AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE

PARTNERSHIP (PPP) PROJECTS IN SELECTED UNIVERSITY

TEACHING HOSPITALS

By

Funmilola Helen OYEDELE

DEPARTMENT OF QUANTITY SURVEYING,

AHMADU BELLO UNIVERSITY, ZARIA
NIGERIA

AUGUST, 2015
AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE
PARTNERSHIP (PPP) PROJECTS IN SELECTED UNIVERSITY
TEACHING HOSPITALS

By

Funmilola Helen OYEDELE, B.Sc (A.B.U) 2008

M.SC/ENV-DESIGN/8003/2011-2012

A DISSERTATION SUBMITTED TO THE SCHOOL OF POSTGRADUATE STUDIES,

AHMADU BELLO UNIVERSITY, ZARIA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD
OF A
MASTER DEGREE IN QUANTITY SURVEYING.

DEPARTMENT OF QUANTITY SURVEYING,

FACULTY OF ENVIRONMENTAL DESIGN
AHMADU BELLO UNIVERSITY, ZARIA
NIGERIA

AUGUST, 2015
 DECLARATION

I declare that the work in this Dissertation entitled AN ASSESSMENT OF USER

SATISFACTION WITH PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS IN

SELECTED UNIVERSITY TEACHING HOSPITALS has been carried out by me

in the Department of Quantity Surveying, Faculty of Environmental Design, Ahmadu

Bello University, Zaria.

The information derived from the literature has been duly acknowledged in the text and a

list of references provided. No part of this dissertation was previously presented for

another degree or diploma at this or any other institution.

Funmilola Helen OYEDELE ____________________ _______________

Signature Date

iii
 CERTIFICATION

This dissertation entitled “AN ASSESSMENT OF USER SATISFACTION WITH

PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS IN SELECTED UNIVERSITY

TEACHING HOSPITALS” by Funmilola Helen OYEDELE meets the regulations

governing the award of the degree of Master of Science (Quantity Surveying) of the

Ahmadu Bello University, and is approved for its contribution to knowledge and literary

presentation.

Prof. A.D. IBRAHIM _______________ ________________

(Chairman, Supervisory Committee) Signature Date

Dr. K. J. ADOGBO _______________ ________________

Member, Supervisory Committee Signature Date

Dr. Y.M. IBRAHIM _______________ _______________

Head of Department Signature Date

Prof. A.Z. HASSAN ________________ _______________

Dean, School of Postgraduate Studies Signature Date

iv
 DEDICATION

This dissertation is dedicated to My Husband, Mr. Babajide Omoniwa; My Son,

Oluwaseyi Omoniwa; My Parents Prof. and Mrs. E. Oyedele; My in-laws, Dr. and Mrs

M. Omoniwa; and My Siblings.

v
 ACKNOWLEDGEMENTS

I am eternally grateful to God for granting me the opportunity to embark on and

complete this Master‟s degree programme. To Him be all the glory.

I wish to sincerely appreciate my Supervisors, Prof. A. D. Ibrahim and Dr. K. J. Adogbo,

for the guidance and assistance they provided me in the course of my research work. For

the relevant documents, guidance, constructive criticisms, encouragement and

suggestions all along the way despite their very tight schedules.

My sincere gratitude goes to Mr B. Kolo, Mrs F. Bello, Mr M. Abdulrazaq, Mr P. Chindo

and a host of other lecturers for their invaluable contribution to my research work and

other assistance to my academic pursuit. Am also grateful to my lecturers; Prof. Yakubu,

Mal. A. Ali, Mrs. K. Mohammed, Dr. Y. Musa-Haddary and all members of staff of the

Department of Quantity Surveying for their contribution to my entire academic pursuit.

I am utterly grateful especially to my Husband for his immeasurable support to me

throughout this work. Am also grateful to my Son, my Parents, Parents-in-law, Siblings

and Brothers and Sisters-in-law for their patience, understanding, assistance, prayers,

overwhelming love and care, I appreciate it all.

Finally, I like to express my sincere appreciation to my friends, colleageues and course

mates, Lynda, Nunaya, Yusuf Baba, Yusuf Datti, Abdullahi, Blessing, Hassana, Sunday,

Mrs Olaniyi, Mr Ikoja, Hassan, Jide, Micheal, Markus, to mention a few. You have made

the journey worthwhile. I also appreciate the entire family of Jesus Capital RCCG,

Ibadan for their encouragement, phone calls and support throughout the research work.

May the Lord bless and abundantly reward you all. Amen.

vi
 ABSTRACT

Government at all levels are forced to prioritise and restrict public expenditures due to
budget deficits and the inefficient management of large infrastructure projects. Due to
the shortage of resources for healthcare delivery leading to decline in the quality of care,
there is considerable interest in PPP initiatives for the provision of finance and
management of health care to ordinary people. The PPP option due to its complexities
has led to some projects failure leading to wastage of huge resources and time. Studies
have shown that majority of these project failures are as a result of public opposition
leading to outright cancellation of the projects. Due to the lack of empirical studies on
user satisfaction with PPP projects in Nigeria, this study assessed the satisfaction of users
of PPP projects from both employees and patients' perspectives of two university
teaching hospitals in Nigeria. A total of 580 questionnaires were distributed to
Employees and Patients of University College Hospital, Ibadan (Oyo state) and Lagos
University Teaching Hospital, Lagos (Lagos state). The data received from these
respondents were analysed using both descriptive and inferential statistics with the aid of
SPSS to determine their levels of satisfaction with the facilities and services provided. It
was observed that the patients were more satisfied with the projects than the employees.
The patients rated the staff members the highest implying that they were quite confident
in the healthcare providers‟ reliability and expertise. The employees were most satisfied
with the reliability of the facilities in maintaining confidentiality. The study also
observed that there is a positive significant relationship between quality parameters and
overall satisfaction. The study therefore concluded that necessary improvement
adjustments need to be done in all areas of quality performance especially the facilities to
increase the satisfaction of the users of these projects.

vii
 TABLE OF CONTENTS

TITLE PAGE.. .. .. .. .. .. .. .. .. ii

DECLARATION.. .. .. .. .. .. .. .. .. iii

CERTIFICATION.. .. .. .. .. .. .. .. .. iv

DEDICATION.. .. .. .. .. .. .. .. .. v

ACKNOWLEDGEMENT.. .. .. .. .. .. .. .. vi

ABSTRACT.. .. .. .. .. .. .. .. .. vii

TABLE OF CONTENT.. .. .. .. .. .. .. .. viii

LIST OF TABLES.. .. .. .. .. .. .. .. .. xii

LIST OF FIGURES.. .. .. .. .. .. .. .. xiii

LIST OF APPENDICES.. .. .. .. .. .. .. .. xiv

1.0 CHAPTER ONE: INTRODUCTION.. .. .. .. .. 1

1.1. BACKGROUND TO THE STUDY.. .. .. .. .. 1

1.2. STATEMENT OF THE PROBLEM.. .. .. .. .. 5

1.3. N

EED FOR THE STUDY.. .. .. .. .. .. .. 6

1.4. AIM AND OBJECTIVES.. .. .. .. .. .. .. 8

1.4.1 Aim.. .. .. .. .. .. .. .. .. 8

1.4.2 Objective.. .. .. .. .. .. .. .. 8

1.5 SCOPE AND LIMITATION.. .. .. .. .. .. .. 9

1.5.1 Scope.. .. .. .. .. .. .. .. .. 9

1.5.2 Delimitation.. .. .. .. .. .. .. .. 9

1.5.3 Limitation.. .. .. .. .. .. .. .. 9
viii
2.0 CHAPTER TWO: LITERATURE REVIEW.. .. .. .. 10

2.1 OVERVIEW OF PPP.. .. .. .. .. .. .. .. 10

2.1.1 Advantages of PPPs.. .. .. .. .. .. .. 11

2.1.2 Considerations for entering into a PPP option.. .. .. .. 12

2.1.3 Critical success factors as efficiency measures.. .. .. 13

2.1.4 Types of PPPs.. .. .. .. .. .. .. .. 16

2.1.5 Risks in PPP.. .. .. .. .. .. .. .. 17

2.1.6 Problems Faced in PPP Project Execution.. .. .. .. 21

2.1.7 Application of PPP in Nigeria.. .. .. .. .. 22

2.2 PAST EMPIRICAL RESEARCH ON PPPs.. .. .. .. .. 22

2.2.1 An Integrated Framework.. .. .. .. .. .. 25

2.3 QUALITY IN PPPs.. .. .. .. .. .. .. .. 26

2.3.1 The Product Dimension.. .. .. .. .. .. 26

2.3.2 The Services dimension.. .. .. .. .. .. 27

2.4 QUALITY PERFORMANCE IN RELATION TO CUSTOMER

SATISFACTION.. .. .. .. .. .. .. .. .. 29

2.5 QUALITY PERFORMANCE IN PPP HEALTHCARE DELIVERY.. 33

2.6 CUSTOMER/USER SATISFACTION.. .. .. .. .. 35

2.6.1 Effect of socio-demographic characteristics.. .. .. .. 35

2.7 USER SATISFACTION IN PPP PROJECTS.. .. .. .. 38

2.7.1 User Involvement.. .. .. .. .. .. .. 39

ix
2.8 PPP IN HEALTHCARE DELIVERY IN NIGERIA.. .. .. .. 42

2.9 SUMMARY OF PPP PROJECTS FOR THE STUDY.. .. .. 45

3.0 CHAPTER THREE: RESEARCH METHODOLOGY.. .. .. 47

3.1 RESEARCH APPROACH.. .. .. .. .. .. .. 47

3.2 THE STUDY POPULATION.. .. .. .. .. .. .. 48

3.2.1 University Teaching Hospital (UCH), Ibadan (Project 1).. .. 48

3.2.2 Lagos University Teaching Hospital (LUTH), Lagos (Project 2).. 49

3.3 SAMPLING.. .. .. .. .. .. .. .. .. 50

3.4 INSTRUMENT FOR DATA COLLECTION.. .. .. .. 52

3.4.1 Questionnaire Design.. .. .. .. .. .. .. 52

3.5 DATA COLLECTION PROCEDURE.. .. .. .. .. 54

3.6 METHOD OF DATA ANALYSIS.. .. .. .. .. .. 55

4.0 CHAPTER FOUR: DATA ANALYSIS AND DISCUSSION OF RESULTS..

.. .. .. .. .. .. .. .. .. .. 56

4.1 DATA ANALYSIS.. .. .. .. .. .. .. .. 56

4.1.1 Socio-demographic Characteristics of Patients.. .. .. .. 56

4.1.2 Socio-demographic Characteristics of Employees.. .. .. 58

4.2 ASSESSMENT OF THE LEVEL OF USERS SATISFACTION WITH PPP

PROJECTS.. .. .. .. .. .. .. .. .. .. 60

4.2.1 Patients level of satisfaction with the PPP projects.. .. .. 60

4.2.2 Employees level of satisfaction with the PPP projects.. .. 62

x
4.3 EVALUATION OF THE RELATIONSHIP BETWEEN QUALITY

DIMENSIONS AND SATISFACTION.. .. .. .. .. .. 64

4.4 DISCUSSION OF RESULTS.. .. .. .. .. .. .. 67

5.0 CHAPTER FIVE: CONCLUSION AND RECOMMENDATION.. .. 71

5.1 SUMMARY OF FINDINGS.. .. .. .. .. .. .. 71

5.2 CONCLUSION.. .. .. .. .. .. .. .. 71

5.3 RECOMMENDATION.. .. .. .. .. .. .. 72

5.3.1 Recommendation for further studies.. .. .. .. .. 73

REFERENCES.. .. .. .. .. .. .. .. .. 74

APPENDICES.. .. .. .. .. .. .. .. .. 87

xi
 LIST OF TABLES

Table 3.1 Sampling Frame of Employees in the Hospitals.. .. .. 51

Table 3.2 Summary of Sample Distribution According to the Hospitals.. 52

Table 4.1 Frequency Distribution for the Socio-Demographic characteristics of

Patients.. .. .. .. .. .. .. .. .. .. 58

Table 4.2: Frequency Distribution for the Socio-Demographic characteristics of

Employees.. .. .. .. .. .. .. .. .. .. 60

Table 4.3 Patients Level of Satisfaction with PPP Facilities and Services.. 62

Table 4.4 Employees Level of Satisfaction with PPP Facilities and Services.. 64

Table 4.5: The Impact of Quality Dimensions on Satisfaction of Patients.. 65

Table 4.6: The Impact of Quality Dimensions on Satisfaction of Employees.. 66

xii
 LIST OF FIGURES

Figure 2.1: The Path Model of Patients‟ Perception of Healthcare Quality, Patients‟

Satisfaction and Patients‟ Trust.. .. .. .. .. .. .. 32

xiii
 LIST OF APPENDICES

APPENDIX I QUESTIONNAIRE (PATIENTS).. .. .. .. 87

QUESTIONNAIRE (EMPLOYEES).. .. .. 89

xiv
 CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Endemic budget deficits and the inefficient management of large infrastructure projects

and services within the public sector are a few reasons why the traditional procurement

method of governments funding infrastructure projects through fiscal budgets is

increasingly considered unviable (Alitheia, 2010).

In the past few decades, developed economies (e.g. the United Kingdom) have modelled

a variety of public private partnerships (PPPs) for the delivery of infrastructure, public

utilities and large services projects, achieving significant successes from harnessing the

competences and expertise from both sectors. Emerging markets such as India and South

Africa are also recording successes using tried and tested PPP templates to create,

expand and modernise infrastructure (Workshop Report, 2008). It is apparent that these

dynamic partnerships between the public and private sectors have become inevitable

across the globe.

Nigeria's infrastructure challenge is huge. Reports suggest that the country requires

between US$12 billion to $15 billion annually for the next six years to meet the

infrastructure requirements (Izuwah, 2010). The World Bank estimates that every 1% of

(government) funds invested in infrastructure leads to an equivalent 1% increase in gross

domestic product (GDP). Nigeria has not had a consistent history of investment in

infrastructure; however, government agenda show that infrastructure development is

gaining momentum. In the past 10 years, over 25 major infrastructure projects have been

rolled out through PPPs. The Federal Government of Nigeria, state and local government

1
areas (LGAs) have contributed over N10 trillion ($66 billion) to these. However, the total

investment required to meet the vision 2020 target for infrastructure projects is N32

trillion ($210 billion) (Izuwah, 2010).It has become evident that the government alone

cannot muster the resources (finance and expertise) to meet this need and the

involvement of the private sector is not just desirous, but necessary.

Governments at all levels are forced to prioritize and restrict public expenditures to

health. Leading to some government (owned and operated) hospitals in dire financial

state and having shortage of resources for health care delivery. These include meeting

patients' expectations in terms of demand for modern medical facilities; the need to

provide care for an aging population; improve quality of care; and also invest in

expensive medical technology. Therefore, there has been considerable interest in Public-

Private Partnership (PPP) initiatives in the health sector in light of the challenges the

public sector is facing in financing, managing and providing health care to ordinary

people (Alitheia, 2010; Asoka, 2014; Anyaehie, Nwakoby, Chikwendu, Dim, Uguru,

Oluka and Ogugua, 2014).

The concept of Public Private Partnership (PPP) is underpinned by a government's desire

to resolve financial constraints by joining forces with the private sector to increase

efficiency and effectiveness in the delivery of public services and facilities, whilst

ensuring better risk management and increasing certainty of outcomes. PPPs are also

often aimed at accelerating economic growth, development and infrastructure delivery;

and achieving quality service delivery and good governance (Akintoye, 2006), especially

in developing countries.

The structure of PPPs are built around two main types - in one case, the cost of providing

the facility/service is borne exclusively by the users of the service and in the other, the
2
private company invests alongside government to provide a service and the cost of

providing the service is wholly or partly carried by the government (Alitheia, 2010).

Overwhelming evidence in the past 50 years of the use of PPP structures indicate that

these arrangements are relatively cost efficient, foster best practices for sharing and

transfer of risk, assure superior value for money, saves time, streamline contracts and

simplifies procurements, facilitates innovation through public-private cohesion,

eradicates bureaucratic and political processes, encourages technology transfer and acts

as vehicles which adopt life cycle approaches to delivering infrastructure and services

(Alitheia, 2010).

PPP is rapidly becoming the preferred method for public procurement for delivering

infrastructure projects throughout the world, thus gaining importance as a vehicle to

finance much-needed public infrastructure across the globe (Gunnigan and Rajput, 2010),

despite the conspicuous absence of systematic evaluations of quality improvement and/or

customer satisfaction in the PPP context (Jamali, 2007), thereby leading to a number of

unsuccessful projects reported as a result of users dissatisfaction (Levy, 1996; El-Gohary,

Osman and El-Diraby, 2006; Gunnigan and Rajput, 2010).

The fierce competition in the wake of globalization is pushing companies to improve

continuously in order to stay in the business. It is a very challenging task to meet the

ever-increasing and diversified customer (user) requirements. To tackle this challenge

effectively and efficiently, the alignment of the business processes with the customer

requirements is vital (Jochem, Menrath and Landgraf, 2010).

El-Gohary et al. (2006) stated that stakeholders are individuals or organisations that are

either affected by or affect the development of the project. Therefore, capturing their

3
input is a crucial component of the project development process. It is important to gauge

stakeholder opinion and concerns to better facilitate the development of a project that

will meet the needs of those stakeholders.

Tangkitsiri, Ogunlana, Oyegoke and Oladokun (2013) opined that customer satisfaction

begins when the customers' service expectations are met i.e. when the level of service

provided by the service provider meets the expectations of the users. The importance of

customer satisfaction in a PPP project is based on the assumption that the private sector

can be more efficient in service delivery than the public sector. And also, if citizens are

now being expected to pay for services they have been delivered free-of-charge in the

past; they should have the right to expect better quality services.

In order to measure levels of stakeholders' satisfaction, it is necessary to study the real

benefits from existing projects (Tangkitsiri et al., 2013) that is, project monitoring. They

further described Project monitoring as a tracking process, comparing actual outcome to

predicted outcome, analysing impact, and making appropriate adjustments.

