Patient satisfaction is the perception of patient towards health care services,  has been considered a mandatory barometer to evaluate how well a healthcare system is working in a number of advanced countries such as France and Germany, however, it receives limited attention in developing countries,¹ Improved patient care has become a priority for all health care service providers with the optimum objective of achieving a high degree of patient satisfaction, therefore is the state of pleasure or happiness that the patients experience while using a health services.² According to Emmanuel K Mpinga³ has moved from theoretical essence to more technical and operational approach, corresponds to expression of patient’s judgment on the quality of care, is an indicator and the voice of the patient, on other hand⁶ found that socio - demographic characteristics contribute minimally to patient satisfaction, patient who is anxious will not comprehend information clearly. In South Sudan generally, is perceived that there is a gap in needs of patients despite external donor`s efforts, hence patients seek healthcare in private health centers. Improving the quality of health care service offered at JTH will improve the service offered Nationwide directly or indirectly. This study is a cross-sectional studies, exploratory based on qualitative interviews one - to one investigator and patient, while structured questionnaire are given to Doctors and Nurses, the Study population aged 15 to 55yrs old, males and females, regardless of occupation and educational levels from all departments, Simple random samples were attained from the period between1st Oct 2012-14th Jan2013 from various wards to reached 50 patients, 20 doctors and 30 nurses were given structured questionnaires which they filled. Followed by extensive discussions and analysis was done using MS Excel &MS Word, data presentation is in the form of plain text, tables, graphs and pie charts.

Results & conclusions: The general performance of doctors and nurses is positive, despite the minority are dissatisfied, 22% of patients residing outside Capital Juba while 78% in Juba City. In regards to education level only 12% had tertiary education, while secondary level with 36% the remaining 52% had none or minimal education, the age group 15-24 had the highest unemployment rate while age 45-54 the least, 78% of the participants agreed that there was no language barrier, only 22% who had communication difficulty, South Sudan is a multi-ethnic country in which some patients  speak their mother tongues or dialects only, 72% of the patients felt that privacy was observed while 28% contrary, because consultation rooms usually overcrowded with medical students, patients are examined in front of students and co-patients, Patients tend to hide information  when they feel their privacy is at stake, leads to patients’ dissatisfaction.  follow up of patients scored high when doctors’ performance was evaluated, However, some slight deviation could be due to doctors working in shifts, swift clinical examinations, impoliteness to colleagues, most doctors are interns and so their competency is always being questioned. JTH is under equipped and it has few Specialists, and the management of chronic cases almost futile attempt. Majority of health care providers at JTH have good attitude towards patients. few answered negatively. The breaches were in the areas of drugs administration, 70% of doctors felt that nurses don’t administer drugs with right doses and timely as prescribed, only 30% believe contrary, 90% of nurses feel they over worked, hindering the quality of care services, in JTH nurses working in strenuous shifts and high patient to nurse ratio with no allowance’s payments, and luck of in service training or luck of capacity building. Inadequate facilities hamper health services in our exploratory studies and investigations, all agreed that improvement of facilities need urgency with 35% agreed for Lab,78.2% agreed for OPD, while 54.2% wards need improvement, 51.6% for pharmacy. high patients to doctor’s ratio resulting in patients taking long to see doctors and their investigation results done. Patients share beds in the emergency wards; others sleep on the floor and outside the ward receiving the treatment this deteriorates patient`s dissatisfaction towards the capacity of the hospital to deliver services. Paradoxically, many patients still prefer JTH as a final resort, Therefore, JTH should rise the capacity of OPD, increase the healthcare workers and increase incentives and motivation, create good working environment. Medical students should be trained basic medical emergency on triage in order to handle growing number of patients. The laboratory should be modernized, and the management of Hospital should be given to who holds administrative and managerial skills.

