AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS

AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS

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.

			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
2.6CUSTOMER/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

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

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

LIST OF FIGURES

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

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

LIST OF APPENDICES

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

QUESTIONNAIRE (EMPLOYEES).. .. .. 89

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 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 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).

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 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,

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).

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.

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.

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:

Identify parameters for assessing satisfaction of PPP facilities and services;

Assess the level of users’ satisfaction with PPP facilities and services in

selected UTHs;

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.

AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS

AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS

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AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS

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