Positive attitudes towards bringing users' ideas into the product development process of

design, delivery and after-care can change the whole situation. Innovative approaches

such as this can lead to new and more user-friendly forms of products and services which

reflect user requirements. Specific requirements of end-users have to be captured in order

to achieve a maximum level of customer satisfaction, which ultimately will contribute to

the success of the business. Therefore, we need to know who the users are, what their

requirements are and how they can be involved in the product development and design

process. Various users need to be part of not only the image and vision of the project, but

also the physical design, which should reflect the way they work. The new culture,

4
images and visions need to be fully shared among all the stakeholders during the

consultation, rather than only after the implementation (Ozaki and Yoshida, 2007).

El-Gohary et al. (2006) opined that PPP infrastructure projects vary in the level of

contention that they raise among stakeholders. Moreover, the involvement of the private

sector - with its profit-making mindset - usually raises concerns that are not usually

likely when the asset is publicly owned (e.g. quality assurance, safety, rate hikes, transfer

agreement, etc.).

There are many studies that have been carried out in various aspects of PPP projects both

nationally and internationally. Some of these studies have shown that the dissatisfaction

of users of some PPP projects have led to the cancellation of some projects which has led

to loss of time and resources (Levy, 1996; El-Gohary et al., 2006; Gunnigan and Rajput,

2010).

1.2 STATEMENT OF THE PROBLEM

Alienation of actual users of the asset and lack of public support have increased project

costs, delayed project completion, and ultimately jeopardized the sustainability of public

services. Lack of communication and poor stakeholder management could become deal-

breakers: a predominant reason for this is lack of effective communication with the

principal stakeholders of the project (Levy, 1996; El-Gohary et al., 2006; Asian

Development Bank, 2007; Gunnigan and Rajput, 2010). Users are critical to the

sustainability of PPP projects they need to communicate their ability and willingness to

pay for the service, express priorities for quality and level of service and also identify

existing strengths and weaknesses in services provided (Inter-American Development

Bank, 2014).

5
Alrubaiee and Alkaa‟ida (2011) recommended that analysis of service quality should

enable management to better direct resources to improve hospital operations that will

impact on customer perceptions of service quality. They also recommended that the

perception of employees on the Hospital and the services need to be evaluated. They

speculated that the perceptions of patients might not match the perceptions of employees.

They also said that hospitals need to have a commonly held quality model to guide

employees in their continuous quality improvement efforts.

However, few studies exist that measures the success of existing PPP projects in Nigeria

from the users‟ perspective. Amissah (2013) reported that studies in the area of customer

satisfaction and quality have been carried out mostly in developed countries (King and

Cichy, 2006; Faullant and Matzler, 2008; Markovi´c and Raspor, 2010; Alrubaiee and

Alkaa‟ida, 2011) leaving developing countries such as Ghana and Nigeria with limited

empirical studies. Therefore, a key approach to success is to understand the different

aspects of service quality and satisfaction and the interactions of these aspects. This

study seeks to fill the gap in service quality and user satisfaction knowledge in Nigeria

and provide useful information for hospital managers as well as private partners to

improve on the PPP projects.

1.3 NEED FOR THE STUDY

In the absence of this study, it is difficult for government agencies and private partners to

adequately analyse the success of PPP projects. The dearth of comprehensive studies in

the area of users satisfaction with successful PPP projects in Nigeria has affected the

development of successful PPP projects due to its capital and risk intensive nature.

6
PPP hospital projects by their very nature should deliver quality services to their

customers. Thereby making patient satisfaction one of the most important indicators

because satisfying patients can save hospitals money by reducing the amount of time

spent resolving patient complaints (Alrubaiee and Alkaa‟ida, 2011) and also avoid

cancellation of the project(s) due to their opposition.

To deliver quality services it is important, to first, understand what constitutes this

concept. Hence, the study presents a detailed description of factors and measures of

quality in PPP healthcare context. The quality of healthcare services is related to patient

satisfaction which is an important measure of performance.

Furthermore, the growing population of Nigeria is expected to place greater demands on

the country‟s health care services. Unless healthcare quality is improved through PPP

option, the consequences are worrying which can include: preventing patients from quick

recovery while increasing their costs, poor quality also prevents the use of local

healthcare providers and the patients search for alternatives mainly in other countries that

assure better quality of care which renders the aim of a PPP option futile.

"In the face of the constraints faced by the public sector, there is now a huge opportunity

for engaging the private sector in a more constructive manner" (Owumi, Adeoti and

Taiwo, 2013) in which these university teaching hospitals are currently tapping into.

However, due to all the complexities involved in the PPP procurement process it will be

cost efficient if the areas of contention or dissatisfaction are known and handled before

the agreements are signed. Therefore, from this study, the users will be able to express

their opinions concerning their perceptions of the facilities they are working with in other

to carry out their services more efficiently, which could then be used as

recommendations for policy decisions.

7
Also, feedback and consultations with the stakeholders will ensure support, client focus,

and improved coordination of the project. Therefore, management of these hospitals and

their private partners through this study will have a better understanding of the

satisfaction level of the users of these facilities and services provided and then know how

to make necessary improvement adjustments consequently.

Lastly, with the rate of accelerated growth in private involvement in healthcare, it is

necessary that adequate structures are put in place for other teaching hospitals to benefit

in this win-win strategy. Hence, the findings of the study can be used in other teaching

hospitals and the government as a whole to incorporate PPP sections in their healthcare

schemes, to enable them start well and get it right the first time. The study highlights

factors that they can incorporate to enable them provide sustainable structures and ensure

stakeholders involvement throughout the projects lifecycle in their policy decision

making process.

1.4 AIM AND OBJECTIVES

1.4.1 Aim

The aim of this study is to assess user satisfaction with PPP projects in selected

University Teaching Hospitals (UTHs).

1.4.2 Objectives

To achieve the aim, the objectives of the study are to:

1. Identify parameters for assessing satisfaction of PPP facilities and

services;

2. Assess the level of users' satisfaction with PPP facilities and services in

selected UTHs;
8
 3. Evaluate the relationship between quality dimensions and satisfaction.

1.5 SCOPE AND LIMITATION

1.5.1 Scope

The study covered the perception of users' of PPP projects in two government Hospitals

situated in Ibadan (Oyo state) and Lagos (Lagos state) using product- and service-quality

dimensions for the assessment of the facilities and services rendered. The quality

dimensions were used to determine the level of satisfaction of the users of this section of

the hospital due to the fact that previous studies carried out in this domain have been

conducted successfully.

1.5.2 Delimitation

The study is delimited to University Teaching Hospitals in South-western Nigeria due to

the fact that this particular PPP arrangement in healthcare delivery is currently

predominant in that region.

1.5.3 Limitation

The study encountered limitations in the responses that were collected. The measurement

of customers' expectations is a difficult task and the fact that a customer's short-term and

long-term evaluations may differ (Reeves and Bednar, 1994; Karna, 2004). Another

limitation of this study is that customers may not know or care about how well the

products and/or services conform to internal specifications; customers want their needs

and expectations met or even exceeded. So they might have given arbitrary and biased

rating which might have affected the results obtained. Consequently, the study asked

them few concise questions and asked employees for their professional opinion.

9
 CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 OVERVIEW OF PPP

The National Council of Public-Private Partnerships of Washington DC (NCPPP, 2008)

defined PPP as "a contractual agreement between the public agency (federal, state, or

local) and a private sector entity. Through this agreement, the skills and assets of each

sector (public and private) are shared in delivering a service or facility for the use of the

public. In addition, to the sharing of resources, each part shares in the risks and rewards

potential in the delivery of the service and/or facility". Firstly, they stated that it is a

contractual agreement. Then they pointed out the tools that the sectors have and use (i.e.

skills and assets) in order to achieve the goal(s) and they stated that risks and rewards

arising from the delivery of this service and/ or facility is shared between the two parties.

The user of the projects as defined by NCPPP (2008) are not actively involved in the

process. Jefferies and McGeorge (2008) defined a PPP consortium as „a temporary

organization with complex network of stakeholders each with competing goals and

objectives'. This definition is more technical and it accommodates all the participants

including the users. Therefore, PPP is not restricted to only the public and private

partners as defined by Jefferies and McGeorge (2008) .

In general, PPPs are a sort of collaboration to pursue common goals, while leveraging

joint resources and capitalizing on the respective competences and strengths of the public

and private partners (Widdus, 2001; Pongsiri, 2002; Nijkamp et al., 2002; Jamali, 2004

and 2007).

The concept of PPP aims to build mutually agreed and concrete relationships and

strategies to obtain collective benefits for all the stake holders (Famakin, Kuma-Agbenyo,
10
Akinola & Onatunji, 2014). According to Zakari (2001), partnerships could be conceived

as a mutual relationship, alliance, cooperation, collaboration or agreements between two

or more interested parties, individuals, groups or organizations etc. each with its

predetermined areas of interest, competence, expertise, and specialization which is aimed

at integrating the parties to achieve common goals and aspirations.

The separation of policy and regulation (which would remain the government's

responsibilities) from the provision of services (which would become the responsibility

of the private operator) would provide accountability through an arm's-length

relationship that was largely missing under public provision (traditional procurement).

The gains from reforming poorly performing utilities were expected to be large enough

to allow private operators to directly finance the investments that were needed to

improve service quality and expand access for the poor (Famakin et al., 2014).

2.1.1 Advantages of PPPs

Norment (2004) stated that the PPP option has the following advantages:

i. Maximizes the use of each sector‟s strength;

ii. Reduces development risk;

iii. Reduces public capital investment;

iv. Mobilizes excess or underutilized assets;

v. Improves efficiencies/quicker completion;

vi. Better environmental compliance;

11
vii. Improves service to the community;

viii. Improves cost effectiveness;

ix. Shares resources;

x. Shares/allocates risks; and

xi. Mutual rewards.

2.1.2 Considerations for entering into a PPP option

PriceWaterhouseCoopers (PWC) (2005), warned that any public sector authority

considering PPPs must understand that there may be situations when they should

exercise caution. Once the public sector authority has chosen to use a PPP, there may be

significant difficulties to overcome. While there will be some cases where the difficulties

and costs will overshadow the perceived benefits of PPPs, there will be other instances

when the benefits will outweigh the difficulties indicating that they are not all the same.

According to PWC (2005), there are issues to be considered by the public sector before

pursuing a PPP approach, they are as follows:

Does sufficient private sector expertise exist to warrant the PPP approach?

For PPPs to be attractive, the private sector must have the necessary expertise.

Private sector players must be:

I. Able to provide a more efficient and effective service. For example, if there is an

incumbent public sector operator, the private sector should have proven

additional management skills to realise service improvements and efficiency

gains.

II. Sufficiently numerous, with enough potential private sector bidders to allow for

12
 an effective competition.

III. Experienced in pricing life cycle costs in the particular field.

IV. Experienced enough to allow them to manage and absorb the particular risks of

the project, country or sector in which the PPP is proposed, thereby reducing the

likelihood that large risk factors are included in their prices.

It is important that any public sector authority understands that PPP procurement is only

one of several options for procuring infrastructure. Consideration must be given as to

whether a project is suited to a PPP structure, and whether there is strong political

support for a PPP solution. The principal reason for using PPPs is that, where the project

is suitable, they can deliver better value for money than the alternatives. All arguments

for and against PPPs must be considered within the context of that overriding objective

(PWC, 2005).

2.1.3 Critical success factors as efficiency measures

The concept of critical success factors (CSF) was developed by Rockart and the Sloan

School of Management with the phrase first used in the context of information systems

and project management. Rowlinson (1999) stated that, critical success factors are those

fundamental issues inherent in any project, which must be maintained in order for team

working to take place in an efficient and effective manner.

More specifically, the efficiency measures correspond to the strong management and

internal organizational structures (adherence to schedule and budget, and basic

performance expectation) which means getting the project out on time, on budget and

13
meeting a quality threshold. On the other hand, the effectiveness measures refer to the

achievement of objectives, users' satisfaction and the use of the project.

The above perceptions are also in line with the opinion of Concerdo (1990) who

proposed a model of performance measurements in terms of outputs and resources to be

measured at different levels. Outputs are measured to determine whether they help to

accomplish objectives (effectiveness) and resources are measured to determine whether a

minimum amount of resources are used in the production of outputs (efficiency). Given

the above, when considering exactly what defines a successful project, it is essential to

emphasize both the aspects of project outputs (efficiency) and outcomes (effectiveness).

However, cost, time, quality standard, safety, maintenance and promotion of harmonious

relationships among project stakeholders and participants' satisfaction have been widely

accepted as the main indices for measuring the overall success of different projects

(Zhang, 2004; Abdel Aziz, 2007; Cheung, 2009). Although, Norment (2004) outlined

seven Keys to Successful PPPs as:

i. Public Sector Champion: Political leadership must be in place which should

include elements such as top administrative officials, leading political figure, a

strong policy statement, and they serve as the spokesperson to promote the PPP.

ii. Statutory Environment: There should be a means of identifying creative and

innovative approaches, a basis for authority for a PPP contract, and also

transparency and open competitive process.

iii. Organized Structure: Dedicated group (tied to the purpose of the partnership),

dedicated and trained personnel to monitor implementation, Conducts Request

For Interest (RFI), Request For Qualification (RFQ) and/or Request For Proposal
14
 (RFP) processes that is, performance, not design specifications, Best Value vs.

Lowest Price that is, may include Value for Money analysis which may be

difficult to administer but worthwhile, need for good governance which should

include assurance of open and fair procurement process, consolidate staff which

will make them easier to monitor and also, independent authority

(domestic/internal or international).

iv. Detailed Business Plan: Performance goal oriented- allowing for innovative

plans, Best Value vs. Lowest Price, the Plan/Contract should include: Specific

milestones and goals, reporting of metrics and frequency, also, risk allocation

which if shifted to the private sector can raise costs, identifying best prices to

retain and which to shift, Dispute Resolution Methodology and also, workforce

development which develops in-country resources and/small businesses.

v. Clearly Defined Revenue Stream: Funds to Cover the Long-Term Financing

which could be through tolls/fees (real or shadow), intelligent transportation

systems which could include a form of tax district, Long-Term maintenance

contracts, availability of payments, underutilized assets, concession model

(limited application) and other creative approaches.

vi. Stakeholder Support: They include End Users, Private Sector, Labor Unions,

those with competing interests and Public Sector Employees. It requires open and

frank discussion between sectors, knowing the FACTS (not myths) and

translating each other‟s language.

vii. Pick Your Partner Carefully: As this is a long-term relationship, the technical

capability and experience of the partner(s) need to be verified; also their financial

15
 capability should be checked. Each member‟s motivation should be put in mind

such as genuine need (market value to the project), political / statutory

environment, the reasonable return on investment and manageable risks and

timely and effective execution vs. development costs.

Norment (2004) also stated that the critical component is strong leadership which makes

all the other factors come together.

In Nigeria, the main critical success factors for selecting the appropriate private partner

are: favourable legal framework, well-organized public agency to negotiate on behalf of

government and strong private consortium (Ibrahim, Price and Dainty, 2006a).

2.1.4 Types of PPPs

There are many different kinds of PPP and approaches to PPP. Robles et al. (2009)

reported that these different types and approaches are permanently evolving in order to

meet the conditions of the projects and specific requirements of the stakeholders, such as

size, complexity, funding sources, and finance needs. Variables may include:

i. the degree of involvement of the public authority in the funding and financing

of the scheme (such as direct contributions, subventions, shadow tolls, state

guarantee, direct tolls, or other forms of direct user fees);

ii. the length and nature of the contract between the public authority and the

private PPP contractor (public contract or a concession contract);

iii. risk sharing between the private and public parties;

iv. the tasks included (design, build, finance, operate, maintain, property,

transfer);

v. the financial scheme;

16
 vi. a mix of green-field projects and takeover projects.

They stated that there might be problems encountered when breaking down PPP into

homogeneous types due to the fact that each specific scheme has a substantial number of

particular conditions that make it unique. This categorization is to help decision makers

to qualify a particular PPP scheme according to a number of key attributes. In this

respect, the variables that are considered more relevant are those referred to in the

definition stated earlier, i.e. the share between the public and the private parties in terms

of risk, funding, and finance.

However, Ibrahim, Ali and Musa – Haddary (2007) reported that the different types of

PPPs include; private finance initiative (PFI), joint venture, privatization and build-

operate- transfer (BOT). The BOT type has a number of variants; these variants reflect

the participation and varying risk arrangements amongst the stakeholders. The major

variants of BOT are Build Own Operate (BOO), Build Transfer Operate (BTO) and

Build Lease Transfer (BLT).

Other variants of PPP include: Build-Transfer (BT), Contract-Add-and-Operate (CAO),

Develop-Operate-Transfer (DOT), Rehabilitate-Operate-and-Transfer (ROT),

Rehabilitate-Own-and-Operate (ROO) (Public Private Partnership Volume One, 2012).

2.1.5 Risks in PPP

One of the primary objectives of PPP is to facilitate the delivery of high quality public

facili ties and services by the private sector over an extended period of time at a cost that

represents value for money, whilst at the same time transferring an appropriate level of

risk to the private sector (Lane and Gardiner, 2003. quoted by Ibrahim, Price and Dainty,

17
2006b). However, transfer of risk and achievement of value for money need to be

balanced appropriately through practical implementation of the basic principles of risk

allocation, which assigns risks to the party best able to mitigate and manage it (Ibrahim

et al., 2006).

2.1.5.1 Types of Risks in PPP

Generally, there are different types of risk classification obtained from literature. Xenidis

and Angelides (2005), classified risk into two types; according to the lifecycle phase that

is a risk occurs during the concession period and according to the source or origin of

each risk. Another type of risk classification by Elbing and Devapriya (2004) is global

(independent of the project) or project risk (Ibrahim et al., 2006b).