Keywords: juba teaching hospital, patient satisfaction, quality of health care, perception of patients, Health providers, attitude of doctors & nurses and south Sudan

In Juba and other parts of South Sudan it is openly perceived that there is a gap in meeting the health needs of patients in Juba Teaching Hospital (JTH), the major referral hospital in South Sudan, hence patients seek healthcare in domestic private healthcare centers and those who can afford seek medical care abroad. Patients leave the hospital complaining that their health demands/needs were not met by JTH. This holds to the fact that JTH is under equipped and also being used as a measure of last resort. Patient satisfaction has been considered a mandatory barometer to evaluate how well a healthcare system is working in a number of advanced countries such as France and Germany, however, it receives limited attention in developing countries.¹ However, less attention has been given to understanding patients' perceptions of their experiences and how these perceptions affect satisfaction and perceived quality, and identifying patients' expectations of what attributes should be provided during healthcare services.¹² Improved patient care has become a priority for all health care service providers with the optimum objective of achieving a high degree of patient satisfaction, therefore Patient satisfaction is the state of pleasure or happiness that the patients experience while using a health service.² Patient`s satisfaction, is the  perception of patient or rather the concept of satisfaction according to studies,<sup>3</sup> has  moved from a more theoretical essence to a more technical and operational approach, similarly understood  as the degree of convergence between the expectations the patients have of ideal care and their perception of the care ,corresponds to the gap between the expected and perceived characteristics, and the expression of patient’s judgment on the quality of care received in all aspects, they also consider that patient satisfaction as an indicator of the quality of care and  Patient’s satisfaction is the voice of patient that counts since it reflects the response to experienced interactions with the care givers. and similar studies has confirmed that, the Patient`s satisfaction has become an established outcome indicator, a tool to analyse the quality of a healthcare system, and input to develop strategies for accessible, sustainable, affordable and acceptable patient care.¹³

Patient’s satisfaction in healthcare has been one of the key factors in measuring level of healthcare institution performance worldwide. The choice of a healthcare institution by patients has in most cases depended on the affordability and the quality of healthcare service given. The dissatisfaction comes in when probably a healthcare provider, facility or administration plays a negative role towards meeting the expectation of patients. A study by the WHO shows that modern health care practice can only function when healthcare providers and patients behave as partners. This research, therefore encouraged us to explore this relationship and determine the   satisfaction at JTH. To achieve this, we evaluated the existing relationship between patients and healthcare providers, assessed patients’ satisfaction, and determined the quality of care offered in Juba Teaching Hospital [JTH], which handles the largest number of patients nationwide. We used questionnaires highlighting different aspects of the relationship as healthcare providers’ attitudes (politeness, professional ethics, experience, cooperation, diligence) towards patients, effect of equipment/facilities (diagnostic tools, drugs, therapeutic devices) and environment (adequate clean wards, toilets, compound) remain the utmost determinants of the level of patients’ satisfaction.  The Knowledge of the quality of health care service offered to patients at JTH, and its findings would reflect the quality of the health care service in the nation as a whole since it is the first research of its kind in the Republic in post War, confirmed by Director General for Policy and Planning for NMOH/ Dr. Richard Lako Lino. Therefore, improving the quality of health care service offered in JTH will improve the health care service offered Nationwide either directly or indirectly through daily referrals from various states in the Country.

