Donabedian 1980 defined medical services quality as ‘the application of medical science

Donabedian (1980) defined medical services quality as ‘the application of medical science and technology in a manner that maximizes its benefit to health without correspondingly increasing the risk. Quality health services are a subjective, complex and multi-dimensional concept. Mosadeghrad (2013) defined quality health services as “consistently delighting the patient by providing efficacious, effective and efficient health services according to the latest clinical guidelines and standards, which meet the patient’s needs and satisfies providers”. He believes that quality health is “providing the right healthcare services in a right way in the right place at the right time by the right provider to the right individual for the right price to get the right results.Quality health service includes characteristics such as availability, accessibility, affordability, acceptability, appropriateness, competency, timeliness, privacy, confidentiality, attentiveness, caring, responsiveness, accountability, accuracy, reliability, comprehensiveness, continuity, equity, amenities and facilities. Ensuring safety and security, reducing mortality and morbidity, improving quality of life and patient involvement have also been seen as quality attributes.2.3 Factors Affecting Provision of Service Quality in the Public Health Sector• Employees Management KnowledgeAccording to a study conducted by Wanjau, Muiruri and Ayodo in 2012 on the factors which affect provision of service quality in the public health sector Kenyatta National Hospital, they identified general low employee’s capacitating, low adoption of technology, poor communication channels and inadequate fund as the main factors that affect delivery of quality health services to patients attending public health facilities and thus having an impact on perception of health service quality, satisfaction and loyalty of patients.Like in most developed countries, managing public health in USA is characterized by emphasis on performance and improving quality of healthcare. In order to attain these critical indicators, public health management is fully equipped with the necessary resources and management skills (Nembhard, Alexander, Hoff & Ramanujam 2009). The hospitals personnel are more equipped with the management skills that enable them to efficiently manage resources and provide evidentiary basis for determining patient, clinician, and organizational outcomes (Nembhard et al., 2009). In other words, the health professionals are well capacitated to enable them improve the patient services health outcomes.• Management Style on Service Delivery Management of Health care system has previously been to some extent inefficient, incoherent and mostly driven by supply, thereby keeping patients on the outside of the design, development and also delivery process (Berenson and Cassel, 2009). With history, health care organizations, mainly public viewed customer service as an independent, non-critical function which was best left to professional judgment of physicians where necessary. But today there is a shift to a model which is organizational in which the patients have influence on every function (Glickman,Baggett, Krubert, Peterson &Schulman 2007). Organizations operating in Public Health, which continuously take up the challenge of huge restructuring have encountered and are still experiencing difficulties in full and proper implementation of these services (Glickman et al., 2007).Effective management is cited as a vital enabler of quality from the providers’ perspective, managers, policy-makers and equally the payers. Management affects everything within the hospital environment (Mosadeghrad, 2014). Good ideas remain useless if people have them for quality improvement, where the management is not good. Most studies have cited lack of professional managers in public healthcare organizations. Most managers are not qualified professional managers, rather are hospital physicians, nurses, doctors or are healthcare professionals (Mosadeghrad, 2014). In fact, in most Public Hospitals, the managers have no experience and knowledge in management. According to Buong’, Adhiambo, Kaseje, Mumbo, Odera and Ayugi, in their study done in 2013 the authors determined that majority of public health managers were trying to resolve problems as short term measures. Besides, there were no criteria and objectives which were in place used to appoint and select managers in healthcare facilities. National policies were considered prescriptive and did not allow for sufficient flexibility which was needed to adapt to local circumstances. Mostly, public healthcare managers were demanding more power in order to identify and recruiting the most appropriate personnel needed to provide quality services to patients (Buong’ et al, 2014).• Patient CooperationPatient involvement and cooperation is needed and affects the quality of medical services. “If doctors do their job well, but the patient does not follow medical orders, the objectives would not be achieved.” Clinical outcomes depend on the ability of patients to provide information and cooperate with clinicians.• Physician Motivation and SatisfactionPhysicians’ job satisfaction is very important in delivering high quality medical services to patients. Medical doctors identified nine organizational factors that they believed influence their motivation and consequently their job satisfaction. These were pay, working environment, managerial leadership, organizational policies, co-workers, recognition, job security, job identity, and chances for promotion.