However, in Nigeria, the risks factors have been classified as either exogenous (risks

which are external to the particular project under consideration) or endogenous (risk

event and consequences of which occur within the system boundaries of the projects

being considered, and includes risks occurring in the relationships between the

stakeholders due to the inherent differences between the working practices and strategies

of the private and public sectors). This type of classification is to further facilitate a

strategic approach to comprehensive management of risks on PPP projects (Ibrahim et al.,

2006b).

Akerele and Gidado (2003) outlined the common risks in PPP schemes as follows:

I. Availability Risk: This is the risk that the services provided by the private sector

party may fall below the standard required by the public sector client. The risk is

borne by the private sector company and contract conditions will penalise the

private sector provider should a problem occur.

18
 II. Completion Risk: This also includes construction and design risk and generally

results in time and/ or cost overruns that will require a substantial increase in

capital and/or interest expenses during construction. It may be attributable to

weather, labour strikes or late delivery of equipment and supplies.

III. Construction Risk: The PPP will seek to place the construction risk with the

bidder. There may be some limitations of risk due to events outside the control of

the parties; however, any limitations are likely to be few. Any defects within the

construction will need to be rectified by the bidder, an important point for those

putting together a team to bid on a project. The contractor within the team will

not want defects in the building to impact on the relationship with others in the

consortium. Funding banks may require contract monitoring on their behalf to

minimise likely problems during the operational phase. Defects will impact

negatively on investment value and on the ability of various parties to dispose of

their interest in the project.

IV. Technical Risk: : There is a range of technical risks to be factored into bid

calculation. While the PPP seeks to encourage innovation, in a technical context

there is a bias against the use of new products or procedures if these have not

been thoroughly tested. The risk areas are not unrelated to each other and

construction and technical specification must work together. A bidder may build

to a higher initial standard in the hope of reducing maintenance costs.

V. Revenue Risk: This risk is associated with all the areas in the contract that relate

to payment. Payment may be reduced because public sector demand for the

services decreases; this is a volume risk. There is also an availability risk, given

19
 the need to make a specified type and amount of accommodation available to

certain standard for occupation and use.

VI. Tax Risk: this risks are divided into two groups. The first group comprises tax

changes that occur while a project is being developed. Tax risks that occur after

project construction or during operation comprise the second grouping. These tax

risks are sub-categorised into three areas. The first is the introduction of a new

tax or, less likely, the removal of an existing tax. The second relates to changes in

tax rate for a particular tax, e.g. the VAT rate on fuel payments being increased.

The third area is an action that leads to a tax being paid.

VII. Political Risk: There is always a political risk with a contract that is to last in the

region of 30 years such as PPPs. The risk can be minimised, but not eliminated.

PFI/PPP projects are being explored in other countries where the political risk

may well be different.

VIII. Contract Risk: Unfortunately parties do default on contracts, sometimes

deliberately, sometimes through little or no fault of their own. The contract

structure will attempt to cover all circumstances and to provide a means by which

the agreement operates. There is a risk that these provisions may be called upon.

There is a further risk that a different legal interpretation may be put on the

contract clause than that which the parties envisaged.

IX. Currency Risk: this is, to a large extent, a part of the construction and operating

risk of the project. Currency risk occurs when the revenue or turnover and

expenses (operating or interest) of a project are in different denominations.

Foreign investors will generally use their primary operating currency in

20
 determining the Internal Rate of Return (IRR) or Net Present Value (NPV) of a

project.

X. Technology Risk: This risk refers to the possibility of changes in the technology

resulting in the services being provided with sub-optimal technology. This risk is

difficult to control. However, when better technology decreases the cost of

providing the services, the private sector provider will almost certainly

implement such changes (Blackwell, 2000; DOFSA, 2000).

2.1.6 Problems Faced in PPP Project Execution

Ahadzi and Bowles, (2004) identified some of the problems faced in PPP execution as

follows;

i. The inability of parties to manage their risk which can be due to inexperience in risk

management.

ii. Lack of good financial market.

iii. The delays and associated cost overruns at the bidding stage are severe for both

public sector client and private sector bidder.

iv. A factor influencing the tendering process is external environment; the elements

include such things as the legal, political, social and technological factors, the

organizational strategies and structures and cultures and characteristics of the

project itself.

Public clients use private funds and draw in managerial skills and operational efficiencies

from the private sector in various types of PPP arrangements.

Several drivers thus help account for the recent proliferation of PPPs, including the

desire to improve the performance of the public sector while avoiding fully-fledged
21
privatization, reducing and stabilizing costs of providing services, and increasing service

quality levels (Miller, 2000; Savas, 2000). Two areas in particular are frequently referred

to when the benefits of PPPs are discussed, namely improvements in efficiency -usually

measured in direct financial terms or productivity and effectiveness -usually indicated by

quality (Ancarani and Capaldo, 2001; Dean and Kiu, 2002). But while various studies

have tackled the efficiency component, resulting in apparent consensus, effectiveness

outcomes in the PPP context remain open to debate (Domberger, 1998; Hodge, 1998;

cited in Jamali, 2007). Factors of quality and co-operation have a strong effect on overall

satisfaction. Therefore, these factors can be used as a basis for improving overall

satisfaction.

2.1.7 Application of Public Private Partnerships (PPP) in Nigeria

In Nigeria, the JV and BOT models are increasingly being implemented at the Federal,

State and Local government levels. These project delivery systems are the most

commonly used for the provision of public infrastructure in Nigeria. An example of

projects procured using BOT method is the operation and management of international

conference centre and eagle square (Ibrahim et al., 2007).

2.2 PAST EMPIRICAL RESEARCH ON PPPs

Past studies on health and social services PPPs often make use of qualitative methods to

include case studies and in-depth probing (European Commission, 2004; Vining,

Boardman and Poschmann, 2005; Smith and Wohlstetter, 2006). Many studies focus on

government and non-profit organizations at the local level (Gazley, 2008). Smith and
22
Wohlstetter (2006) developed a typology in order to provide a framework for the on-

going study of PPPs and networks in California charter schools. These researchers

grouped interview data across four categories:

I. Origin refers to the circumstances under which PPPs are created; and

II. Form is defined according to whether a formal agreement exists for the

partnership. Gazley (2008) found a large proportion of government-non-profit

collaboration in Georgia operating without a formal agreement;

III. Content pertains to the resources provided by each partner and can be financial,

human, informational or managerial; and

IV. Depth which concerns the level of shared governance and is determined through

identification of organizational members actively involved in the PPP. Just as

Sowa (2008) classified inter-agency collaboration into "shallow collaboration",

"medium collaboration", and "deep collaboration," similarly, PPPs can be

classified according to the typological criteria outlined above. In other words,

resource-sharing, information-sharing, power-sharing and even profit-sharing can

be important criteria for PPPs.

Radically different from the leadership in a closed-system, hierarchical structure, some

research suggests that PPP leadership requires shared governance, "consensus-oriented

decision making" (Ansell and Gash, 2008), "depersonalized leadership techniques" (Page,

2003), and "softguidance" (Agranoff 2007). PPPs, as in network settings, require

collaborative leadership. "It is conceivable that the collaborative leader must exhibit

behaviours that are substantively different from practices in a hierarchical setting." Such

differences relate to teamwork, resources, understanding, stakeholder support, and trust

(Silva, 2011).
23
The empirical literature also suggests that PPPs should emphasize accountability and

transparency. PPPs may cause what is called "diffusion of accountability" (Agranoff,

2007). Establishment of performance measures and implementation of performance

management in a partnership setting is challenging. As in a network setting, performance

evaluation criteria should be made at different levels and for each different partnership

program. PPPs present a different set of transparency issues from programs administered

by individual governmental and nongovernmental agencies. Information disclosure and

audits may not be required for less formal PPPs. On the other hand, parties to contractual

PPPs are increasingly expected to have contract management expertise.

In her survey of local governments in Georgia, Gazley (2008) noted that PPPs tended to

be concentrated in several service areas including social, health, and human services,

public safety, emergency response and economic development. Further, she found a trend

toward informal agreements which resulted in "more frequent exchange of information,

sharing of volunteers, joint recruitment of staff and volunteers, and non-profit service on

a public board." Formal contractual agreements for activities involved government

funding, information exchange and equipment which would certainly make sense in

terms of compliance with federal accountability regulations. Government agencies

overall provided the bulk of financial, material and human resources in almost all PPPs

studied; public managers maintained a fairly high level of control within all PPPs.

Gazley emphasizes that staff are much more likely to be shared in the context of informal,

non-contractual arrangements, a large number of which have been in place for many

years and are characterized by many respondents as "longstanding relationships." Indeed,

these seemingly institutionalized arrangements range from nine to twenty-four years and

are treated as "implied contracts." Gazley's detailed study indicates that factors such as

24
trust, a certain level of environmental stability, institutional capacity, shared governance

and quality of leadership all matter in a collaborative network setting.

2.2.1 An Integrated Framework

Based on the above literature review, it is clear that a more comprehensive framework of

PPPs should incorporate the intersectoral network and collaboration perspectives and the

findings from the empirical research. To synthesize these different perspectives,

apparently one assumption is needed. It is assumed that PPPs are those networks and

collaborations that involve both public and private sectors.

A comprehensive model of PPPs should examine the characteristics of PPPs,

organizational factors of PPPs, characteristics of individual PPP organizations, key

management issues and major complicating factors that bring additional complexity to

PPPs. It is clear that characteristics of PPPs include origins and motivations of creating

and sustaining PPPs, forms, content, depth, and durability/length of PPPs. Organizational

factors include the leadership, governance, and social capital in the PPPs. The

characteristics of individual participants in the PPPs, including goals of participating

organization's operations and organizational strategies, also matter. Complicating factors

for PPPs are types of services provided through PPPs, number of participants and

stakeholders, degree of differentiation and integration, and environmental variables.

Management issues such as accountability and transparency are constant challenges for

PPPs. Additional insights can be gained through borrowing from other fields, including

economics, sociology, and organization theory (Xu, Yeung, Chan, Chan, Wang and Ke,

2012).

25
2.3 QUALITY IN PPPs

Quality as defined by ISO 8402, is the degree of excellence in a competitive sense, such

as reliability, serviceability, maintainability and individual characteristics (Ibrahim and

Sodangi, 2007). Quality performance (QP) has been divided into two categories:

corporate-level and project-level, while the project-level QP is further divided into

product and service quality dimensions (Ibrahim and Sodangi, 2007). QP at corporate-

level, can be viewed as the quality culture comprising of organizational value system that

encourages quality-conscious work environment, establishing and promoting quality and

continuous improvement through values, traditions and procedures (Geotsch and Davis,

2000; Ibrahim and Sodangi, 2007).

According to Parasuraman, Zeithaml and Berry (1988), there is the SERVQUAL

instrument for measuring customer satisfaction. The SERVQUAL instrument was

originally categorised under 5 dimensions which are tangibility, reliability,

responsiveness, assurance and empathy further explanations for each category are given

below. QP at project-level includes the quality of the constructed facility (product) as

well as the quality of the services. Below are the product and services interpretations

from literature.

2.3.1 The Product Dimension

The product quality dimensions are enumerated below:

i. Performance - is the basic function of the facility to which it meets the end-user's

needs and intents;

26
 ii. Features - they are the characteristics that supplement the basic functions of the

facility;

iii. Reliability - it is the level of confidence with which the end-user may use the

facility, to the end of its design life, without failure;

iv. Conformance - it is the degree to which construction operations meet the design

standards and specifications;

v. Durability - the amount of use end-users get from the facility before replacement

is preferred to continued use;

vi. Serviceability - speed, courtesy, competence, with which maintenance on facility

can be carried out;

vii. Aesthetics - the level of satisfaction the end-user experiences with the facility's

look, feel, sound, taste or smell; and

viii. Perceived quality - the level of satisfaction the end-user experiences with the

facility's image and publicity (Gavin, 1988).

2.3.2 The Services dimension

They include:

i. Time - the duration of the contract, including the wait for mobilization on site;

ii. Timeliness - completion of the contract on the scheduled date;

iii. Completeness - the amount of items on the punchlist upon completion of the

project;

27
 iv. Courtesy - the degree of respect, politeness, friendliness and kindness of the site

and other personnel;

v. Consistency - the ability to repetitively provide the same level of service to all

clients;

vi. Accessibility and convenience - the ease with which the contracting service is

obtained;

vii. Accuracy - the ability to provide the right service the first time with minimum

amount of work;

viii. Responsiveness - the ability to react to the unexpected problems encountered

during the contract. Willingness and readiness to provide prompt service;

ix. Reliability - ability to perform the promised service dependably and accurately;

x. Communication - keeping customers informed in a language they can understand

and listening to the customer when necessary;

xi. Credibility - honesty, trustworthiness;

xii. Security - physical, financial and confidentiality;

xiii. Competence - possession of required skills and knowledge of all employees;

xiv. Tangibles - the physical facilities and equipment, and appearances of employees;

xv. Understanding - the ability to comprehend the client's needs and requirements;

xvi. Assurance - knowledge and courtesy of employees and their ability to inspire

trust and confidence;

28
xvii. Empathy - the degree of caring, individualized attention the firm provides its

customers; and

xviii. Recovery - the ability to regain momentum and improve after each project

completion (Parasuraman, Zeithaml and Berry, 1985; Parasuraman et al., 1988;

Gronroos, 1988; Evans and Lindsay, 2005; Ibrahim and Sodangi, 2007; Delgado

and Aspinwall, 2008).

Yasamis, Arditi and Mohammadi (2002) described quality in construction as quality of

both design and level of conformance to design. He further described performance as

requiring the following:

i. a combination of criteria (not a single measurement),

ii. a level of analysis (such as end-users, employees, etc.),

iii. a certain focus (kind of performance desired),

iv. a time frame (short or long range), and

v. a measurement system (quantitative versus qualitative, objective versus

subjective) (Szilagyi, 1988 cited by Yasamis et al., 2002).

2.4 QUALITY PERFORMANCE IN RELATION TO CUSTOMER/USER

SATISFACTION

Generally, quality can be viewed from two approaches: conformance to requirements and

customer satisfaction. In terms of conformance to requirements, quality refers to how

well the constructed facility conforms to design specifications. This is the contractors'

29
view of the definition of quality. On the other hand, the customer satisfaction approach

defines quality as the extent to which a product or service meets and/or exceeds a

customer's expectations. The strength of this approach is that it captures what is

important for the customers rather than establishes standards based on management

judgments that may or may not be accurate (Karna, 2004). Torbica and Stroh (2001)

however opined that, it is possible to have dissatisfied, or at least not satisfied, customers

even though explicit time, cost, and performance criteria have been met. From their study,

it was found that service is the most important component for overall satisfaction and is

also the area the providers performed the poorest. They are of the opinion that services

deserve the most attention and positively influence customer satisfaction.

Customer satisfaction thus approaches quality from a customer's point of view, that is,

the customer defines quality (Beatty, Richmond, Tepper and DeJong, 1998; Dansky and

Miles, 1997; Braunsberger and Gates, 2002). Customer satisfaction can be used for the

evaluation of quality and ultimately for assessment of the success of a company's quality

improvement programme (Karna, 2004). According to Torbica and Stroh (2001), a

quality improvement effort will lead to a higher product and service quality, which will

lead to improved customer satisfaction.

In order for clients and end-users of completed facilities to realize the best value, the

concept of quality culture must be stressed in the industry to improve the QP offered by

various organizations (Ibrahim and Sodangi, 2007). Yasamis et al. (2002) said there is

the assumption that the product quality dimensions are mostly associated with the end-

user, whereas the owner is the most direct recipient of all service quality processes. In

some cases the owner and the end-user are the same entity. When they are not, the

30
product and service quality dimensions reflect the perceptions of the party that most

directly experiences the product or the service associated with the construction process.

Performance objective states the performance levels that the stakeholders expect the PPP

project to achieve. It can assist the public sector to establish a clear relationship with the

private sector, facilitate the private sector to develop an innovative PPP method, and

make both adhere to the PPP project's budget, programme planning and performance

measures (Yuan, Skibniewski, Li and Zheng, 2009).

A model produced by Alrubaiee and Alkaa‟ida (2011) indicating the relationship between

quality dimensions, patients satisfaction and patients trust is a good example to buttress

the point that customer satisfaction is very much related to quality. The authors looked at

the mediating effect of patient satisfaction in the patients‟ perceptions of healthcare

quality – patient trust relationship. They verified that there is indeed a direct, positive

relationship between quality performance and patients satisfaction and patient trust.

Below is the model indicating the relationships.

31
 Healthcare Quality

Tangibility

Reliability Patients Trust

Responsiven
ess

Assurance

Empathy

Patients Satisfaction

Figure 2.1: The Path Model of Patients‟ Perception of Healthcare Quality, Patients‟

Satisfaction and Patients‟ Trust.

Source: Alrubaiee and Alkaa‟ida ( 2011).

The above model incorporates a factor not explicitly highlighted in this study which is

Patient Trust. The researchers viewed it as the patients being able to check the process of

healthcare delivered to them even when honest mistakes (which are possible), are spotted

and corrected, they continue to trust even if harmed. This term in other domains can be

viewed as customer loyalty, however, in this study, it is inferred that a patient should

continue to use these facilities and services only if it trusts the service providers.

This model is cited in this study due to its relevance to the study. It is a study that was

carried out in a hospital environment similar to this study, it was carried out on patients

and also, the study has both quality dimensions and Patient satisfaction as variables for

the study. Although the above model is holistic in its domain, it is quite inadequate to be

adopted for this study as it is, this is due to the fact that the hospital used for the study
32
was owned by the public sector while this study is looking at the PPP project within a

government hospital and the employees assessment of the quality of the facility(s) they

used were not evaluated. Therefore, this study has identified other quality dimension that

will be better suited for a PPP project type due to its peculiar trait of multiple

stakeholders. Also, as recommended by the above researchers, the employees were

included in this study not only to assess the facility(s) but to do so in relation to how it

enables them carry out their work better.

2.5 QUALITY PERFORMANCE IN PPP HEALTHCARE DELIVERY

Patients‟ quality perceptions have been shown to account for 17-27 percent of variation

in a hospital‟s financial measures such as earnings, net revenue and asset returns. There

is evidence that several constructs make up the overall care quality and satisfaction

model. Researchers have called for empirical cross-cultural studies of healthcare quality

and patient satisfaction (Badri, Attia and Ustadi, 2008; Alrubaiee and Alkaa‟ida, 2011).

