Assessment of patient satisfaction toward pharmaceutical benefit package provided by a health insurance corporation of Khartoum State

Introduction

Following the dramatic change in the role of pharmacists observed in the last decades to be more patient centred, patient satisfaction has emerged as a prerequisite in pharmaceutical care. It can be defined as personal appraisal of the pharmaceutical care; it is a subjective and multidimensional measure which answers the questions about what patients expect and what patients find.^1,2

Achieving satisfaction is the best way to convince the patient about the health services provided, ensuring adherence to therapy and consequently improving health outcome. Therefore, patient satisfaction has driven the attention of developed as well as developing countries; in fact there have been several attempts to develop a validated tool to measure the patient satisfaction.^2–5

Patient care indicators (PCIs) are one of World Health Organization's (WHO) core drug use indicators, they are used to reflect the quality of the pharmaceutical services delivered by the health facility by describing what the patient experienced at the health facility and to what extent the patient has been trained to deal with the pharmaceuticals that have been dispensed, through measuring several factors including: average consultation time (ACT), average dispensing time (ADT), percentage of drugs actually dispensed (PMAD), percentage of drugs actually labelled (PMAL), and patients’ knowledge of correct dosage (PKCD). Given their vital role in determining the quality of the pharmaceutical service, the WHO have comprehensively described PCIs in terms of providing detailed protocol of how to measure each parameter as well as setting out the optimal range of each indicator.^6,7

Previous studies from Egypt, Nigeria, Kingdom of Saudi Arabia (KSA), Ethiopia, Pakistan, and Spain have provided detailed descriptions of one or all PCIs in either a hospital or out-patient pharmacy.^6,8–11 A similar study was conducted recently in Sudan, where the pattern of drug use by using WHO's PCIs was estimated in four hospitals in Khartoum state.⁷

Health Insurance Corporation of Khartoum State (HICKS) is one of leading Social Health Insurance (SHI) organizations limited to Khartoum State which provides services to primary healthcare facilities of the State Ministry of Health and the Federal Ministry of Health hospitals. The HICKS receives its funds mainly through the State Ministry of Health and house-holds (36.5% and 27% respectively).¹² Other sources of funding are parastatal organizations and private employers’ contributions. Despite the presence of SHI in Sudan for more than 20 years, universal coverage has not been achieved yet; it faces many obstacles such as rising healthcare costs due to inflation and lack of affordability by beneficiaries. Moreover, the quality of the services provided including patient satisfaction is poorly understood.¹² This study was conducted to measure the overall patient satisfaction towards the Pharmaceutical Benefit Package provided by HICKS and to predict the possible association between PCIs and overall satisfaction.

Methods

Results

Discussion

Patient satisfaction is one of the most important factors that affects medication adherence and subsequently treatment success/failure. In this study, a total of 378 questionnaires were distributed to out-patients who sought their medication at one of the HICKS pharmacies with the aim of assessing the level of satisfaction. The overall satisfaction was 62.2% and all PCIs were found to be associated with patient satisfaction.

The mean age of the participates was 47 years old, with 49.3% male and 50.7% female participants (Table 1). A study conducted in Canada aiming to validate published satisfaction scales in larger and more diversified patient populations included 682 patients and reported that the percentages of male and female participants were 36.9% and 63.1% respectively.¹⁷ In another study setting in Peru, a slightly lower mean of age (42.8) was reported, while the percentage of the females was 59.6% and males was 40.4%.¹⁸ A similar study that was conducted in United Arab Emirates (UAE) reported a lower mean of age across the participants of 34, and in the same study, the percentages of males and females was 39% to 61% respectively.³ This slight fluctuations in age and gender among the studies might be due to the difference in study population, area and sample size.

In this study, the mean of satisfaction was found to be 3.11 (62.2%). This finding is comparable to the finding in a Nigerian study (60.4%),¹⁹ and higher than the result obtained in Ethiopia and Pakistan in 2019 and 2018 respectively,^8,9 in which the satisfaction was reported to be 51% and 55.6% respectively. On the other hand, this level of satisfaction is lower than that obtained in Spain and South Korea (76% and 74.6% respectively).^2,20 This variation is probably due to the fact that each study adopts different tools to assess satisfaction and undoubtedly reflects the difference in the services in the different countries.