Patient satisfaction is low generally in Sub-Saharan Africa due to the following reasons: inadequate nurse to population ratio, inadequate competency, scarcity of resources and ineffective healthcare system. According to, ¹⁴ the Poor quality healthcare can result in loss of patient lives, revenue, time and resources, trust and respect, community apathy and negative hospital reputation. The World Bank study group¹³ reported that the ratio of healthcare workers to the population is below the WHO standard of 2.28 per 1000 population, Patient satisfaction has been considered a mandatory barometer to evaluate how well a healthcare system is working in a number of advanced countries such as France and Germany, however, it receives limited attention in developing countries,¹ Improved patient care has become a priority for all health care service providers with the optimum objective of achieving a high degree of patient satisfaction therefore Patient satisfaction is the state of pleasure or happiness that the patients experience while using a health service,² Patient Satisfaction is the perception of patient towards health care services , this concept of patient`s satisfaction according to<sup>3</sup> has moved from a more theoretical essence to a more technical and operational approach, similarly understood  as the degree of convergence between the expectations patients have about the  ideal care and their perception of the care itself ,corresponds to the gap between the expected and perceived characteristics and the expression of patient’s judgment on the quality of care received in all aspects, they also consider that patient satisfaction as an indicator of the quality of care and  Patient’s satisfaction is the voice of patient that counts since it reflects the response to experienced interactions with the care givers. The quality of health care services reflected by the relationship of the health care provider and patient, Patient's perception about health care services is generally ignored due to overburdened health facilities, poor management, dissatisfied health care providers, and quick delivery of care, although it is a crucial tool for improving the quality of health care services.<sup>4</sup> Better understanding of factors relevant to patient satisfaction would help the administrators to take appropriate decisions as well as in framing the services, therefore is the major influence on practitioner and patient satisfaction and thereby contributes to practice maintenance and prevention of practitioner burnout and turnover, and is the major determinant of compliance.<sup>5</sup> According to a research carried out in Uganda on patient satisfaction with services in outpatient clinics at Mulago Hospital in Kampala<sup>6</sup> it showed that despite the negligible differences between the services provided by different providers with similar qualification, patients have different experiences and expectations and the socio-demographic characteristics contribute minimally to patient satisfaction. However, the same research showed that there was a positive relationship between having primary or secondary and higher levels of education towards satisfaction compared with no education at all. Waiting time is a well-established predictor of patients’ satisfaction and health care quality and so is technical competence of provider, accessibility, convenience and availability of services especially prescribed drugs. The doctor–patient relationship has been and remains a keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, healing, patient activation, and support are provided. Satisfaction with the doctor–patient relationship is a critical factor in people's decisions to join and stay with a specific health facility or health provider, patient who does not trust or like the practitioner will not disclose complete information efficiently. A patient who is anxious will not comprehend information clearly. The relationship therefore directly determines the quality and completeness of information elicited and understood, in a study done by Susan Dorr Goold<sup>7</sup> is in consistent with a study by WHO which showed that modern health care practice can only function when health care providers and patients behave as partners. Experience and research reveal that patients who are informed, involved in the process of their treatment and whose rights are respected by health care practitioners, recover more quickly and have shorter stay in hospitals. Health care providers must communicate effectively to the understanding clients while patients should also relate well their illness for proper diagnosis and treatment. According to Emanuel EJ<sup>10</sup> there is a need to an ideal conception of the physician-patient relationship, this ideal can be summarized by six C's: Choice, Competence, Communication, Compassion, Continuity, and (no) Conflict of interest. For the 37 million uninsured Americans there is little chance of realizing the ideal physician-patient relationship, since they lack the choice of practice setting and physician, receive care in a rushed atmosphere that undermines communication and compassion, and have no continuity of care such can hampered the quality of health care services affecting the Patient`s satisfaction, In all health care activities, the patient’s dignity and interest must be paramount. Further still, patients are entitled to information, consent, privacy and confidentiality. A study carried out by the School of Nursing, University of Pennsylvania in Philadelphia USA demonstrated that patients’ reports of satisfaction are higher in hospitals where nurses practice in better work environments or with more favorable patient-to-nurse ratios. A research outcome by Ann Kutney-Lee¹¹ recaps, improving nurse`s work environments, including nurse staffing, may improve the patient experience and quality of care. A study carried out at the Muhimbili National Hospital in Dar es Salaam, Tanzania<sup>8</sup> it was found that patients were satisfied with the services and care received when viewed from the context of a ranked public health care delivery system, the services and care offered could only be excellent compared to that provided by lower level health facilities. However, some patients expressed dissatisfaction with specific aspects of the services that they received. They were particularly dissatisfied with long waiting times before receiving services, poor level of hygiene in the wards and negative attitudes of staff towards patients this finding in accordance with studies published by Syed Saad Andaleeb<sup>9</sup> Overall, it is paramount to note that Patients’ perceptions about health services seem to have been largely ignored by health care providers in developing Countries of which South Sudan is inclusive. That such perceptions, especially about service quality, might shape confidence and subsequent behaviors with regard to the choice and usage of the available health care facilities is reflected in the fact that many patients avoid the system or avail it only as a measure of last resort. Those who can afford it seek help in other countries; the concept of interpersonal justice was also evident in patients’ discourse about their health care interactions and relationships. In a study done by Camilla Holmvall<sup>15</sup> reported the statements regarding the level of sensitivity, dignity, and respect afforded to the patient were made, informational justice was also evident not only in terms of the provision of explanations for courses of action and treatments, but also in terms of information about one’s condition and educational information. Indeed, patient satisfaction studies<sup>3</sup> have proved of value as a health indicator and allowed the implementation of improvement strategies in the health sector based on “the voice of the patient”, thus becoming a potential right to health indicator and that they should be put as such on the public health agenda. Perhaps patient satisfaction could be considered in the future as a right to health indicator making its contribution in monitoring the progress Countries have achieved in regard to implementing the right to health for the populations they are in charge of. Indeed, patient satisfaction studies do yield valuable information on accessibility / inaccessibility to quality health care as well as on true/fake patient participation, adequate / inadequate circulation of information and appropriate / inappropriate allocation of resources, ultimately being of interest to health policy decision makers. The findings of this study would help as a baseline data for improving the quality of services and making them more patients centered and identifies the service quality factors that are important to patients, also advocating for  justice towards  Patient`s  voice that must begin to play a greater role in the design of health care service delivery processes in South Sudan by  studying their relations to patient satisfaction and quality of health care in the context of Juba Teaching Hospital / JTH and Country of South Sudan in general.