• Resources and facilitiesAvailability of resources affects the quality of medical services. The demand for medical services is beyond the capacity of healthcare organizations: “Healthcare resources are limited but people expectations are very high”. Participants provided concrete examples of low quality medical services because of resource shortage: Insufficient infrastructures, resources, and equipment inhibit delivery of quality medical services. For instance, a good patient information system is necessary for effective patient diagnosis and treatment.• Collaboration and Partnership DevelopmentIt is important for practitioners to have good support services. A nurse should administer medicines on time and should not administer wrong medicines to patients; nurses should be more responsible and should be reserved for sets there. Practitioners should show ability to effectively communicate with other health professionals or institutions to consider the delivery of high quality medical services for example, the hospital does not have a CT- Scan thus the patient relative has to get an appointment from other hospital and then take the patient there for CT-Scan. All these complications can be sorted out easily through collaboration between two hospitals.• Financial ResourcesThe fixed budget is widely used in hospitals, often based on historical spending levels, with a (frequently inadequate) provision for price changes (Peters, Elmendorf, Kandolaand Chellaraj, 2000). Such a system clearly can secure good expenditure control and is administratively undemanding (Smee, 2002). However, it can often perpetuate historical inequities and fail to respond to new demands and priorities (Peters et al, 2000). Moreover, fixed budgets offer few incentives to maximize the effectiveness, quality, or quantity of care offered by hospitals (Smee, 2002). Indeed, many budget systems continue to finance hospitals through line-item budgets directly from the ministry of health. Such mechanisms allow central bureaucracies to exert the maximum level of control over peripheral spending with little or no capacity at peripheral levels for flexible use of funds in response to local needs (Arhin-Tenkorang, 2000). Thus, centralized budget systems can contribute to technical inefficiency by preventing local managers from optimizing the deployment of inputs thereby perpetuating poor quality of service (Peters et al, 2000).Financial management, in service organizations, has been a constraint and an obstacle to other functions that contribute to service delivery (Adams and Colebourne, 1989). They suggest an ‘enlightened’ approach to finance in service organizations which consists of an approach that is more participative and positive rather than being an obstacle, it contributes to strategic planning, costing systems, personnel motivation, quality control, continued solvency, and keeping outsiders’ confidence in management (Arhin-Tenkorang, 2000). In particular, ‘good costs’ that improves organizational capabilities and quality service delivery need to be distinguished from ‘bad costs’ that increase bureaucracy hence becoming obstacles to service delivery (Sun and Shibo, 2005). Allocation of resources for health flow should be done through various layers of national and local government’s institutions on their way to the health facilities (Blas and Limbambala, 2001). Financial accountability using monitoring, auditing and accounting mechanisms defined by the country legal and institutional framework is a prerequisite to ensure that allocated funds are used for the intended purposes (Oliveira- Cruz, Hanson, and Mills. 2001). Governments lack the financial and technical capacity in many developing countries to effectively exercise such oversight and control functions, track and report on allocation, disbursement and use of financial resources (Smee, 2002).2.4 Theoretical Literature ReviewThis section covers diverse concepts and objective of topic done by different researchers. It additionally covers theories in connection to the study being contemplated as a method for contextualizing research thought.2.4.1 Adoption TheoryThe adoption theory was developed by Rogers Everett in 1962 which focuses on new product adoptions and new product diffusion in the market and to understand how and why as well as to what extent a new product is adopted by Individuals or organizations. It can also be known as theory of product adoption. The new product can be targeted towards individuals or organizations in the market. In any top company, there are long product line and product depth due to the fact that each of these product line and depth exists because some marketer somewhere thought that the product is required. After the product has been launched in the market adoption theory plays a critical role in adopting the product. As per the adoption theory, a new product which is being launched in the market, should have previous empirical data pointing towards the possible success of a product. A product is not directly launched in the market and then to watch it fail. First the product is to be tested and then it is launched. The possible tool for the Adoption theory in marketing is carrying out the market test. The theory assumes that there are