The current study reveals that the participants were highly satisfied with the pharmacist who provided the health services; an over 70% satisfaction rate was reported by the participants to the way the pharmacists are dealing with them, care to inquiries and clarity of instructions (Table 2). Similar to this figure; Spanish, Pakistani and Ethiopian participants were also satisfied with the approach or communication of the health professional providing the services.^8,9,20 Fortunately, knowledge and practice of the pharmacy staff are the most important factors for delivering a better pharmaceutical service and hence improving patient satisfaction. In contrast, the study reveals the weakest domain which affects patient satisfaction: unavailability of all medications under the umbrella of health insurance (41.2%) was the least rated factor (Table 4). A higher figure was obtained by several studies conducted in Pakistan, UAE and in some regions in Ethiopia with 63.8%, 70% and 59.6% respectively,^3,8,9 however, a study conducted in different regions in Ethiopia reported a lower percentage 33.1%.²¹ In this context, while the study reports a relatively higher overall satisfaction (62.2%) this finding is alarming since several studies demonstrate a significant association between satisfaction and medication availability; this is considered a hidden factor that might negatively impact the whole medical care.

In this study, parameters that are used to measure rational use of medicine which are associated with patient satisfaction were considered. The ADT was 5.78 minutes in which 60% of the participants have more than 5 minutes ADT. A significant association (P = 0.002) between ADT and overall satisfaction was reported in this analysis (Tables 3 and 4). The reported ADT is two times higher than that reported in India (3 minutes) and much higher than that reported in KSA (1.5 minutes) and Kuwait (1 minute).^6,22,23 It is known that short ADT is insufficient to explain the dosage regimen, adverse effects of drugs and all precautions, while the reported ADT is longer in comparison to the previous studies, this might be due to the fact that the pharmacist spent a longer time explaining to the patient the insured and non-insured medication in the prescription as HICKS do not cover full insurance for all medication.

The percentage of medicine dispensed was 67%; this figure was lower than the WHO recommended percentages (100%). The obtained PMD was statistically associated with satisfaction (P = 0.00) (Table 4). It is lower than that reported in Egypt, Kenya and KSA,^6,24,25 and slightly higher than a previous study conducted in Sudan (58%).⁷ This finding reflects the huge medicine shortage in the health system, where adequate supply is the corner stone in the health system and if left unmanaged, health crises might arise.

The WHO recommended that the proper labelling must include patient name, dose regimen and drug use. Due to the unavailability of proper labelling machines, labelling was considered proper if the dose regime and drug use were hand written correctly. In this regard, the PML was 58% (Table 3), a far lower percentage than WHO recommendation (100%), and even lower than that reported in Kenya, Kuwait, and KSA.^6,23,25 This finding indicates the poor labelling practise among the pharmacists which might be due to lack of knowledge or because some patients object to the labelling since they take these medications on a regular basis.

Regarding patient knowledge, a slightly lower percentage (96.6%) than the WHO recommendation (100% knowledge) was obtained (Table 3); similar figures were reported in Kenya (96%) and Egypt (94%),^24,25 while it is higher than that reported previously in Sudan and KSA (79%).^6,7 This could be attributed to fact that most of the coverage medications were for chronic diseases taken regularly by the patients. With respect to patient's ability to pay despite health insurance, one out of three patients are not able to pay (Table 3). This is an alarming finding, as it is known that ability to pay is affected by out-of-pocket costs (expenses for medical care that aren't reimbursed by insurance) which is considered to be a significant barrier to accessing or maintaining care for those with chronic diseases,²⁶ and consequently might make the whole health service valueless.

One of the key limitations in this study is the study area: since it was conducted in one locality in Khartoum, a more diverse area with a larger sample could provide a more robust result. Moreover, this study used interview questionnaires which were conducted at the time of patients visiting the pharmacy and hence it is subjected to social desirability bias.

Conclusions

The overall satisfaction score was (62%). However, medication unavailability remains to be a hidden factor which undoubtedly affects the patient satisfaction.

Data availability