Problem significance

The study by the WHO shows that the modern health care practice can only function when healthcare providers and patients behave ideally as partners. Generally in Sub-Saharan Africa the patient satisfaction is low due to the following reasons: inadequate nurse to population ratio, inadequate competency, scarcity of resources and ineffective healthcare system. According to Amporfro DA¹⁴ the Poor quality healthcare can result in loss of patient lives, revenue, time and resources, trust and respect, community apathy and negative hospital reputation. In South Sudan due to the scarce literature in regards we are encouraged to explore this relationship and determine the satisfaction at JTH by evaluating the existing relationship between patients and healthcare providers, assessed patients’ satisfaction, and determine the quality of care offered in Juba Teaching Hospital [JTH], which handles the largest number of patients nationwide, and seen as the last resort despite under equipment as major challenges, therefor undertake this cross sectional studies is aiming at providing direction by improving the client focused services and clinical practices thus increase the quality care.

General objectives

To evaluate the existing relationship between patients and Health Care Providers at Juba Teaching Hospital

 Specific objectives:

1. To assess patients’ satisfaction on health services offered at Juba Teaching Hospital- South Sudan
2. To measure the quality of service offered at Juba Teaching Hospital.
3. To determine the existence of association between services offered and attitudes of the health care providers at the Hospital.

Study design: Cross-Sectional studies, based on qualitative interview one- to one investigator and patient, while questionnaire are given to Doctors and nurses in order to evaluate the existing relationship between the health care providers and patients during the period from (1^st  Oct 2012- 14^th  Jan2013) at (JTH) Juba Teaching Hospital- South Sudan.

Study population

Patients: aged 15 to 55yrs old, males and females, of sound mind, regardless of occupation and educational levels, with varying health care needs, who were hospitalized for at least two days in the following departments Obstetrics, Pediatrics, Medicine, Surgical, Orthopedics, and Obs & Gynecology.

Health care providers

Doctors with varying working experiences in different departments at JTH for at least six months. Nurses; with varying experiences and qualifications who were working in different departments at JTH for at least six months. Sample Size; Our study targeted one hundred (100) participants grouped as follows; Fifty (50) patients, thirty (30) nurses and twenty (20) doctors from the above-mentioned departments at JTH.

Sampling methods

Simple random sampling, from various wards to obtained 50 patients, the patients were interviewed using one-to-one structured questionnaire. This method was then applied in all the mentioned wards at JTH. The doctors and nurses were randomly selected in various wards and given structured questionnaires which they filled. 

Ethical consideration and confidentiality issues

Permission was sought from Hospital Administration, and clearance was obtained from University of Juba, College of Medicine before the research was carried out. Our study observed all the due rights of the participants and conscious of the confidentiality of the information obtained and kept the anonymity of the participants during and after the scheduled period of the study. The exercise was voluntary and any participant deserved the right to withdraw during the period of the research. They were not subjected to any risks or challenges during the study.

