provided in the home, the community, the

workplace, or health facilities as appropriate

SA- Strongly Agree; A-Agreed; U-Undecided; SD-Strongly Disagree; D-Disagreed

Thank you for your time

Appendix iv. Ethical clearance

Appendix v. Introduction letter from the University

Appendix vi. Research Licence

Appendix vii. Approval to collect data in Meru County

ASSESSMENT OF FACTORS INFLUENCING SERVICE DELIVERY

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