According to Braunsberger and Gates (2002), the quality of healthcare traditionally has

been defined from the provider's point of view (Berwick, 1997; Kramer, 1997) due to the

fact that healthcare professionals felt that patients lack the required knowledge to

evaluate care intelligently. In recent times, the focus has shifted to patients' perspective

of care delivery due to rapidly changing competitive market and increasingly

sophisticated patients/customers demanding more focus on their needs and wants

(Decker, 1999). However, Eiriz and Figueiredo (2005) opined that health care services

quality should not be evaluated exclusively by customers, due to the complexity,

ambiguity and heterogeneity of health care services. They consequently developed a

33
framework for health care evaluation based on the relationship between customers

(patients, their relatives and citizens) and providers (managers, doctors, other technical

staff and non-technical staff). It is also the conclusion of Terry and Israel (2005) that

customer satisfaction is influenced by employees' performance.

Lee (2011) asserted that the healthcare industry has undergone changes in healthcare

service deliveries in the last two decades due to higher service expectations from patients,

ever-advancing technology, greater access to health information through the internet and

the digital media, and a holistic approach to health and well-being concerns as identified

by Francis (2010). The Institute of Medicine (IOM) established six aims for improving

healthcare quality, they are: Safe- avoiding injuries to patients from the care that is

intended to help them; Effective - providing services based on scientific knowledge to all

who could benefit and refraining from providing services to those not likely to benefit;

Patient-centered - providing care that is respectful of and responsive to individual patient

preferences, needs, and values, and ensuring that patient values guide all clinical

decisions; Timely - reducing waits and sometimes harmful delays for both those who

receive and those who give care; Efficient - avoiding waste, including waste of

equipment, supplies, ideas, and energy; Equitable - providing care that does not vary in

quality because of personal characteristics such as gender, ethnicity, geographical

location, and socioeconomic status (IOM, 2001). They are of the view that a health care

system that achieves major gains in these six areas would be far better at meeting

patients' needs. Also, health workers would benefit through their increased satisfaction at

being better able to do their jobs and thereby improve health, greater longevity, less pain

and suffering, and increased personal productivity to those who receive their care (IOM,

2001).

34
Eiriz and Figueiredu (2005) opined that patient‟s expectations and priorities vary among

countries and are highly related to cultural background and to the healthcare system.

Furrer, Liu and Sudharshan (2000) indicated that weak customers in large power distance

cultures placed less importance on reliability, empathy and responsiveness. Alrubaiee and

Alkaa‟ida (2011) highlighted studies that indicated that customers in different countries

evaluate good service in different ways - differences in service quality perceptions

between customers - and therefore, measures and scales developed in one culture may

not always work as well in other cultures. The studies further noted that due to

differences in response styles and interpretation of items, not all measures of service

quality and satisfaction are equivalent across cultures. Therefore, countries and cultures

must evaluate service quality perceptions before adopting other countries or cultures

systems.

2.6 CUSTOMER/USER SATISFACTION

Kamara (2000) describes the „customer' as a body that incorporates the interests of the

buyer of construction services, prospective users and other interest groups (Karna, 2004).

El-Gohary et al. (2006) defined a stakeholder as "any person or organization that has a

legitimate interest in a project". They further described an impacted stakeholder as "an

organization or individual who is directly or indirectly affected by the development

process; and can be classified into three main sub-domains: residents, users and owners".

Customer satisfaction is a function of perceived quality and disconfirmation - the extent

to which perceived quality fails to match repurchase expectations (Karna, 2004).

35
Some researchers defined a satisfied customer as "one who receives significant added

value" to his/her bottom line. Customer satisfaction differs depending on the situation

and the product or service (Oliver, 2010; Tangkitsiri et al., 2013). Customers compare

the perceived performance of a product (service, goods) with some performance standard.

Customers are satisfied when the perceived performance is greater than the standard

(positively disconfirmed), whereas dissatisfaction occurs when the performance falls

short of the standard (negatively disconfirmed) (Ozaki, 2003; Karna, 2004; Tangkitsiri et

al., 2013).

Definitions of satisfaction view satisfaction as a post-consumption evaluation containing

both cognitive and affective elements, distinguishing for example between "satisfaction

as contentment", "satisfaction as pleasure", and "satisfaction as relief" on the basis of

level of reinforcement and arousal (Oliver, 1989; Jamali, 2007).

According to Karna (2004), understanding the customer's requirements is essential in

ensuring customer satisfaction, and the demand for the construction product must be

viewed in relation to the intended use of the facility. However, Partnerships UK (2006)

highlighted that though user satisfaction is relevant in the determination of service

performance, it can be problematic especially in areas involving multiple layers of users

such as hospitals. They cited an example of a hospital manager who observed that more

complaints received were from the hospital staff than from patients, but then they felt

that faults should be prevented or rectified before they affect the end user.

Alrubaiee and Alkaa‟ida (2011) are of the opinion that satisfied customers are likely to

exhibit favorable behavioral intentions, which are beneficial to the healthcare provider‟s

long-term success. Measuring the degree of patient satisfaction can help facilitate

36
hospital service provision and management, as well as increase and maintain the quality

of the service provision.

2.6.1 Effect of socio-demographic characteristics

Socio-demographic variables such as: age; gender; occupation; period of using the

facility; years of practice, and so on have varying effects on satisfaction. Results,

however, are inconsistent and sometimes contradictory, other than the finding that older

patients consistently tend to report higher levels of satisfaction than do younger ones

(Calnan, Katsouyiannopoulos, Ovcharov, Prokhorshas, Ramic and Williams, 1994;

Braunsberger and Gates, 2002). Nguyen, Briancon, Empereur and Guillemin (2002)

found that men tended to be more satisfied than women (Braunsberger and Gates, 2002)

and women tended to complain more often than men do. Priporas, Laspa and Kamenidou

(2008) found that males and young patients tend to rate satisfaction a little higher than

females and older patients which is contrary to the reports of the previous studies. Tucker

(2002) found significance of patient‟s demographic variables in moderating their

satisfaction. Consistent with previous studies, patient age was found to be the most

frequent predictor of satisfaction of all the socio-demographic factors considered (Calnan

et al., 1994). Older patients tend to be higher in rank, more educated, and married.

Individual factors positively associated with patient satisfaction are health status and

education.

Younger, less educated, lower ranking, poorer health and high-service use were

associated with lower satisfaction. Angelopoulou, Kangis and Babis (1998) found that

patients in private hospitals were more satisfied than patients in public hospitals. On the

contrary, Jabnoun and Chaker, (2003) found that public hospitals have higher overall

healthcare quality than private hospitals. Another study found that the patient‟s health
37
quality assessment appeared to change with the introduction of patient‟s socio-

demographic characteristics. Buttle (1996) found that gender and age significantly

predicted patients‟ quality perceptions, but on only one dimension – facilities. Females

valued the facilities more than males. Perceived facility-related quality was found to be

better for older than younger respondents (cited in Alrubaiee and Alkaa‟ida, 2011).

Tucker and Adams (2001) produced an integrative patient evaluation model showing

how caring, empathy, reliability, responsiveness, access, communication and outcome

dimensions predict satisfaction and quality as moderated by the patients‟ socio-

demographic characteristics. Conway and Willcocks‟ (1997) integrated model applies

service quality to healthcare settings. It incorporates influencing factors such as patient

personality and socio-economic factors with measurement issues (i.e. reliability,

responsiveness, and so on). A study in Ohio, reported better patient assessments in

nonteaching hospitals and in hospitals with fewer beds, fewer deliveries and fewer

caesarean deliveries (Janssen et al., 2000). Despite the extensive validity and reliability

tests that were conducted in Badri et al. (2008) study, it was recommended that such tests

should be repeated in different countries to ensure their validity and reliability and also

could be used to compare the performance of public against private hospitals (Alrubaiee

and Alkaa‟ida, 2011).

2.7 USER SATISFACTION IN PPP PROJECTS

Various problems have been encountered on PPP initiatives around the world that have

eventually led to project failure. Public opposition from civil societies, local media, and

other stakeholders (Gunigan and Rajput, 2010) due to various factors has been reported

38
as the main reason for failure in several instances. PPP projects both before and after the

concession award have reportedly been cancelled due to stakeholder opposition.

Alienation of actual users of the asset (Gunigan and Rajput, 2010), lack of adequate

awareness of the concept of PPP and lack of public support (Anyaehie et al., 2014) have

increased project costs, delayed project completion, and ultimately jeopardized the

sustainability of public services (El-Gohary et al., 2006). Lack of effective

communication with the principal stakeholders of the project is a crucial gap towards

success (Gunigan and Rajput, 2010).

2.7.1 User Involvement

There are difficulties in meeting user demands especially when there are so many users

with diversified and sometimes conflicting requirements (Ozaki and Yoshida, 2007).

Therefore, one important question in construction projects is how to reflect user

requirements in the planning and production of the actual physical buildings. In order to

produce a building on users' terms, the product must have a certain degree of flexibility

to meet individual aptitudes and interests. This can be achieved by increasing customer

choices in design and increasing user involvement in the decision-making process

(Yasamis et al., 2002).

El-Gohary et al. (2006) affirms that a positive involvement with stakeholders can be a

decisive factor that can „make or break' a project and that understanding the concepts that

underlie Stakeholder involvement in infrastructure projects is an essential step towards

creating a strong involvement programme that will help project proponents and

stakeholders to communicate effectively. From ADB (2007) the stakeholders include: the

39
political decision makers; the company management and staff; the consumers; investors;

and strategic consultants.

Political decision makers: Establish and prioritize goals and objectives of PPP and

communicate these to the public, they approve decision criteria for selecting preferred

PPP option, and also approve recommended PPP option, approve regulatory and legal

frameworks.

Company management: Identify company-specific needs and goals of PPP and staff,

they provide company-specific data, assist in marketing and due diligence process and

also implement change.

Consumers: Communicate ability and willingness to pay for service, express priorities

for quality and level of service, identify existing strengths and weaknesses in service.

Investors: Provide feedback on attractiveness of various PPP options, they follow rules

and procedures of competitive bidding process, perform thorough due diligence resulting

in competitive and realistic bidding.

Strategic consultants: Provide unbiased evaluation of options for PPP, review existing

framework and propose reforms, act as facilitator for cooperation among stakeholders.

Another classification of stakeholders according to NPPPP (2009) is: the government,

the private sector and non-state actors which include: financial institutions, academic

institutions, non-governmental organizations (NGOs), community based organizations

(CBOs), faith based organizations (FBOs), employees, trade unions, environmentalists,

political leaders, community groups, sector interest groups and the general public.

Whereas, Cheung (2009) summarizes the key parties involved in PPP projects as: the

40
government/public sector, the consortium/private sector, the employees of the project

and the users of the facility or service. The above categorization suits this research more

due to the fact that it distinguishes the employees from the users (that is,

customers/patients).

Therefore, Hashimoto (2009) describes interaction of stakeholder interests as a loop; that

is, conflicts among parties enhance cost schedule inefficiencies, more cost schedule

inefficiencies leads to less user satisfaction, less user satisfaction leads to more revenue

risk of the private partner and more revenue risk of the private partner leads to more

conflicts among parties.

Therefore, we need to know who the users are, what their requirements are and how they

can be involved in the product development and design process for different project

types.

For quality improvements to be effective and long lasting, they need to be supported by

all parties involved in all the processes. Hence, it is critical for owners to make sure that

their and the end-users' expectations are well represented in contractor evaluation and

selection systems (Yasamis et al., 2002).

The Public-Private Advisory Group on PPPs (2001) stated steps that should be taken in

stakeholder consultation. They include:

i. Stakeholders include employees and their trade unions, the public, the people

who will use the assets and services provided, local community groups and

sectorial interest groups. In selecting, developing and implementing PPP

projects, the economic, social and environmental concerns of those directly

affected at local level should be taken into account along with the statutory rights

41
 and legitimate economic interests of stakeholders in line with the stated

recommendations.

ii. Existing structures and agreements should be used to ensure extensive

consultation and open communication in respect of PPP projects. Public service

employees should be informed at the earliest possible stage of proposals for the

introduction of PPPs and of significant developments throughout the process.

They should also have the opportunity to contribute positively to the development

of projects, building on progress in the development of workplace partnerships

under the PPP. The partnership approach should be maintained throughout the

project‟s lifetime.

iii. All parties to a PPP arrangement should have regard to appropriate industry

norms in terms of pay and conditions and of prevailing national and/or industry-

wide agreements including health and safety regulations. Such an approach

should be consistent with protections provided under the Transfer of

Undertakings (Protection of Employees) Regulations and the Acquired Rights

Directive. PPPs should be approached on the basis that no less favourable terms

than the Transfer of Undertaking Regulations apply.

2.8 PPP IN HEALTHCARE DELIVERY IN NIGERIA

The Nigerian Medical Association (NMA) stated that the aggregate performance of the

nation's health sector in 2013 was not remarkably different from that of 2012 despite

some efforts made to address the challenges carried over from 2012. They attributed the

42
poor performance to the unsatisfactory amount allocated to the health sector in the 2013

National budget and also the slow process of release of funds (Enabulele, 2013).

There has been considerable interest in private sector participation in health care delivery

in Nigeria as a result of the challenges faced by the government in providing qualitative

health care to the people (Owumi et al., 2013). Presently, the private sector is involved in

all aspects of healthcare delivery from hospital-based services, ambulatory care,

diagnostic centres, laboratories, retail pharmacies, and to ancillary services as well

(Owumi et al., 2013) and they are preferred because of responsiveness to consumer

preferences and accessibility (Anyaehie et al., 2014).

Meanwhile, the public sector is still struggling with the backlog of unmet health needs

for the control of infectious diseases, malnutrition and other poverty-related diseases; it

is continuously saddled with a growing threat of non-communicable diseases such as

diabetes, high blood pressure and cancer (Akinkugbe, 1992; Ajayi, and Adebamowo,

1999, Ezzati, Vander Hoorn, Lawes, Leach and James, 2005). Therefore, the private

sector appears to be the main source of health care for majority of the population

including the poor (Ogungbekun, Ogungbekun and Orobaton, 1999; Owumi et al., 2013).

Leading to a large proportion of citizens' income spent on health services in the private

sector with variable levels of quality (Soyibo, 2004). These have resulted in the outcry

for government at all levels to consider partnership with private sector for the provision

of the much needed healthcare services (Adirieje, 2013; Uduaghan, 2014).

Akinci and Sinay (2003) opined that with increasing competition in the local and

regional healthcare markets, and growing interest in assessing the effectiveness of

services and patient outcomes, satisfaction measures are becoming prominent in

43
evaluating the performance of healthcare system. While Olakunde (2012) stated that in

Nigeria, achieving the objectives of good health outcome, equity, patients and providers'

satisfaction is very challenging.

In terms of stakeholder participation, it is important for the project sponsors to

disseminate information among the various stakeholder groups about the virtues of

partnership options and convince them about the benefits that would accrue to them.

Feedback and consultations with the stakeholders will ensure support, client focus, and

improved coordination of the project. It is also observed that the degree to which the

formation and stewardship of the rules is undertaken without harming or causing

grievance to people will populate decency. It will also provide transparency within the

PPP process with a degree of clarity and openness with which decisions are made leading

to accountability to which political actors are responsible to society for what they say

and do (Gunnigan and Rajput, 2010).

Therefore, partnership with the private sector, when properly structured and executed can

lead to increasing the resources available to the health sector as well as expand the

delivery of vital services to targeted populations and underserved areas. This is in

addition to making effective use of the private sector's expertise and comparable

advantage in undertaking certain organizational functions such as marketing,

communications, enhancement of service quality and a potential to attract and retain

better performing staff. In the past, government ministries of health paid little or no

attention to the private sector; the approach to the private sector has rarely gone beyond

enacting legislations and issuing regulations that were usually not enforced (Soyibo,

2004).

44
There are several PPP projects already completed or are currently in progress in

developing countries (Ofori, 2007), some PPP initiatives domiciled in public health

institutions are on-going in Nigeria, such as the Lagos State University Teaching

Hospital (Anyaehie et al., 2014) and University College Hospital, Ibadan. Other projects

have just been signed or are currently in the procurement stage such as a separate

Dialysis Unit in the Delta State University Teaching Hospital, Oghara (Frontiersnews,

2014) and the Ekiti State Teaching Hospital PPP Diagnostic Centre was at tender stage in

February, 2014 (InfraPPP, 2014).

2.9 SUMMARY OF PPP PROJECTS FOR THE STUDY

The PPP projects that were used for the study are the University College Hospital,

Ibadan; and Lagos University Teaching Hospital, Lagos. The facilities provided are of

different types, some of the structures are newly constructed while some are remodelled

to suit the healthcare intention. The facilities provided are outlined below.

2.9.1 University Teaching Hospital (UCH), Ibadan (Project 1)

The PPP facilities include:

 Stress Eco Suite;

 Endoscopy Suite;

 Cardiac theatre;

 Cardiac Intensive Care Unit (ICU); and

 Computerized Axial Tomography (CAT) laboratory.

45
2.9.2 Lagos University Teaching Hospital (LUTH), Lagos (Project 2)

The PPP sections include:

 Magnetic Resonance Imaging (MRI) Suite,

 PATHCARE Laboratory,

 Marvina Neuro Diagnostic Centre,

 LUTH Guest House.

46
 CHAPTER THREE

3.0 RESEARCH METHODOLOGY

3.1 RESEARCH APPROACH

Research approach as defined by Creswell (2003) are the plans and procedures for

research that span the steps from broad assumptions to detailed methods of data

collection, analysis, and interpretation. Creswell (2003) further stated that the selection

of a research approach can be based on the nature of the research problem or issue being

addressed, and then categorized the approaches to research into three which are:

Quantitative, Qualitative and Mixed methods. Creswell, (2003) also described the

relationship between the approaches as a continuum with qualitative approach at one end

and quantitative on the other end thereby having the mixed method in the middle of the

continuum.