multiple factors which are responsible for influencing the decision of the customer. These factors might include the consumer’s knowledge and awareness of the product, his acceptance of innovation, as well as experience in buying such products. The marketer thus gathers more information so that he can influence purchasers to buy the product thereby resulting in faster product penetration in the market. Overall, the diffusion of innovation is a part of the adoption theory whereby the diffusion of a new and innovative product or even normal product is studied. It is observed that there are five categories of purchasers. Products are always picked up first by innovators, then by early adopters, early majority, late majority and finally laggards (Rogers, 1962)2.4.2 Agency Theory.Agency theory centers on the relationship where by one or more persons (the principal(s)) engage another person (the agent) to perform some work on their behalf (Jensen and Meckling, 1976).The unit of analysis in the agency theory is the contract that exists between the principal and agent. These contracts (written and unwritten) specify the rights of the agent, performance criteria on which agents are evaluated, and the payoff functions that they face (Fama and Jensen, 1983).Similarly, in the health care sector the relationship between provider and patient is often characterized as a principal-agent relationship (agency theory). The principal who is the patient appoints an agent who is the health provider to advise the principal in making decisions about treatment or to make decisions on behalf of the principle. Thus, the provider is expected to be a perfect agent who will combine his/her professional knowledge alongside with the patient’s preferences that would help the patient to make a choice/ decision based on the information provided to him. However, the principal-agent problem arises as the provider chooses instead to maximize his or her own interests, which in many cases do not align with the patient’s interests.The issue of information pertaining to the principal-agent relationship as Arrow (1963) has pointed out that there is a high degree of uncertainty in the healthcare market. Perhaps neither the provider nor the patient is certain about the disease and the optimal treatment or more likely, the provider has a greater knowledge of the patient’s condition than the patient has. As the patient becomes more empowered and informed about his or her health conditions and possible treatment alternatives, the provider is less able to deviate from the role of a perfect agent.2.4.3 Resources Based View TheoryResource based theory has a central focus on the resources and capabilities controlled by a firm that underlie persistent performance difference among firms (Peteraf & Barney, 2003).Resource Based View (RBV) focuses on the link between organizational strategy and firms’ resources through the VRIO framework: V (value), R (rare), I (inimitable) and O (organization) (Barney, 1995). Resources can either be tangible or intangible and are gathered as a result of ‘in-firm decision making and external strategic factors. Resources are the basic physical, human and organizational assets (Wheelen & Hunger, 2008) within an organization and form the basis of RBV (Bell & Dyke, 2012). They are the building blocks where by an organization can develop its strategy and in turn acheive organizational success (Wernerfelt, 1984; Priem & Butler, 2001; Barney, 2001).Capabilities refer to the capacity an organization has to exploit its resources in a way that is organized (Wheelen & Hungr, 2008) hence, taking advantage of their attributes, by using organizational processes to achieve a desired result.Therefore, it is likely that the supreme collection of resource capabilities which is necessary for healthcare organizations to achieve successful innovation and implementation is going to rely ontheir ability to identify, organize and subsequently take advantage of their own valuable, rare and inimitable resource capabilities (Peteraf, 1993). Also, by applying RBV perspective to healthcare, enables the organization to focus on unique and strategic capabilities that will facilitate an exploration of how these capabilities can be identified and developed, including an assessment of their value, rarity and inimitability relationship to institutional advantage (Coates &McDermott, 2002).2.4.4 Service Quality TheoryIt is recognized that quality service is key to achieving the highest possible clinical outcomes within available resources (Øvretveit 1992, 2009). Quality can be defined in a variety of ways but is commonly regarded as the provision of healthcare that is safe, effective, patient-centered, timely, efficient and equitable (Boaden, Harvey, Moxham $Proudlove 2008). Zeithaml (1981) has stated that Customers of hospitality often blame themselves when dissatisfied for their bad choice. Therefore, Employees must be cautious and aware about that since some dissatisfied customers may not complain and therefore the employees should seek out sources of dissatisfaction and resolve them. Parasuraman (1988) enlists the components of perceived service quality as Assurance, Reliability, Tangibles, Empathy and Responsiveness this are the five dimensions of which were used to study the service quality in service industry comprised of banking, tourism, and transport as well as healthcare industry.

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