Data analysis

After data sampling, extensive discussions and members of group debate analysis was done, data analysis was done using MS Excel &MS Word Data presentation was in the form of plain text, tables, graphs and pie chart 1–8.

Chart 1 (Table 2) Showing the level of education and occupational distribution of the patients at JTH between Oct.2012 - Jan.2013.

Chart 2 Graph showing the effect of inadequacy of facilities/equipment on performance of health workers at JTH between Oct.2012 -Jan.2013.

Chart 3 % of patients who were able to carry out all the investigations requested within JTH Oct.2012 - Jan.2013.

Chart 4 Showing the percentages of the availability of all prescribed drugs at the pharmacy at JTH between Oct.2012-Jan.2013.

Chart 5 The prioritized departments to be upgraded and need improvement, the views of the three groups at JTH between Oct.2012 - Jan.2013.

Chart 6 Patients’ preference of JTH to private clinics as shown between Oct.2012 - Jan.2013.

Chart 7 The patient contact with a health worker on arrival at JTH between Oct.2012 and Jan.2013.

Chart 8 Showing the time taken by patient to see a health worker at JTH between Oct.2012 - Jan.2013.

From our findings, the results indicate the general performance of doctors and nurses at JTH is going in the right direction, despite the minority of our participants are dissatisfied with the services offered, Results shown in table 1, those living within Juba are more than those residing outside Juba 78% & 22% respectively for all age groups. In regards to education level only 12% had tertiary education, while secondary level with 36% the remaining 52% had none or minimal education, the data shows the occupation, age group 15-24 had the highest unemployment rate and 45-54 the least see table 2, when comes to communication, 78% of the participants agreed that there was no language barrier in the initial encounter with the doctor/nurse/clinical officer (Table 3). A few22% who had communication difficulty could be due to the fact that in our socio-demographic data, majority of patients interviewed had little or no formal education (Table 2). South Sudan is a multi-ethnic country in which some patients who attend healthcare speak their mother tongues or dialects only, hence relying on translation may not allow them to express clearly what they want the health worker to know about their illnesses. This is important in the sense that if the patient understands the language in which the health worker is speaking mostly English and Arabic, he/she is able to understand, comply and implement the instructions given. The right to privacy during examination, 72% of the patients felt that their privacy was observed while 28% felt there was no adequate privacy (Table 3). This could be due to the fact that the consultation rooms are usually overcrowded. On the other hand, JTH is a teaching hospital for medical students, so, during the clinical rounds, patients are examined in front of students and co-patients, and most of the time no proper use of barriers. Patients tend to hide information from medical workers when they feel their privacy is at stake. This in the long run leads to poor/ wrong diagnosis, treatment and eventually patients’ dissatisfaction. Health worker competency, attitude, cooperation with colleagues, follow up of patients scored highly when doctors’ performance was evaluated (Table 3 & 4).

However, some slight deviation could be due to doctors working in shifts, swiftly during clinical examination, rudeness to colleagues, most doctors are interns and so their competency is always being questioned. JTH is under equipped (Table 3 & 4) and it has few specialists, hence doctors are over-worked and the management of chronic cases is almost always a futile attempt. Majority of health care providers at JTH have good attitude towards the patients. As per the nurses, the general findings after evaluation were positively, few answered negatively. The breaches were in the areas of drugs administration, over-working, cooperation with colleagues, cooperation of nurses with patients, unprofessional behavior towards doctors (Table 3 & 4).  70% of doctors felt that nurses don’t administer drugs in the right route; right doses and timely as prescribed, only 30% believe contrary, (Table 4). These concerns make nurses not to cooperate with doctors. 90% of nurses feel they over worked, hindering the quality of care services, worsening morbidity or subsequent mortality and these contribute to patients’ dissatisfaction with health care service offered at JTH. This poor administration of drugs could be too due to nurses working in strenuous shifts and high patient to nurse ratio with no allowance’s payments, and luck of in job continues training or capacity building. Our research showed that three quarters of nurses interviewed had an average experience of ten years. Evidence suggests that improving nurse working environments could result to improving patient outcome including better patient experience. Our research showed that there was unprofessional behavior of nurses towards doctors and this could be due to most doctors being interns hence undermined by the most experienced nurses, 30% (Table 4).