The study began with literature review to develop a good theoretical background on

PPPs, user satisfaction, quality performance, user involvement, healthcare delivery and

relationships between them.

The quantitative approach which makes use of closed-ended questions, numerical

expressions and statistical tools to analyse data was used for the study. This approach is

used for examining the relationships among variables, measuring such variables on

instruments and analysing them using statistical procedures (Creswell, 2003). The study

assessed the satisfaction of the users of the facilities provided for healthcare under a PPP

arrangement in University teaching hospitals of University of Ibadan, in Oyo state and

University of Lagos, Lagos state using the survey (questionnaire) method. According to

Creswell (2003), "a survey is a quantitative or numeric description of some fraction of

47
the population - the sample, which enables researchers to generalize their findings from a

sample of respondents to a population within the limitations of the sampling method".

3.2. THE STUDY POPULATION

To ensure adequate and reliable data collected, the sample is required to be homogenous

and comprehensive and should give a true representation of the population. Therefore,

the target populations of this study were the employees (medical and non-medical staff)

and patients of the two teaching hospitals in south western Nigeria. The medical staff

comprise of doctors, pharmacists, laboratory staff and nurses. The non-medical staff

comprise of administrative and other support staff all referred to as administrative staff.

The patients considered in the study were those conversant with the projects (i.e. the

structures and services rendered) at the time of conducting the research. The employees

should be able to assess the facilities from a professional point of view. In other words,

how satisfied are they as professionals in delivering their services using the facilities

provided? Also, patients should be able to assess the structures and the services they

receive in the facilities in line with their expectation(s).

3.2.1 University Teaching Hospital (UCH), Ibadan (Project 1)

The University College Hospital, (UCH) Ibadan was established by an act of parliament

in November 1952 in response to the need for the training of medical personnel and other

healthcare professionals for the country and the West African Sub-Region. The

establishment of the Hospital was sequel to a Visitation Panel in 1951 to assess the

clinical facilities for the clinical postings of medical students registered for M.B.B.S.

48
degree of the University of London. The visitation panel, led by Dr T. F. Hunt of the

University of London rejected the enhanced facilities provided by the

Government/Native Authority Hospital at Adeoyo, Ibadan following the establishment of

a Faculty of Medicine in the University College, Ibadan (now University of Ibadan) in

1948.

3.2.2 Lagos University Teaching Hospital (LUTH), Lagos (Project 2)

LUTH and the Medical School Complex grew out of a Cabinet decision of April, 1961

when the Council of Ministers set up a Cabinet Committee to consider the

recommendations of Sir Eric Ashby's Commission on Post-Secondary Education in

Nigeria. Two of the many recommendations of the Committee approved by the Council

of Ministers were:-

 The effective and rapid re-organization of hospitals in Lagos, Surulere, Ibadan,

Kaduna and Enugu for teaching clinical medicine;

 The establishment of a full-fledged Medical School in Lagos as soon as possible

to make use of the existing medical institutions.

The objective was to train at least 100 Doctors annually in Medical Schools in Nigeria

from 1975 onwards. The Cabinet reshuffle of June that year saw two of those who served

on the Committee being appointed to implement these decisions. These were Senator

(Dr.) M.A. Majekodunmi, Minister of Health and Mr. C. O. Lawson, Permanent

Secretary, Ministry of Health.

49
3.3 SAMPLING

Cochran (1963) said that there are two broad types of sampling, they are probability

sampling (representative samples) and non-probability sampling (non-representative

samples). Sampling can be defined as a representative picture of the population without

studying the entire population. For the sample frame of the study, the convenience

sampling method was used. A convenience sample is a study of subjects taken from a

group that is conveniently accessible to a researcher (Molenberghs, 2011). This method

was used in order to further separate the required employees (those in the PPP sections)

for the study from the general employee (all workers in the UTHs) population and also

the required patients. Therefore, the survey was carried out within and around the PPP

facilities, the advantage of this method is that it was easy to access the required

respondents with little effort and time. Which can be viewed as a disadvantage for other

studies considering this method due to the fact that it is not an accurate representation of

the entire population, thereby skewing the results quite radically.

In the collection of data for patients, the purposive sampling technique was further used.

Purposive sampling is also known as judgmental, selective or subjective sampling and is

a type of non-probability sampling technique. Non-probability sampling focuses on

sampling techniques where the units that are investigated are based on the judgment of

the researcher (Molenberghs, 2011).

This method was chosen to increase precision and to ensure that the respondents are only

those who have utilized the PPP facilities for a period of time and not random first timers.

The reason for this categorization is because the study requires the information from

those who are quite conversant with the facilities to provide valid assessment and not

arbitrary responses.
50
Sample size is the number of units in the sample (Molenberghs, 2011). Evborokhi (2003)

cited by Dandajeh (2011) stated that three factors determine the size of an adequate

sample: the nature of the population, type of investigation and degree of precision

desired. These factors were considered in the choice of the sample size. The

circumstance of the study should determine what number or what percentage of the

population is ideal for sample size (Nwana, 1999). Also, Borg (2000) recommended that

a minimum of 20% of a population that is under 1,000 subjects; 10% of a population that

is up to 5,000 and 5% of a population that is up to 10,000 and above. Also, Mendenhall,

Reinmuth and Beaver (1993) and Leedy (1997) asserted that „a minimum sample size of

30 is considered sufficient to provide an effective normal approximation as a general rule

of thumb, regardless of the shape of the population frequency distribution‟. Therefore,

the sample size of 580 respondents was drawn as shown in Table 3.2. The population of

the various users are as shown in Table 3.1.

Table 3.1 Sampling Frame of Employees in the Hospitals.

Hospitals Doctors Pharmacists Nurses Lab Admin Patients

Staff Staff

UCH 32 24 75 110 106 1961

LUTH 45 20 65 86 87 1214

Total 77 44 140 196 193 3175

From the Table 3.1, 40% (medical and non-medical staff) and 10% (patients) of the

population was used as recommended by Borg (2000) and the selected numbers from

each hospital are shown in Table 3.2. Note that the admin staff in Table 3.1 are all the

non-medical workers. Also, the patient population in Table 3.1 was determined based on
51
the registered patients collected daily during working hours (8am – 4pm) over a period

of five days (Monday-Friday) of each hospital.

Table 3.2 Summary of Sample Distribution According to the Hospitals.

Hospitals Medical Staff Non-Medical Staff Patients (10%)

(40%) (40%)
UCH 96 42 196

LUTH 86 35 121

Total 182 77 317

3.4 INSTRUMENT FOR DATA COLLECTION

There are several research instruments which include case studies, content analysis,

evaluation research, interviewing, surveys and a host of others. The questionnaire

adopted for the study was obtained majorly from two research works; Parasuraman et al.,

(1985); and Gavin, (1988) others include; Johnson (1995); Qin et al., (2010); Cappelli,

Guglielmetti, Mattia, Merli and Renzi, (2010); Hoxley (2000); and Yuan et al. (2010).

The questionnaire was customized to focus on user satisfaction with product- and

service-quality dimensions of the two projects considered.

3.4.1 Questionnaire Design

The questionnaire started with a brief summary of the purpose of the survey, the

importance of responding and the fact that data of individual respondents would be kept

confidential. It was divided into two types and both divided into three sections. The two

52
types are: members of staff, that is, those using the facilities and providing the services

and patients experiencing both. The first section categorized the respondents'

demography that is, in terms of age, gender, occupation, and so forth. While the second

section focused on the assessment of customer satisfaction based on product and service

quality dimensions and the third section provided an avenue for the respondents to

express themselves freely concerning any aspect within the research area. For the

questionnaires, a total of 21 questions were in the second section for the patients and 28

questions for employees comprising all close-ended questions. They all were derived

from literature but customized and simplified for this study. The questions were used to

assess the quality performance of the facilities in the respondents' hospital unit and also

the services provided by rating their satisfaction levels on a five-point Likert scale.

Simple questions were formulated to tackle each dimension in view of the need for quick

understanding of the questions asked and to capture their satisfaction levels as accurately

as possible.

The Questionnaires were administered to the users as they utilised the facility. Service

delivery was not disrupted for questionnaire administration purposes, and data gathering

did not influence user evaluations.

The study used Likert style rating, using a five-point scale to elicit respondents' opinions

of their agreement to each nominated variable. The scale intervals are interpreted as

follows: Excellent = 5; Very good = 4; Good = 3; Fair = 2; Poor = 1 (Amissah, 2013).

The questionnaires were administered to members of staff and patients using the

facilities, the members of staff include: Doctors; Pharmacists; Nurses; medical laboratory

scientists; Laboratory Attendants; administrative staff, maintenance department staff

53
members as well as other relevant staff members using the facilities were included in the

survey. The inclusion criteria was that respondents must have used/be using the facility

for some time. This is to obtain a good assessment of these facilities and discourage

arbitrary or biased evaluations.

From data collected, Statistical Package for Social Sciences (SPSS) analytical tool was

employed to analyse individual responses on the indicators for evaluating the users'

satisfaction. This was used to assess the quality of the facilities provided by and for PPP

projects in the selected UTHs. Hence, the interactions between quality dimensions and

satisfaction were evaluated thereafter from the data obtained.

3.5 DATA COLLECTION PROCEDURE

The questionnaire administration took place in February 2015 and was carried out by

field workers with the assistance of some professionals working in the study areas. The

ethical clearance received by the ethical committees of the two teaching hospitals

assisted in getting access to records and all other requirement the study requested for that

could be granted. Out of the 580 questionnaires administered in both UCH Ibadan and

LUTH Lagos (i.e. 260 for employees and 320 for patients respectively), 437 (216 and

231 respectively) were returned from which 355 (173 and 182 respectively) were found

suitable for analysis. This represents 61.2% of the total number of questionnaire sent

which is suitable for the study based on the opinion of Moser and Kalton (1971) that the

result of a survey could be considered unsuitable and of little significance if the rate of

return was lower than 30-40%.

54
3.6 METHOD OF DATA ANALYSIS

Appropriate methods of data analysis are necessary to process the data collected from the

field survey. The data collected was analysed using SPSS analytical tool to analyse

individual responses from the descriptive perspective. Descriptive statistics simply

segregate and aggregate the data and use various methods to present the data such as

measures of central tendency (mean, median, and mode), frequency distribution,

graphically (e.g. histograms, pie charts, tables, etc.). The study used frequency count for

the demographic section of the questionnaires.

The level of users‟ satisfaction was assessed using Mean and Standard deviation (SD).

The Mean value is the average of the total responses received from respondents on each

question asked. SD is the measure of dispersion of a set of data from its mean. The more

spread apart the data, the higher the deviation. SD was used to measure the extent to

which individual scores deviated from the population mean. The scale for the remark is

as follows: Less than 3.0 = Fair, 3.0 - 3.5 = Average, 3.6 - 4.0 = High, 4.5 - 5.0 = Very

High.

Lastly, the regression analysis was used to examine the combined effect of the product

and service variables (independent) with customer satisfaction (dependent variable).

Regression analysis generates an equation to describe the statistical relationship between

one or more predictors and the response variable (Frost, 2013) as seen in Tables 4.7 and

4.8.

55
 CHAPTER FOUR

4.0 DATA ANALYSIS AND DISCUSSION OF RESULTS

4.1 DATA ANALYSIS

This section provides details of the data collected from the field survey. The respondents

were categorized into two groups namely the patients and the employees as mentioned

earlier in the study.

4.1.1 Socio-demographic Characteristics of Patients

Table 4.1 shows the frequency distribution for each of the Socio-Demographic

characteristics for the respondents (Patients) of the study.

As shown in Table 4.1, there were more responses from patients in UCH Ibadan than

from LUTH Lagos. The patients that responded were skewed to the younger ages of

between 21-30 years indicating that the results are not even across all age groups as

studies carried by Braunsberger and Gates (2002) indicates that older patients as

compared to younger patients are more satisfied with the healthcare they receive. There

is also the problem of gender being skewed towards the females with a response rate of

65.4% against males with 34.6% response rate also indicating that the overall satisfaction

might not be evenly distributed. Braunsberger and Gates (2002) in their study opined that

male patients as compared to female patients are more satisfied with the healthcare they

receive. For the „period of using the facility‟ factor, the patients who have used the

facilities between 7 – 11 months have the highest response rate of 48.9% which is good

for the study due to the fact that the study requires that the respondents should be

conversant with the PPP facilities.

56
Table 4.1 Frequency Distribution for the Socio-Demographic characteristics of

Patients

Frequency %

Location
Ibadan 97 53.3
Lagos 85 46.7

Age
Less 20yrs 11 6.0
21 to 25yrs 54 29.7
26 to 30yrs 43 23.6
31 to 35yrs 28 15.4
36 to 40yrs 22 12.1
41 to 45yrs 16 8.8
46yrs and above 8 4.4

Gender
Male 63 34.6
Female 119 65.4

Period of Using the Facility

1 to 6 months 39 21.4

7 to 11months 89 48.9
1 to 2years 33 18.1
3 to 4yrs 21 11.5

Respondent

Patient 30 16.5
Patient's family 133 73.1

Others 19 10.4

Total 182 100.0

In the case of respondents, the patients family ranked the most with response rate of

73.1% this might also affect the results adversely due to the fact that the respondent

might be rating the facility and services rendered from his/her point of view and not from

the patient‟s viewpoint which might defer for a variety of reasons such as: difference in

57
gender, age, perception, and a host of other reasons.

4.1.2 Socio-demographic Characteristic of Employees

Table 4.2 shows a tabular representation of the frequency distribution for the Socio-

Demographic characteristics of the employees that participated in the study.

As shown in Table 4.2, there were more responses from employees (53.8%) in UCH

Ibadan than from LUTH Lagos (46.2%).

Also, similar issues were observed in the employees age and gender distribution as seen

in the patients category. For the „years of practice‟ factor, the employees who have

worked for 6 – 10 years have the highest response rate of 52.6% which indicates that

they are professionally apt for the survey. The „period of using the facility‟ factor, has

the results skewed to respondents who have used the facilities for 1 – 2 years with a

response rate of 59.5% which is useable for the study due to the fact that the study

requires that the respondents should have been using the PPP facilities for some time.

The data under „occupation‟ revealed that 56 representing 32.4% of the respondents are

Nurses which implies that majority of the medical respondents were Nurses while the

non-medical staff were the overall highest (33.5).

58
Table 4.2: Frequency Distribution for the Socio-Demographic characteristics of
Employees
Frequency %

Location

Ibadan
93 53.8

Lagos 80 46.2
Age
Less than 20yrs 8 4.6
21 to 25yrs 60 34.7
26 to 30yrs 31 17.9
31 to 35yrs 8 4.6
36 to 40yrs 21 12.1
41 to 45yrs 29 16.8
46 yrs and above 16 9.2
Gender

Male 69 39.9
Female 104 60.1
Years of Practice
1 to 5yrs 34 19.7
6 to 10yrs 91 52.6
11 to 15yrs 40 23.1
16 to 20yrs 8 4.6
Period of Using the Facility

1 to 6 months 3 1.7
7 to 11months 13 7.5
1 to 2years 103 59.5
3 to 4yrs 8 4.6
5 to 6 yrs 27 15.6
7yrs and above 19 11.0
Occupation
Doctor 9 5.2
Pharmacist 14 8.1
Nurse 56 32.4
Laboratory Staff 36 20.8
Admin Staff 58 33.5
Total 173 100.0

59
4.2 ASSESSMENT OF THE LEVEL OF USERS SATISFACTION WITH PPP

PROJECTS

4.2.1 Patients level of satisfaction with the PPP projects

The patients had the mean of their lowest rating to be 3.45 (appearance of the facility)

which as stated above shows that they are quite satisfied with both the structures and

services received at this section of the hospital. The mean of the highest rating was on

the individual attention given to them which was 3.94 approximately 4.00 implying that

they were quite impressed in that area. Generally speaking, the patients reported that the

competence of staff members was commendable that is, the behaviour of staff members

instilled confidence in them, the staff members were willing to help them, the staff

members were friendly and courteous towards them, they felt safe in the staff members

care, the general knowledge of the staff members in understanding their predicaments

was very good. And also the time spent waiting to be attended to as well as on laboratory

investigations was acceptable.

The Table 4.3 shows the SD closest to its Mean to be Competence (0.397) indicating that

the individual responses in that group were close to each other confirming that their

individual and collective assessment of quality in competence of staff members is around

3.70.

The next section that was rated high is convenience. The highest in that section was the

accessibility of the facility followed by clarity of guidance around the facility and then

the amount they were charged for their treatment. The reliability of the staff members in

rendering their professional services as well as promptness of services alongside

scheduling and booking time for services were the next in the rating hierarchy. The

60
farthest SD to its mean is „the facility meeting their healthcare needs‟ (1.074), this

indicates that the individual responses on that question were more disperse than the other

questions that is, the respondents have varied views on the reliability of the facilities to

meet their healthcare needs.

Table 4.3. Patients Level of Satisfaction with PPP Facilities and Services

Mean S.D Remarks

Rate the overall performance of this facility 3.59 1.062 Good
TANIBILITY 3.52 .682 Average

Rate the appearance of the facilities 3.45 1.016 Average

Rate the personal appearance of staff members 3.59 1.056 Average

RELIBILITY 3.60 .549 High

Rate the facility in meeting your healthcare needs 3.62 1.074 High

Rate the professional services provided 3.69 1.059 High

Rate the promptness of the services provided 3.53 1.034 Average

Rate the scheduling and booking time of services required 3.57 1.016 Average

COMPETENCE 3.70 .397 High

Assess staff members willingness to help you 3.69 .999 High

Does the behavior of the staff members instill confidence in you 3.80 .977 High

Rate your feeling of safety in their care 3.67 1.062 High

Rate their friendliness and courtesy towards you 3.70 1.015 High

Assess their general knowledge to answer your questions 3.69 1.048 High

Assess the individual attention given to you 3.94 .981 High

Rate their understanding of your specific needs 3.66 1.010 High

Assess the duration of waiting time before being attended to 3.63 1.036 High

Assess the time spent on laboratory investigations 3.52 .846 Average

CONVENIENCE 3.65 .506 High

How accessible is the facility 3.81 .968 High

Rate the clarity of guidance and information sign for the facilities 3.53 .852 Average

Assess the general quality of service received 3.62 .913 High

How will you rate the cost of care 3.62 .790 High

Rate the overall performance of the PPP section 3.63 .999 High
Less than 3.0 = Fair, 3.0 - 3.5 = Average, 3.6 - 4.0 = High, 4.5 - 5.0 = Very High.
SD = Standard Deviation

61
The questions under the group; Tangibility were found to be rated the lowest in the

patients survey. This area consists of the appearance of the members of staff as well as

the facilities and they rated how satisfied they were with them. Their individual SD are

high (1.056 and 1.016 respectively) although the SD as a group (0.682) dropped

drastically.

The questionnaires inquired of the users general satisfaction twice which was at the

beginning and the end of the second section of the questionnaire. Their rating of this

question was higher at the end than the beginning indicating that the quality questions

asked, made them appreciate the facilities and services better thereby, increasing their

overall satisfaction.

4.2.2 Employees level of satisfaction with the PPP projects

The employees were not quite satisfied from the ratings they did. The mean of their

highest rating was 3.39 in terms of the facility maintaining confidentiality which is vital

in their profession. The mean of the lowest rating was 2.83 in terms of health and safety

provisions available for them as a parameter for assessing their productivity. Also, their

SD further confirms their rating due to the fact that only one question had its SD greater

than 1 (i.e. facility assisting in provision of care: SD = 1.006) as shown in Table 4.4.

From Table 4.4, it is observed that the security group under the services dimension has

the highest average rating which indicates that from their perspective, the facilities

maintain confidentiality as well as protection against danger, risks, etc.

The next group under product dimension is aesthetics; they rated the appearance of the

facilities as well as how it influences their work purpose. The next group is productivity;

they rated their satisfaction with the PPP projects in terms of promotion and career

62
development opportunities; job security; the work environment (location, space, and

amenities); salary and remuneration; reward and recognition scheme; level of job

satisfaction; training and re-training programs as well as health and safety provisions, in

descending order.

Table 4.4: Employees Level of Satisfaction with PPP Facilities and Services
Mean S.D Remark
Rate the overall performance of the facility 3.05 0.936 Average
PRODUCT DIMENSION 3.06 0.422 Average
Rate the basic function of this facility to meet your professional purpose 3.01 0.946 Average
Rate your satisfaction on the characteristics that supplement the basic
functions of the facility (restroom, lounge etc.) 2.97 0.885 Fair
Rate the availability of special facilities for the elderly/disabled 2.99 0.924 Fair
Rate the structure in term of its frequency of repairs 2.99 0.839 Fair
Rate the appearance of the facility 3.16 0.942 Average
How well does the facility advertise itself 2.98 0.895 Fair
SERVICE DIMENSION 3.14 0.402 Average
Rate the facility in creating a friendly environment to make you willing to
help patients professionally and promptly 2.93 0.893 Fair
How does the facility rate in providing individual attention to patients such as
privacy 3.05 0.948 Average
How conducive is the appearance of the facility to your work need/purpose? 3.27 0.983 Average
How does the facility assist in provision of care 3.15 1.006 Average
Rate the facility in providing ease to carry out services to parents 3.07 0.962 Average
Rate the ease of accessibility around the environment and clarity of route 3.04 0.936 Average
Rate the neatness of the facility and its environment 3.00 0.921 Average
Rate the facility and environment in relieving patients pain 3.24 0.79 Average
Rate the facility in inspiring, pride, diligence and thoroughness 3.10 0.998 Average
Rate the facility in terms of meeting your professional requirements 3.32 0.82 Average
Rate the facility in terms of freedom from danger, risks etc. 3.23 0.89 Average
Rate the facility in terms of maintenance of confidentiality 3.39 0.79 Average
PRODUCTIVITY 3.11 0.450 Average
Training and re-training program 3.07 0.86 Average
Reward and recognition scheme 3.09 0.878 Average
Promotion and career development opportunities 3.28 0.831 Average
Work environment: location, space, amenities 3.14 0.911 Average
Health and safety provision 2.83 0.936 Fair
Job security 3.23 0.85 Average
Salary and remuneration 3.12 0.895 Average
Level of job satisfaction 3.09 0.917 Average
Taking into account the above, rate the performance of the PPP section 3.05 0.92 Average
Less than 3.0 = Fair, 3.0 - 3.5 = Average, 3.6 - 4.0 = High, 4.5 - 5.0 = Very High.
SD = Standard Deviation
63
Furthermore, the features group (product dimension) was next as they rated the facilities

in providing supplementary functions such as special features for elderly/disabled people.

Following that group closely is the responsiveness group (service dimension) which

rated the facilities environment in terms of neatness, relieving patients‟ pains and also in

inspiring them to do a thorough work. Accessibility was rated the next in terms of ease of

carry out their duties and also the ease of finding ones way around the environment. The

sections rated lowest are performance and reliability of the structures (product

dimension).

4.3 EVALUATION OF THE RELATIONSHIP BETWEEN QUALITY

DIMENSIONS AND SATISFACTION

The relationship between quality dimensions and satisfaction can be evaluated using the

equation derived from the regression analysis carried in Tables 4.5 and 4.6 for both

patients and employees respectively.

Table 4.5 The Impact of Quality Dimensions on Satisfaction of Patients.

Standardized
Model Unstandardized Coefficients Coefficients t Sig.
B Std. Error Beta
1 (Constant) 1.223 .608 2.012 .046
Tangibility .531 .074 .484 7.210 .000
Reliability .086 .093 .063 .921 .358
Competence -.092 .126 -.049 -.730 .466
Convenience .150 .099 .102 1.513 .132

Table 4.5 shows mathematically the combined effect of all the independent quality

variables on satisfaction using regression analysis. The equation derived from the

relationship is as shown below.

64
S = c + 0.531(T) + 0.086(R) + (-0.092)(Cp) + 0.150(Cv) ……(i)

Where; c = constant, T = Tangibility, R = Reliability, Cp = Competence, Cv =

Convenience and the numbers to three decimal places are the coefficients of the

independent variables.

The constant „c‟ in the equation does not change, the other variables can be changed but

the constant remains unchanged. Therefore, the implication is that if there is no quality

input, there will still be satisfaction which is 1.223.

Tangibility „T‟ has a coefficient 0.531 as shown in equation (i), this implies that the

impact of tangibility on satisfaction is half (0.531). in relation to other quality

dimensions, it indicates that tangibility impacts satisfaction six (6) times more than

reliability and competence and three (3) times more than convenience.

Competence as shown in equation (i) is negative, this indicates that it has a negative

impact on satisfaction although small but present. Its implication is that when

competence quality improves or increases, satisfaction decreases.

Therefore, giving the independent variables a value between 1 and 5 (Likert scale rating

used for the study) to test the equation. Using 2.00 across, we have;

S = 1.223 + 0.531 ( 2) + 0.086 (2) + (-0.092)(2) + 0.150 (2)

S = 1.223 + 1.062 + 0.172 + (-0.184) + 0.300

S = 2.573.

65
From the equation above, it shows that when the independent variables are increased by

2, the impact they make on satisfaction is 2.573. Therefore it is clear that there is a

positive collective relationship of the independent quality variables on satisfaction.

Also to test the competence variable, using T = 2, R = 3, Cp = 1 and Cv = 2, we have;

S = 1.223 + 1.062 + 0.172 – 0.092 + 0.300

S = 2.665

Therefore, the lower the competence variable the higher the satisfaction

Table 4.6 The Impact of Quality Dimensions on the Satisfaction of Employees.

Unstandardized Standardized
Model Coefficients Coefficients t Sig.
Std.
B Error Beta
1 (Constant) 1.904 0.486 3.92 0
PRODDIM -0.033 0.135 -0.02 -0.245 0.807
SERVDIM 0.284 0.163 0.167 1.749 0.082
PROTVY 0.114 0.151 0.075 0.757 0.45
Table 4.6 shows mathematically the combined effect of all the independent quality

variables of employees on satisfaction. Using the same equation derived from the

relationship shown for the patients, the employees equation will therefore be as shown

below.

S = c + (-0.033)(PD) + 0.284(SD) + 0.114(PTy) ……(ii)

Where; c = constant, PD = Product Dimension, SD = Service Dimension, PTy =

Productivity.

Here the constant „c‟ is 1.904, that is, if there is no quality input, satisfaction is 1.904.

also, the equation indicates that product dimension „PD‟ negatively impact satisfaction.

66
Hence, when product quality increases, satisfaction decreases as shown in the patients

category. On the other hand, service dimension „SD‟ impacts satisfaction twice as much

as productivity „PTy‟.

Therefore, giving the independent variables a value 2.00 also, to test the equation. We

have;

S = 1.904 + (-0.033) ( 2) + 0.284 (2) + 0.114 (2).

S = 1.904 + (-0.066) + 0.568 + 0.228

S = 2.634

From equation (ii) above, it shows that when the independent variables are increased by

2, the impact they make on satisfaction is 2.634. Therefore, it is clear that there is also a

positive collective relationship of the independent quality variables on satisfaction.

4.4 DISCUSSION OF RESULTS

Wiess (1988) and AlQatari and Haran (1999) are of the opinion that regularity of using

the health facilities is a predisposing factor for satisfaction. The familiarity of the patients

with the health personnel reflects the relationship with the personnel in the health

facilities which is a reflection of satisfaction (AlQatari and Haran, 1999).

Studies have shown that socio-demographic characteristics have an impact on users

satisfaction (Braunsberger and Gates, 2002; Butt and Run, 2010; Alrubaiee and

Alkaa‟ida, 2011) however, Seraj, Ghadimi, Mirzaee, Ahmadi, Bashizadeh, Ashofteh-

Yazdi, SahebJamee, Kharazi and Jahanmehr (2014) opined that some socio-demographic

67
characteristics such as gender might not significantly affect satisfaction. Therefore, this

study noted that some of the socio-demographic factors such as gender and age

distribution were skewed in a particular direction which might have affected the results

obtained. Butt and Run (2010) observed that the ages of their respondents were skewed

towards the younger generation (<20 – 35 years) similar to this study (<8 – 30years) it

was stated that this might affect the results as they are least expected to visit medical

facilities. It means that a more stratified sample might produce a more applicable result

to represent all demographic groups (Butt and Run, 2010).

The quality dimensions have varying impact on the overall satisfaction of respondents as

observed from previous studies as well as this study. This study observed that the highest

rating for patients was on the competence of staff members which is contrary to the

results of Butt and Run (2010), they reported staff members competence lowest

indicating that they did not trust them and also they doubted that they will receive the

right service the first time. However, Alrubaiee and Alkaa‟ida (2011) reported that this

factor has the greatest impact on customer satisfaction. It has therefore been confirmed

from this study, as shown in Table 4.7, that the competence of staff members has the

highest impact on overall satisfaction as stated by Alrubaiee and Alkaa‟ida (2011).

The section which was rated next to the highest was convenience of the facility as well

as services rendered to them, this section was not highlighted in the SERVQUAL

instrument for measuring satisfaction. Hence it was included from literature to capture

specific issues such as cost of care which is usually an issue in PPP projects. In this study,

the cost of care was rated 3.62 which is good indicating that they were quite pleased with

the amount they were charged for healthcare which is in line with studies carried out by

Sharif (2012), they observed that price had an insignificant impact on satisfaction

68
although Sharif (2012) reported that western European markets showed an inverse

relationship between price and customer satisfaction. The results of this study is contrary

to the general belief that PPP projects are usually on the high side and unaffordable.

The next section in descending order is reliability of both staff members and the services

provided. This was contrary to reports from Butt and Run (2010) and Alrubaiee and

Alkaa‟ida (2011) who observed low ratings for reliability of staff members. This study

reported tangibility the lowest in the hierarchy but Alrubaiee and Alkaa‟ida (2011)

reported tangibility immediately after responsiveness and Butt and Run (2010) reported

that reliability was the least.

The employees as earlier stated were not quite satisfied with the PPP projects from the

ratings they did. This study confirms the speculation Alrubaiee and Alkaa‟ida (2011)

made in their study that the perceptions of patients might not match the perceptions of

employees. Their highest rating was on „the facility‟s maintenance of confidentiality

factor‟. Their lowest rating was under the productivity category the „health and safety

provisions‟ available for their use.

The ratings of employees on productivity was averagely „good‟ as also reported by Seraj

et al. (2014) study in which they were „somewhat satisfied‟ with their general

occupational conditions. The employees rated „promotion and career development

opportunities‟ the highest under the productivity section which was quite different from

Seraj et al. (2014) as they rated interactions with fellow colleagues highest. Their

greatest dissatisfaction was as earlier stated, the „health and safety provisions‟ available

for their use followed by training and re-training program. Seraj et al. (2014) stated that

their respondents greatest dissatisfaction were in the areas of salaries, benefits,

promotion, acknowledgement and recognition.

69
From the results obtained in this study, it was observed that competence and product

dimensions (under patients and employees categories respectively) had negative impacts

on overall satisfaction, this could be as a result of sampling error, probably from the

sampling technique used (might not have been suitable for the study). Also, it can be

confirming the law of diminishing return from economics which states that “when any

factor of production is increased while the other factors are held constant, the output per

unit of the variable factor will eventually diminish (Mankiw, 2008).

Due to the level of dissatisfaction especially from the staff members, steps need to be

taken to improve the work environment and also enhance job satisfaction (Seraj et al.,

2014) to increase productivity as well as general user satisfaction levels in these PPP

projects.

70
 CHAPTER FIVE

5.0 CONCLUSION AND RECOMMENDATION

5.1 SUMMARY OF FINDINGS

 The patients using the PPP facilities were generally more satisfied with the

projects than the employees.

 The patients were most satisfied with the competence of the staff members in

carrying out their professional duties especially in the individual attention staff

members gave to them. They were least satisfied with the appearance of the

facilities.

 The patients rated their overall satisfaction at the end of the survey more than

they did in the beginning indicating that they appreciated the projects more after

they had assessed the individual quality dimensions.

 The employees were most satisfied with the reliability of the facilities and rated

the maintenance of confidentiality the highest factor. They were least satisfied

with the health and safety provisions put in place for them.

 The employees generally rated their overall satisfaction with the PPP projects the

same both at the beginning and end of the survey implying that the individual

quality aspects of the projects had no influence on their satisfaction level.

5.2 CONCLUSION

The study has attempted to shed some light on the satisfaction of users with the quality

of facilities and services provided for two PPP projects from a conceptual and practical

perspective. It concludes that the satisfaction of users of a particular facility as in this

71
case PPP projects, is very important and should be considered seriously. Generally, the

overall perception of users‟ satisfaction of these projects as obtained by this study is that

the healthcare quality is „good‟. However, the patients rated the competence of staff

members a little bit higher than other factors indicating that their satisfaction levels were

not the same for all the factors evaluated. It also indicates that the patients are quite

confident in the healthcare service providers‟ reliability and expertise. On the other hand,

the employees indicated lower levels of satisfaction as compared to the patients,

indicating that they may have higher expectation from PPP projects than they are

experiencing.

Therefore, management at all levels are required to note the areas with low ratings and

come up with improvement strategies to increase their quality levels. Also they should

carry out user satisfaction surveys constantly to ensure that quality is not only maintained

but improved upon regularly to ensure good productivity and customer satisfaction.

5.3 RECOMMENDATION

i. In terms of the methodology used for the study, attention should be paid to the

socio-demographic distributions of respondents to avoid the results being skewed

to one direction.

ii. The structures need to be looked into due to the fact that both employees and

patients had their lowest ratings on the appearance and functionality of the

facilities.

iii. Also, the employees need to be motivated; their overall ratings were quite low

generally which might begin to affect their output which was well rated by the

patients.

72
iv. Lastly, the customised questions used for the research can be used periodically to

assess the satisfaction levels of users of PPP projects.

5.3.1 Recommendation for further studies

1. Studies can also be carried out to compare the satisfaction of users of the other

sections of the hospital with the users of the PPP section to assess the benefits of

PPP projects in the health sector.

2. Finally, studies can be carried out to investigate the impact of patients‟

satisfaction on the employees to find out how the satisfaction of patients affects

the employees in carrying out their work.

73
 REFERENCES

Abdel-Aziz, A. M. (2007). Successful Delivery of Public Private Partnerships for

Infrastructure Development. Journal of Construction Engineering
Management, 133 (12), 918-931.

Abdel-Razek, M. E. (2008). Causes of delay in building construction projects in Egypt.

Journal of Construction Engineering and Management, 134 (11), 831-841.

Ahadzi, M. and Bowles, G. (2004). Public- private partnerships and contract

negotiations: an
empirical study, Construction management and economics, 22, 967-978.

Ajayi, O.O. and Adebamowo, C.A. (1999). Surgery in Nigeria. Arch Surg. 134 (2) pp
206 - 211 cited in Nigerian Health Review (2007).

Akadiri, P.O. (2011). Development of a Multi-criteria Approach for the Selection of

Sustainable Materials for Building Projects. An unpublished PhD thesis, University
of Wolverhampton, United Kingdom.

Akerele, D. and Gidado, K. (2003). The risks and constraints in the implementation of
PFI/PPP in Nigeria. In: Greenwood, D J (Ed.), 19th Annual ARCOM Conference,
3-5 September 2003, University of Brighton. Association of Researchers in
Construction Management, Vol. 1, 379-91.

Akinci, F. and Sinay, T. (2003). Perceived access in a managed care environment:

determinants of satisfaction. Health Services Management Research, vol. 16, pp
85-95.

Akinkungbe, O.O. (1992). Non-Communicable Diseases in Nigeria. Lagos: Federal

Ministry of Health and Human Services of Nigeria. Cited in Nigeria Health review
(2007).

Akintoye, A. (2003). The financial structure of private finance initiative projects.

Proceedings of the 17th ARCOM Annual Conference, Salford University,
Manchester, 361-369.