They feel that they know everything, given the many years they have worked at JTH compared to junior doctors. Surprisingly, 100% of nurses answered that they counsel and re-assure patients (Table 4). As expected, the doctors and nurses feel the lack of facilities and equipment adversely affect their work and the quality of service that they feel should be offered to the patient fig 2. Consequently, patients are the victims because they end up dissatisfied. Inadequate or lack of facilities hampers health services in our exploratory studies / investigation, patients, nurse & doctors agreed that improvement of facilities need urgency with 35% agreed for Lab,78.2% agreed for OPD, while 54.2% wards need improvement, 51.6% for pharmacy (Table 7). With OPD, at JTH and in our context, this could be due high patients to doctor’s ratio, therefor patients taking long to see doctors and get their investigation results chart 9. Patients share beds in the emergency wards; others sleep on the floor and outside the ward while receiving treatments. These lead to nosocomial infections, furthering deterioration of the condition, hence increase rates of morbidity & mortality and deteriorates patient dissatisfaction towards the capacity of the hospital to deliver services. In this way there is daring need to improve the OPD to meet patients’ expectations and prevent unnecessary health costs burden. the interviewees agreed that there is also a need to improve laboratory since most of the investigations were done outside the hospital in a very expensive private laboratories (Table 5). All investigations should have been done at JTH. It was not possible partly due to lack of facilities and qualified personnel. In terms of cleanliness and hygiene, 44% of patients answered yes to toilets being dirty, and gave more priority to improvement of toilets over wards or general outside environment (Table 6).

Chart 9 General performance of Doctors at JTH between Oct.2012 and Jan.2013.

The studies done in Public Hospitals in Pakistan² reiterate that, poor people visit public hospitals, and their satisfaction is very important. There is a need for doctors/physicians to be polite, empathetic and concerned with their patients. They should behave politely with the patients and their attendants. Physicians should give them a thorough check up and examination; treat them with courtesy and respect. Therefore, in this sector, the working conditions and surroundings are not healthy, and the workload and numerous patients are solely responsible for the physician/doctors’ rudeness. However, in public sector hospitals, governments should focus on hiring additional staff to overcome the workload.

This research proved that inadequate or complete lack of facilities and equipment hampers service delivery of health care to the patients consequently affect seriously the patients satisfaction toward services. Paradoxically, many patients still prefer to go to JTH, some as a final resort, rather than going to private clinics despite these deficiencies.  JTH is a referral hospital in South Sudan, receiving a big number of patients, there is inevitable need to improve all the facilities and equipment. Re-stocking pharmacy with essential drugs that can save the lives should be a key concern especially during the rainy seasons when the incidence of endemic diseases such as malaria is very high, OPD should be improved to reduce over-crowding of patients which may be the first medium of nosocomial infections. Therefore, JTH should rise the capacity of OPD, increase the healthcare workers and increase incentives and motivation, pay health workers in time and create good working environment. Medical students should be trained basic medical emergency skills on patients triage in order to handle increasing number of patients in the OPD. The laboratory should be modernized in order to improve patient`s diagnosis and prognosis. This research proved that inadequate or complete lack of facilities and equipment hampers service delivery of health care to the patients consequently affect seriously the patients satisfaction toward services. Paradoxically, many patients still prefer to go to JTH, some as a final resort, rather than going to private clinics despite these deficiencies. JTH is a referral hospital in South Sudan, receiving a big number of patients, there is inevitable need to improve all the facilities and equipment. Re-stocking pharmacy with essential drugs that can save the lives should be a key concern especially during the rainy seasons when the incidence of endemic diseases such as malaria is very high, OPD should be improved to reduce over-crowding of patients which may be the first medium of nosocomial infections. Therefore, JTH should rise the capacity of OPD, increase the healthcare workers and increase incentives and motivation, pay health workers in time and create good working environment. Medical students should be trained basic medical emergency skills on patients’ triage in order to handle increasing number of patients in the OPD. The laboratory should be modernized in order to improve patients diagnosis and prognosis.

None.

The author declares there is no conflict of interest.

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