Akintoye, A. (2006). Public private partnerships for sustainable development of

infrastructure in developing countries. In: Okewole, I. A. et al, Eds., Proceedings of
International Conference on the Built Environment, Covenant University, Nigeria,
January 24-26, pp. 443-445.

Alitheia Capital. (2010). http://www.howwemadeitinafrica.com/public-private-

partnerships-the-answer-to-nigerias-infrastructure-problems/6254/ .

Al-Qatari, G and Haran, D. (1999). Determinants of Users‟ Satisfaction with Primary

Health Care Settings and Services in Saudi Arabia. International Journal for
Quality in Health Care. Vol.11, no 6, pp 523-531.

Alrubaiee, L. and Alkaa‟ida, F. (2011). The Mediating Effect of Patient Satisfaction in

the Patients' Perceptions of Healthcare Quality – Patient Trust Relationship.
74
 International Journal of Marketing Studies, Vol. 3, (1).

Alsugair, A. M. (1999). Framework for evaluating bids of construction contractors.

Journal of Management in Engineering, 15(2), 72-78.

Amissah , E. F. (2013). Tourist Satisfaction with Hotel Services in Cape Coast and
Elmina, Ghana. American Journal of Tourism Management 2(1A): 26-33.

Ancarani, A. and Capaldo, G. (2001), "Management of standardized public services: a

comprehensive approach to quality assessment", Managing Service Quality, Vol.
11, No. 3, pp. 331-41.

Andrew, P., Li-Yin, S. and Deng, X. P. (2006). Role of public-private partnership to

manage risks in public sector projects in Hong Kong. International Journal of
Project Management. 24(6), 587-594.

Angeles, N. H. and Walker, D. (2000). BOOT schemes - a project delivery system for a
new millennium. Chartered Building Professional, 13(5), 21-23.

Angelopoulou, P., Kangis, P. and Babis, G. (1998). Private and Public Medicine: A
Comparison of Quality Perceptions. International Journal of Health Care
Quality Assurance, vol. 11, (1), pp. 14-20.

Anyaehie, U.S.B., Nwakoby, B.A.N., Chikwendu, C., Dim, C.C., Uguru, N, Oluka, C.P.I.
and Ogugua, C. (2014). Constraints, Challenges and Prospects of Public‑Private
Partnership in Health‑Care Delivery in a Developing Economy. Annals of Medical
and Health Sciences Research, Vol. 4, (1).

Atkinson, R. (1999). Project management: cost, time and quality, two best guesses and a
phenomenon, it's time to accept other success criteria. International Journal
of Project Management, 17(6), 337-342.

Asian Development Bank. (2007). Public-Private Partnership Handbook. Manila: Asian

Development Bank.

Asoka, T. (2014). Improving the Performance of Healthcare Organizations in Nigeria

through Public-Private Partnership (PPP) initiatives.
www.carenet.info/.../improving_the_performance_of_healthcare_organizations_in
_nigeria_through_public-private_partnership_initiatives/ accessed on 27/07/2014
22:55pm.

Badri, M., Attia, S., and Ustadi, A. (2008). Testing the not so obvious models in
healthcare quality. International Journal for Quality in Healthcare, Vol. 21 (2),
pp. 159-74.

Beatty, P.W., Richmond, G.W., Tepper, S. and DeJong, G. (1998). Personal assistance for
people with physical disabilities: consumer direction and satisfaction with services.
Archives of Physical Medicine and Rehabilitation, Vol. 79 (6), pp. 674-7.

Berwick, D.M. (1997). Patient's perspective: the total customer relationship in health
care: broadening the bandwidth. The Joint Commission Journal on Quality
75
 Improvement, Vol. 23 (5), pp. 245-50.

Black, C., Akintola, A. and Fitzgerald, E. (2000). An analysis of success factors and
benefits of partnering in construction. International Journal of Project
Management, 18(6), 423-434.

Blackwell, M. (2000). The PFI/PPP and Property, Chandos Publishing Limited, Oxford.

Borg, I. (2000). Instrument of Leadership in Employee Surveys: Theory, Tools and

Experiences (2nd edition. Applied Psychology press.

Braunsberger, K. and Gates, R.H. (2002). Patient/enrollee satisfaction with healthcare

and health plan. Journal of Consumer Marketing, Vol. 19 (7), pp. 575-590.

Bryant, B. and Cha, J. (1996). Crossing the threshold: some customers are harder to
please than others, Journal of Marketing Research, Vol. 15 (1), pp. 7-27.

Bryant, M. (2002). Med students think poorly of elderly, survey finds, Reuters, available
at: story.news.yahoo.com/nm/20020510 /hl_nm/elderly_medstudents.

Butt, M. M. and Run, E. C. (2010). Private healthcare quality: applying a SERVQUAL

model. International Journal of Health Care Quality Assurance Vol. 23 (7), pp.
658-673.

Bryman, A. (1992). Quantity and Quality in Social Research, Routledge, London.

Buttle, F. (1996). SERVQUAL: review, critique, research agenda. European Journal of

Marketing, Vol. 30 (1), pp. 8-32.

Calnan, M., Katsouyiannopoulos, V., Ovcharov, V. K., Prokhorshas, R., Ramic, H. and
Williams, S. (1994). Major determinants of consumer satisfaction with primary
healthcare in different health systems. Family Practice, vol. 11 (4), pp. 468-478.

Cappelli, L., Guglielmetti, R., Mattia, G., Merli, R. and Renzi, M.F. (2010). Statistical
Techniques for continuous Improvement: A citizen's satisfaction survey. The TQM
Journal, vol. 22 (3), pp 267-284.

Capper, P. (1995). Overview of risk in construction. Risk Management and Procurement

in Construction, 13(7), 11-25.

Chapman, C. B. and Ward, S. C. (1997). Risk Management. John Wiley & Sons, New
York.

Cheung (2009). Developing a Best Practice Framework for Implementing Public Private
Partnerships (PPP) in Hong Kong. Unpublished PhD Thesis, Queensland
University of Technology.

Cochran, W. G. (1963). Sampling Techniques, 2nd Ed., John Wiley and Sons, Inc. New
York.

Cooke-Davies, T. J. (2002). The real success factors on projects. International Journal of

76
 Project Management, vol.20, 185-190.

Concerdo, R. (1990). The measurement of innovation performance in the firm: an

overview. Research Policy, vol.19, 185-192.

Conway, T. and Willcocks, S. (1997). The role of expectations in the perception of

healthcare quality: developing a conceptual model. International Journal of
Healthcare Quality Assurance, Vol. 10 (3), 131-140.

Creswell, J. W. (2003). Research Design: Qualitative, Quantitative, and Mixed Method

Approaches, Thousand Oaks, Sage Publication, California.

Creswell, J. W. (2007) Qualitative Inquiry and Research Design: Choosing Among the
Five Approaches, Sage Publication, 2nd ed. Thousand Oaks, California.

Dandajeh, A. M. (2011). An Assessment of the therapeutic performance of Teaching

Hospitals in North- Western Nigeria. Unpublished MSc Thesis, Ahmadu Bello
University Zaria, Nigeria.

Dansky, K. and Miles, J. (1997). Patient satisfaction with ambulatory healthcare services:
waiting time and filling time. Hospital and Health Services Administration, Vol. 42
(2), pp. 165-77.

Dean, A. and Kiu, C. (2002). Performance monitoring and quality outcomes in

contracted services, International Journal of Quality & Reliability Management,
Vol. 19, (4), pp. 396-413.

Decker, P.J. (1999). The hidden competencies of healthcare: why self-esteem,

accountability, and professionalism may affect hospital customer satisfaction
scores. Hospital Topics: Research and Perspectives on Healthcare, Vol. 77 (1), pp.
14-26.

Delgado-Hernandez, J.D. and Aspinwall, E. (2008). A framework for building quality

into construction projects - part 1. Total Quality Management, Vol. 19 (10), pp
1013-1028

Delmon, J. (2005). Project Finance, BOT Projects and Risk. Kluwer International.

Department of Finance, South Africa (2000) Guidelines for Public-Private Partnership,

South Africa.

Dissanayaka, S. M. and Kumaraswamy, M. M. (1999). Comparing contributors to time

and cost performance in building projects. Building and Environment, 34(1),
31-42.

Domberger, S. (1998). The Contracting Organization, Oxford University Press, New

York, NY.

Egan, J. (1998). Rethinking Construction, CIB, London.

Eiriz, V. and Figueiredo, J. A. (2005). Quality evaluation in health care services based on
77
 customer‑provider relationships. International Journal of Health Care Quality
Assurance, Vol. 18 (6), pp.404 – 412.

Elbing, C. and Devapriya, K.A.K. (2004). Structured risk management process to

achieve value for money in public private partnerships, Journal of Financial
Management of Property and Construction, 9(3), 121-127.

El-Gohary, N.M., Osman, H. and El-Diraby, T.E. (2006). Stakeholder Management for
Public Private Partnerships, International Journal of Project Management, Vol. 24,
595-604.

Enabulele, 2013. http://www.openmindfoundation.com/index.php/saving-healthcare-in-

nigeria-a-practical-ppp-approach/

European Commission. (2004). Public-Private Partnerships and Community Law on

Public Contracts and Concessions.

Evan, J.R. and Lindsay, W.M. (2005). The Management and Control of Quality, 6 th edn.,
South-Western, Thompson corporation.

Ezzati, M., Vander Hoorn, S., Lawes, C.M.M., Leach, R. and James, W.P.T. (2005).
Rethinking the Diseases of Affluence Paradigm: Global Patterns of Nutritional
Risks in Relation of Economic Development. PLOS Med 2 (5): e 133. Cited in
Nigeria Health Review (2007).

Famakin, I.O., Kuma-Agbenyo, M., Akinola, J.A. & Onatunji, O.O. (2014) Assessment
of Critical Success Factors and Benefits of Public Private Partnership in
construction Projects. International Journal of Emerging Technology and
Advanced Engineering, vol 4 (6), pp 742-751

Flanagan, R. & Norman, G. (1993). Risk management and construction. Oxford:

Blackwell.

Flybjerg, B., Berzilius, N. and Rotthengatter, W. (2003). Mega projects and risk: an
anatomy of ambition. Cambridge University Press, United Kingdom.

Francis, S. (2010). Plan for uncertainty: Design for change. In Kaioglou, M. and
Tzortzouplos, P. (Eds.). Improving healthcare through built environment
infrastructure (pp. 4-52). Oxford: Blackwell.

Frenkel, R. (2004). La política macroeconómica para el crecimiento y el empleo,

Estrategia de crecimiento y empleo en el Mercosur, Lima, International
Labour Organization (ILO), preliminary version.

Frost, J. (2013). How to Interpret Regression Analysis Results. www.blog.minitab.com.

Furrer, O., Liu, B.S.C. and Sudharshan, D. (2000). The relationships between culture and
service quality perceptions. Journal of Service Research, Vol. 2 (4), pp. 355-71.

García, N. (2002). Estrategia de crecimientoy empleo: el enfoque, Estrategia de

crecimientoy empleo en el Mercosur, Lima, International Labour
78
 Organization (CIES), preliminary version.

Gavin, D.A. (1988). Managing Quality. The Free Press. New York.

Goetsch, D.L. and Davis, S.B. (2000). Introduction to Total Quality: Quality
Management for Production, Processing and Services, Prentice-Hall, Englewood
Cliffs, NJ.

Gbeleyi, A. (2009). Public-Private Partnership and the future of infrastructural

development in Nigeria.

Gunnigan, L. and Rajput, R. (2010). Comparison of Indian PPP Construction Industry

and European PPP Construction Industry: Process, Thresholds and Implementation,
Proceedings of CIB WORLD CONGRESS, Salford, 10-13 May.

Gronroos, C. (1988). Service Quality; the six criteria of good perceived service quality.
Review of Business, vol. 9 (3), 10-13.

HM Treasury, (1991). Competing for quality: buying better public services. London:
HMSO.

Hodge, G. (1998). Contracting public sector services: a meta-analytic perspective of the

international evidence. Australian Journal of Public Administration, Vol. 57, (4),
98-110.

Hoxley, M. (2000). Measuring UK construction professional service quality: the what,

how, when and who. International Journal of Quality & Reliability Management,
Vol. 17 (4), pp.511 – 526.

Ibrahim, A. D., Ali, A. A. and Musa - Haddary, G.Y. (2007). Financing Public
Infrastructures using Public- Private Partnerships: Contractual and tendering
arrangements for Build- Operate- Transfer (BOT). Construction focus 1 (1), 13 -
22.

Ibrahim, A. D., Price, A.D. F, and Dainty, A. R. J. (2006a). An analysis of success factors
for Public Private Partnerships in infrastructure Projects in Nigeria. Journal of
Financial Management of property and construction 12 (3), 51-68.

Ibrahim, A. D., Price, A.D. F, and Dainty, A. R. J. (2006b). The Analysis and Allocation
of Risks in Public Private Partnerships in Infrastructure Projects in Nigeria.
Journal of Financial Management of property and construction 11 (3), 149-163.

Ibrahim, A. D. and Price, A. D. F. (2006). Public private partnerships and sustainable

primary healthcare facilities in Nigeria. In: Okewole, I.A. et al, Eds.,
Proceedings of International Conference on the Built Environment, Covenant
University, Nigeria, January 24-26, 221-227.

Ibrahim, A.D. and Sodangi, M. (2007). An Assessment of Quality Performance in

Construction Using Clients' Perspective of Contractors' Project-Level Quality
Performance. The Information Manager, Vol. 7 (1).

79
Infrastructure Concession Regulatory Commission (ICRC) (2009). National Policy on
Public private partnership (PPP), July, 22-37.

Infrappp, 2014. http://infrapppworld.com/pipeline-html/projects-in-nigeria

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 2
1st century. Washington, DC: The National Academy of Sciences.

Inter-American Development Bank (IDB) (2014). An Overview of the Brazilian PPP

Experience from a Stakeholders‟ Viewpoint.

Izuwah, C. (2010). The 2nd National Project Management Conference, Abuja –

September 2010.

Jabnoun, N., and Khalifa, A. (2005). A customized measure of service quality in the
UAE. Managing Service Quality, Vol. 15 (4), pp. 374-88.

Jamali, D. (2004). Success and failure mechanisms of public private partnerships in

developing countries: insights from the Lebanese context, The International
Journal of Public Sector Management, Vol. 17 (5), 414-30.

Jamali, D. (2007). A Study of Customer Satisfaction in the context of a public private

partnership. International Journal of Quality & Reliability Management, Vol. 24,
(4), pp. 370-385.

Jefferies, M. and McGeorge, D. (2008). Using Public-private partnerships to procure

social infrastructure in Australian. Engineering, Construction and Architectural
Management, Vol. 16, (5), pp. 415-437.

Jochem, R., Menrath, M. and Landgraf, K., (2010). Implementing a Quality-Based

Performance Measurement System, A Case Study Approach. Total Quality
Management Journal, Vol. 22 (4) pp 410-422.

John, B. and Sarah, P. (2010). Partnering in the construction industry: code of practice
for strategic collaborative working with Chartered Institute of Building.

Kagioglou, M., Cooper, R. and Aouad, G. (2001). Performance management in

construction: A conceptual framework. Construction. Management. Economics,
19 (1), 85–95.

Kamara, J.M. and Anumba, C.J. (2000). Establishing and processing client requirements-
a key aspect of concurrent engineering in construction. Engineering
Construction and Architectural Management. Vol.7 (1), pp. 15-28.

Karlsen, J. T. (2002). Project stakeholder's management. Engineering Management

Journal, 14(4), 19-24.

Karna, S. (2004). Analysing customer satisfaction and quality in construction – the case
of public and private customers. Nordic Journal of Surveying and Real Estate
Research. Special Series Vol. 2, pp. 67-80.

80
Katz. R. (2000). Skills of an effective administrator. Harvard Business Review, 52(5),
90-102.

Kramer, A.M. (1997). Rehabilitation care and outcomes from the patient‟s perspective,
Medical Care, Vol. 35 (6), pp. JS48-JS57.

Krejcie, R. V. and Morgan, D. W. (1970). Determining Sample Size for Research

Activities. Educational and Psychological Measurement, 30, 607-610.

Lagos University Teaching Hospital, 2015. Luthnigeria.org/contact.php

Lane, M. and Gardiner, J. (2003) Risk management and Insurance issues. In: Public
Private Partnerships – a review of key issues, European Construction Institute,
pp. 61-70. (2005) The allocation of risks in PPP/PFI construction projects in the
UK. International Journal of Projects Management, 23, 25-35.

Latham, M. (1994) Constructing the Team, HMSO, London.

Lee, J.N. and Kim, Y.G. (1999). Effect of partnership quality on IS outsourcing:
conceptual framework and empirical validation. Journal of Management
Information Systems, Vol. 15 (4), pp 29-61.

Lee, S. (2011). Evaluating Serviceability of Healthcare Servicescapes: Service Design Pe

rspective. Vol. 5, No 2.

Leedy, P. D. (1997). Practical research: Planning and design, 6th Edition. Merrill, New Je
rsey. USA.

Levy, S. (1996). Build, Operate, Transfer: Paving the Way for Tomorrow‟s Infrastructure.
John Wiley & Sons, Inc. New York.

Love, P. E. D. and Holt, G. D. (2000). Construction business performance measurement:

The SPM alternative. Business Process Management, vol. 6 (5), pp. 408-416.

Mankiw, G. N. (2008). Principles of Economics. 5th Edition, South-western Cengage

Learning, Canada.

Marin, P. (2009). Public-Private Partnership for urban water utilities. International

Journal of Facility Management, 20, 23-34.

Mendenhall, W., Reinmuth, J. E. and Beaver, R. (1993). Statistics for Management and
Economics, 7th Edition, Duxbury Press, Belmont, California, USA.

Meyer, W. M. (2000). Environments and organizations. Jossey-Brass. London.

Miaoulis, George and Michener, R. D. (1976). An Introduction to Sampling.

Kendall/Hunt Publishing Company, Dubuque, Iowa.

Miller, J.B. (2000). Principles of Public and Private Infrastructure Delivery, Kluwer
Academic Publishers, London.

81
Mogbo, T. C. (2001). The construction sector and economic growth of Nigeria. The
Quantity Surveyor, 35(2), 8-13.

Molenberghs, G. (2011). Survey Methods & Sampling Techniques.

www.censtat.uhasselt.be

Moser, C. and Kalton, G (1971). Survey Methods in Social Investigation. AbeBooks.com.

National Planning Commission (NPC) (2004). National Economic Empowerment

Strategy (NEEDS). Abuja: National Planning Commission.

National Public Private Partnership (PPP) Policy (2009). Prime Minister‟s Office, The
United Republic of Tanzania.

Nijkamp, P., Van der Burch, M. and Vidigni, G. (2002). A comparative institutional
evaluation of public private partnerships in Dutch urban land-use and
revitalization projects. Urban Studies, Vol. 39 (10), pp. 1865-80.

Norment, R. (2004). The Framework of Public-Private Partnerships. The National

Council for Public-Private Partnerships.

Nguyen, T., Briancon, Empereur and Guillemin. (2002). Factors determining inpatient
satisfaction with care. Social Science & Medicine, 54 , pp. 493–504.

Nyhan, R. C. and Martin, L. L. (1999). Comparative performance measurement. Public

Productivity & Management Review, 22(3), 348-364.

Ofori, G. (2007). Construction in Developing Countries Construction Management and

Economics, 25 (1), pp1-6.

Ogungbekun, I., Ogungbekun, A. and Orobaton, N. (1999). Private Health in Nigeria:

walking the Tigh trope. Health Policy and Planning, 4 (2), 174-181.

Ogunsemi, D. R. (2002). Cost and time performance of construction projects in South-

western Nigeria. A Unpublished PhD Thesis in the Department of Quantity
Surveying, Federal University of Technology, Akure, Nigeria.

Olakunde, B.O. (2012). Public health care financing in Nigeria: Which way forward?
Annals of Medical and Health Sciences Research; vol. 6, pp4‑10.

Oladapo, M. A. (2000). Project performance in a changing environment. Association for

the Advancement of Cost Engineering International Transactions Calgary,
Canada, June 25-28, 1-10.

Oliver, R. (1989). Processing of the satisfaction response in consumption: a suggested

framework and research propositions. Journal of Consumer Satisfaction,
Dissatisfaction and Complaining Behaviour, Vol. 2, pp. 1-16.

Oliver, R.L. (2010). Satisfaction: A Behavioural Perspective on the Consumer. The

McGraw-Hill Companies, Inc. New York.

82
Owumi, B.E. (1996). Society and health Social Pattern of Illness and Medical Care: cited
in Readings in Medical Sociology.

Owumi B.E., Adeoti, A. B. and Taiwo, P. A., (2013). National Health Insurance Scheme
Dispensing Outreach and Maintenance of Health Status In Oyo State.
International Journal of Humanities and Social Science Invention ISSN
(Online): 2319 – 7722, www.ijhssi.org Vol. 2 (5) PP.37-46 www.ijesi.org.

Ozaki, R. (2003). Customer-focused approaches to innovation in house building.

Construction Management and Economics, vol.21, pp 557–564

Ozaki, R. and Yoshida, S. (2007). User Analysis and End-User Involvement. Proceedings
of CME 25 Conference Construction Management and Economics ‘Past,
Present and Future’. Reading, 16th-18th July, pp459-470.

Parasuraman, A., Zeithaml, V. A. and Berry, L. L. (1985). A conceptual model of service

quality and its implications for future research, Journal of Marketing, Vol. 49,
pp. 41-50.

Parasuraman, A., Zeithaml, V. A. and Berry, L. L. (1988). SERVQUAL: a multiple-item

scale for measuring consumer perceptions of service quality, Journal of
Retailing, Vol. 64 (1), pp. 12-40.

Partnerships, U.K. (2006). Report on Operational PFI Projects, March 2006, available at
www.partnershipsuk.org.uk (accessed 14 March 2008).

Petrovic-Lazarevic, S. (2003). Change of governance as a key factor for adding value to

Serbian economy.

Pitagorsky, G. (1998). The project manager/functional manager partnership. Project

Management Journal,

Pongsiri, N. (2002). Regulation and public private partnerships. The International

Journal of Public Sector Management, Vol. 15 (6), pp. 487-95.

Porter, G. (2003). Challenging the frontiers in global business and technology:

implementation of changes in values, strategy and policy, CD Rom 1418-
1427.

Priporas, C., Laspa , C. and Kamenidou, I. (2008). Patient satisfaction measurement for
in-hospital services : A pilot study in Greece. Journal of Medical Marketing, Vol.
8, (4) 325–340.

Public Private Partnership Volume One, (2012). Understanding PPP Concepts and
Frameworks: A PPP Manual for Local Government Units.

Reeves, C. A. and Bednar, D. A. (1994). Defining quality: alternatives and implications.

Academy of Management. The Academy of Management Review. Vol.19 (3), pp.
419-445.

Robles, A. O. (2009). Public Private Partnerships. Conference of Europeans Directors of

83
 Roads (CEDR) Reports.

Rockart, J.F. (1982). The changing role of the information systems executive: a critical
success factors perspective. Sloan Management Review, 24(1), 3-13.

Rowlinson, S. (1999). Selection criteria, In Rowlinson, S. and McDermott, P. (Eds),

Procurement Systems: A Guide to Best Practice. E. and F.N. Spon, London,
276-99.

Savas, E. S. (2000). Privatization and the new Public Management. Fordham Urban Law
Journal, vol.28 (5) pp. 1731-1737.

Seraj, B., Ghadimi, S., Mirzaee, M., Ahmadi, R., Bashizadeh, H., Ashofteh-Yazdi, K.,
SahebJamee, M., Kharazi, M. J and Jahanmehr, M. (2014). Job satisfaction and
its influential factors in dental academic members in Tehran, Iran. Ann Med
Health Sci Res 4:192-7.

Sharif, K. (2012). Impact of category management practices on customer satisfaction –

Findings from Kuwaiti grocery retail sector. Journal of Targeting, Measurement
and Analysis for Marketing (2012) 20, 17–33.

Slevin, D. P. and Pinto, J. K. (1986). The project implementation profile: a new tool for
project managers. Project Management Journal, 17(4), 57-70.

Smith, J. M. (1998). Evaluating the client-briefing problem: an exploratory study.

Engineering Construction and Architectural Management, 5(4), 387-398.

Soyibo, A. (2005). National Health Accounts of Nigeria 1998-2002, University of Ibadan,

www.unaids.org.

Statistical Concepts (2015).

www.statisticalconcepts.blogspot.com/2010/04/interpretation-of-
correlation.html

Szilagyi Jr., A. D. (1988) Management and Performance, 3rd Edn, Scott, Foresman,
Glenview, IL.

Tangkitsiri, W. and Ogunlana, S.O. (2004). A Study on Stakeholder Satisfaction with a

BOT Project: The Case of the Bangkok Mass Transit System (BTS). CIB W107
Symposium on Globalisation and Construction. CIB Proceeding Publication:
747-758.

Tangkitsiri, W., Ogunlana, S.O., Oyegoke, A.S. and Oladokun, M.G. (2013). Dynamic
Modelling of User Satisfaction: The Case of the Bangkok Mass Transit System
(BTS). www.systemdynamics..org/.../P1340.pdf (accessed on 07/06/2014 at
01:48am).

Terry, B.D. and Israel, G.D. (2004). Agent Performance and Customer Satisfaction Dece
mber 2004, Vol. 42, (6), http://www.joe.org/joe/2004december/a4.php. Accessed
on 02/09/2014, 4:36pm.

84
The National Council of Public-Private Partnership, (NCPPP) (2008). Web home page, h
ttp://www.ncppp.org

Toor, S. and Ogunlana, S. O. (2010). Beyond the iron triangle: stakeholder perception of
key performance indicators (KPIs) for large-scale public sector development
projects. International Journal of Project Management, 28, 228-236.

Torbica, Z.M. and Stroh, R.C. (2001). Customer Satisfaction in Home Building. Journal
of Construction Engineering and Management. Jan/Feb, pp. 82-86.

Tucker, J. (2002). The moderators of patient satisfaction. Journal of Management in

Medicine, Vol. 16 (1), pp. 48-66.

Tucker, J. III, and Adams, S. R. (2001). Incorporating Patients‟ Assessment of

Satisfaction and Quality: An Integrative Model of Patients‟ Evaluation of Their
Care. Managing Service Quality, 11(4), 272-286.

Turskis, Z. (2008). Multi-attribute contractors ranking method by applying ordering of

feasible alternatives of solutions in terms of preferability technique.
Technological and Economic Development of Economy, 14(2), 224-239.

Uduaghan, 2014. http://www.punchng.com/news/delta-seeks-public-private-partnership-

on-health-care/.

University College Hospital, Ibadan (2015) University of Ibadan. Oyo State. www.uch-
ibadan.org.ng

Waterridge, J. (1998). How can IS/IT projects be measured for success. International
Journal of Project Management, 16(1), 59-63.

Weiss, G. L. (1988). Patients Satisfaction with Primary Medical Care: Evaluation of

Socio-demographic and Predispositional Factors. Medical Care Vol. 26: 383-
392.

West-Phal, J. D. and Zajac, E. J. (1997). Defections from the inner circle, social
exchange, reciprocity and the diffusion of board in U.S. Cooperate
Administrative Science Quarterly, 42(1), 161-172.

Widdus, R. (2001). Public private partnerships for health: their main targets, their
diversity and their future directions, Bulletin of the World Health Organization,
Vol. 79 (4), pp. 713-20.

Workshop Report (2008) Public Private Partnership in India.

World Health Organization in Belarus; Health for All. www.undp.by/en/who/healthforall/

(accessed 10/07/2014 at 1:23pm).

Xendis, Y. and Angelides, D. (2005). The financial risks in build-operate-transfer projects.

Construction Management and Economics, 23, 431-41.

Xu, Y., Yeung, J. F. Y., Chan, A. P. C., Chan, D. W. M., Wang, S. Q. and Ke, Y. (2010).
85
 Developing a risk assessment model for PPP projects in China – A fuzzy
synthetic evaluation approach. Automation in Construction, 19, 929–943.

Yasamis F., Arditi D. and Mohammadi J. (2002) Assessing Contractor Quality

Performance, Construction Management and Economics. Vol 20, pp 211-223.

Yuan, J. F., Zeng, A. J. Y., Skibniewski, M. J. and Li, Q. M. (2009). Selection of

performance objectives and key performance indicators in public-private
partnership projects to achieve value for money. Construction Management
Economics, vol. 27(3), pp 253-270.

Yuan, J., Skibniewski, M.J., Li, Q. and Zheng, L. (2010). Performance Objectives
Selection Model in Public-Private Partnership Projects Based on the Perspective
of Stakeholders. Journal of Management in Engineering, Vol. 26, (2), 89-104.

Yusuf, M. L. (2005). Build Operate Transfer method of project delivery: the AIPDC
experience. In: Proceedings of BOT Awareness Seminar, Abuja Investment and
Property Development Company, Nicon Hilton Hotel, Abuja, March 16-17.

Zakari, M. (2007). Public-Private Partnership in library and information services. In

Nigerian Libraries for the future: Progress, Development and Partnerships.
Uyo: Nigerian Library Association, 45th Annual National Conference and
AGM.

Zhang, X. Q. (2004). Concessionaire Selection: Methods and Criteria. Journal of

Construction Engineering Management, vol. 130 (2), 235-244.

86
 APPENDICES
APPENDIX I
QUESTIONNAIRE (PATIENTS)
Assessment of users' satisfaction with Public Private Partnership (PPP) Projects in selected
University Teaching Hospitals.
Good day, I am OYEDELE FUNMILOLA HELEN a Master of Sciences (MSc) student from the Department of Quantity
Surveying, Ahmadu Bello University, Zaria. I am conducting a study on the above subject and hereby, request your
voluntary participation. The results from this study will help for probable interventions to improve Public Private Partnership
project delivery in Healthcare in Nigeria.
All the information you provide will be kept confidential.
Thank you.

GENERALINFORMATION

A SOCIO-DEMOGRAHIC CHARACTERISTICS OF RESPONDENT

Please indicate with a tick where necessary

A1 Age
20 & Below 21-25 26-30 31-35 36-40 41-45 45 & above
A2 Gender
Male Female
A3 Period of using
the Facility
1-6 months 7-11months 1-2 years 3-4years 5-6years 7years& above

A4 Respondent
Patient Patient's family Others
A4.1 Other(s), please specify ________________________________________

C. QUALITY PERFORMANCE OF THE PPP FACILITIES AND SERVICES PROVIDED

Please indicate with a tick your chosen response where 5 is Excellent; 4 - Very Good; 3 - Good; 2 - Fair; 1 - Poor.

C
PATIENTS WILL ASSESS THE PERFORMANCE OF THE FACILITIES
5 4 3 2 1
AND STAFF MEMBERS TO THEIR NEEDS
C1
How would you rate your overall satisfaction of this facility?

C2
TANGIBILITY

2.1 How would you rate the appearance of the facilities?

2.2 How would you rate the personal appearance of staff members?

C3
RELIABILITY (patients are required to assess members of staff)

3.1
How would you rate the facility in meeting your healthcare needs?

3.2
How would you rate the professional services provided?

87
3.3
How would you rate the promptness of the services provided?

3.4 How would you rate the scheduling and booking time of services required?

C4 COMPETENCE (patients are also to assess members of staff)

4.1 Assess staff members' willingness to help you.

4.2 Does the behaviour of the staff members instill confidence in you?

4.3
How would you rate your feeling of safety in their care?

4.4
How would you rate their friendliness and courtesy towards you?

4.5
Assess their general knowledge to answer your questions.

4.6 Assess the individual attention given to you.

4.7 How would you rate their understanding of your specific need(s)?

4.8 Assess the duration of Waiting time before being attended to.

4.9 Assess the time spent on laboratory investigations.

C5
CONVENIENCE

5.1 How accessible is the facility?

5.2
How would you rate the clarity of guidance and information signs for the facilities?

5.3
Assess the general quality of service received.

5.4
How will you rate the cost of care?

C6
How would you rate your overall performance of the PPP section?

Section D
We appreciate your kind participation!
Please state your suggestions and comments about other factors that may be missing at the time but are
also important for the performance of these facilities as well as the services provided by the members of
staff of this section:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………….

88
 QUESTIONNAIRE (EMPLOYEES)
Assessment of users' satisfaction with Public Private Partnership (PPP) projects in selected
University Teaching Hospitals.
Good day, I am OYEDELE FUNMILOLA HELEN a Master of Sciences (MSc) student from the Department of Quantity
Surveying, Ahmadu Bello University, Zaria. I am conducting a study on the above subject and hereby, request your
voluntary participation. The results from this study will help for probable interventions to improve Public Private Partnership
project delivery in Healthcare in Nigeria.
All the information you provide will be kept confidential.
Thank you.

GENERALINFORMATION

A SOCIO-DEMOGRAHIC CHARACTERISTICS OF RESPONDENT

Please indicate with a tick where necessary

A1 Age 20 & Below 21-25 26-30 31-35 36-40 41-45 45 & above

A2 1 Male 2. Female
Gender
A3 Years of
Practice 1-5 6-10 11-15 16-20 21-25 25 &above

A4 Period of using
the Facility 1-6 months 7-11 months 1-2 years 3-4 years 5-6 years 7 years & above

A5 Occupation
Doctor Pharmacist Nurse Laboratory Staff Admin Staff Others
A5.1 Other(s), please specify ________________________________________

B. QUALITY PERFORMANCE OF THE PPP FACILITIES PROVIDED

Please indicate with a tick your chosen response where 1 - is Poor; 2 - Fair; 3 - Good; 4 -Very Good; 5 -
Excellent.

B
1 2 3 4 5

B0
How would you rate the overall performance of the project?

PRODUCT DIMENSION
1.1 How will you rate the basic function of this facility to meet your professional
purpose (medical care)?
1.2 Rate your satisfaction on the characteristics that supplement the basic functions
of the facility (reception, restroom, lounge, etc).
1.3
Rate the availability of special facilities for the elderly/disabled.

1.4 How will you rate the structure in terms of its frequency of repairs
(maintenance)?
1.5
How will you rate the appearance of the facility?

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1.6
How conducive is the appearance of the facility to your work needs/purpose?

1.7
How well does the facility advertise itself?

B2
SERVICE DIMENSION
6.1 Rate the facility in creating a friendly environment to make you willing to help
patients professionally and promptly
7.1 How does the facility rate in providing individualized attention to patients such
as privacy
7.2
How does the facility rate in assisting in provision of care?

8.1 How will you rate the facility in providing ease to carry out services to
patients?
8.2
Also the ease of finding one's way around the environment and clarity of route.

9.1
How will you rate the neatness of the facility and its environment.

10.1 How will you rate the facility and its environment in enhancing relief from pain
of patients.
11.1
How will you rate the facility in inspiring pride, diligence and thoroughness.

12.1 Rate the facility in terms of meeting your specific professional requirements
(e.g wash hand basin where you need it).
13.1
Rate the facility in terms of freedom from danger, risks etc.

13.2
Also rate the facility in terms of maintenance of confidentiality

B3
PRODUCTIVITY

How would you assess your level of satisfaction in the following areas?
3.1
Training and Re-training program.

3.2
Reward and Recognition Scheme.

3.3
Promotion and Career Development Opportunities.

3.4
Work Environment: location, space, amenities.

3.5
Health and Safety provisions.

3.6
Job Security.

3.7
Salary and Remuneration.

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3.8
Level of job satisfaction.

B4 Taking into account the above aspects, how would you rate the performance of
the PPP section?

Section C
We appreciate your kind participation!
Please state your suggestions and comments about other factors that may be missing at the time but are
also important for the performance of these facilities as well as the services provided by the members of
staff of this unit:

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
……………………………………………………………………………………………………………….

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