CHAPTER ONE

INTRODUCTION

1.1 Background of Study

Primary Health Care (PHC) forms the bedrock of health care service delivery in any country. Globally, PHC represents the first point of contact between individuals and the health system, and its quality significantly determines the overall health status of populations. According to the World Health Organization (WHO), PHC services should be efficient with regard to cost, technique, and organization; readily accessible to those concerned; acceptable to the community served; and provided at a reasonable cost (Endalamaw et al., 2023). Health care services should be available in a manner and language that is suitable to the community it serves, accommodating of local traditions and customs, and at a price which the population can afford.

Patient satisfaction has been extensively documented as a critical indicator of the quality of health care delivery. Research consistently links patient satisfaction with improved patient compliance, continuity of care, better clinical outcomes, greater service utilization, and reduced medico-legal risk (Ferreira et al., 2023). Patient satisfaction is thus a key marker for the quality of health care delivery and an important indicator for evaluation and improvement of health care services.

Measuring client or patient satisfaction has become an integral component of health facility management strategies across the globe (Jibril et al., 2024). The success of a health facility depends on client perceptions of health care quality because of the impact it has on client satisfaction based on services provided by health professionals. Satisfaction of clients not only ensures compliance with treatment and instructions about their illness, but also influences utilization of health facilities.

The SERVQUAL model, widely adopted in health care research, identifies five core determinants of patient satisfaction (Hammanjoda & Singh, 2024; Parasuraman et al., 1988):

• Reliability: The ability to perform the promised service dependably and accurately.

• Responsiveness: The willingness to help patients and provide prompt service.

• Assurance: The knowledge and courtesy of employees and their ability to convey trust and confidence.

• Empathy: The provision of caring and individualized attention to patients.

• Tangibles: The appearance of physical facilities, equipment, personnel, and communication materials.

A cross-sectional study conducted in five selected primary health care facilities in Adamawa State, Nigeria by Hammanjoda and Singh (2024) confirmed that all five SERVQUAL dimensions significantly influence patient satisfaction in Nigerian primary care settings. Among these dimensions, assurance and empathy emerged as the most influential predictors of overall patient satisfaction, highlighting the critical role of interpersonal care in the Nigerian health care context.

In a broader cross-national survey conducted in 14 countries using the People’s Voice Survey dataset fielded in 2022 and 2023, Geldsetzer et al. (2023) found that approximately 44% of respondents rated their usual source of care as very good or excellent. The study found that having a regular primary care provider was strongly associated with higher uptake of preventive services, greater access to treatment, and greater health system endorsement, underscoring the importance of continuous and person-centred PHC delivery.

Contemporary health care discourse has increasingly shifted from a “disease-centred” model toward a “patient-centred” approach in which patients have greater involvement in the care they receive. This paradigm shift emphasises respecting patients’ values, needs, and preferences as fundamental to quality service delivery (Berry et al., as cited in Jódar-Sánchez et al., 2025). A scoping review by Endalamaw et al. (2023) on the successes and challenges of improving PHC service quality confirmed that quality services build communities’ and patients’ trust in health care, enhance acceptability of services, and increase health service coverage.

Health care in Nigeria has over the years been characterised by poor provider-client relationships, which has made clients and some health providers raise serious concerns about service delivery. Provision of high-quality client-centred care is therefore one of the greatest challenges of the Ministry of Health (MOH). The need to improve the quality of health care has attracted serious policy attention, with subsequent efforts to identify key issues for systemic improvement. A systematic review of patient satisfaction with Nigeria’s National Health Insurance Scheme (Nwanaji-Enwerem et al., 2022) highlighted persistent quality gaps driven by negative provider attitudes, inadequate infrastructure, and poor drug availability.

Studies investigating attributes of primary health care experiences have consistently found that among access, staff care, and physician care, physician care is most influential in determining patient satisfaction, closely followed by staff care, with access having least influence. However, it is the combination of all these factors that influences patient satisfaction and must be assessed to ensure a positive experience at the health care facility (Persai et al., 2022). A cross-sectional study of PHC facilities in Kaduna State, Northwest Nigeria by Jibril et al. (2024) revealed that only 31% of clients were satisfied with PHC services, with healthcare provider attitude and drug availability emerging as significant predictors of client satisfaction.

1.2 Statement of the Problem

Health facilities at all levels of care are required to provide quality health care that meets the expectations of their clients. This is, however, not uniformly achieved across Nigeria. Provider-client relationships have remained poor in many public primary health care facilities, resulting in growing concern among clients about the quality of care received. A scoping review of PHC quality indicators by Endalamaw et al. (2023) identified inadequate human resources for health, weak infrastructure, poor drug supply chains, and limited community participation as persistent structural challenges undermining primary care quality in low- and middle-income countries, including Nigeria.

The Nigerian Health Services recommends client satisfaction surveys by health facilities at least twice a year to monitor and improve the quality of care delivered by health professionals. However, evidence suggests that many primary health care centres and clinics across the country do not conduct such surveys regularly or at all (Jibril et al., 2024). Consequently, the level of quality of care provided by professionals in these facilities remains largely unknown.

A study by Akafa and Iseko (2024) in a North Central Nigerian tertiary hospital identified long waiting times, poor communication, and inadequate empathy from health professionals as major determinants of patient dissatisfaction. Similarly, Hammanjoda and Singh (2024) noted that negative provider attitudes and limited responsiveness were the most reported complaints among patients accessing primary care services in Adamawa State, Nigeria. These findings underscore the urgency of assessing patient satisfaction at the primary care level, particularly in Enugu State where such evidence remains scarce.

The health centres and clinics in Enugu State have not been consistently conducting client satisfaction surveys, and the level of quality of care by professionals is therefore not well known in these facilities. This study therefore addresses the gap by investigating patient perception and satisfaction with healthcare professionals at primary health care facilities in Enugu State.

1.3 Research Objectives

The general objective of this study is to describe patient perception and satisfaction with healthcare professionals at primary health care facilities in Enugu. The specific objectives are:

1. To describe and compare the perceived quality of care at the various levels of care in Enugu.

2. To determine the level of client satisfaction with health care professionals in the health facilities.

3. To identify the predictors of perception of quality of care and client satisfaction in the health facilities.

1.4 Research Questions

The following research questions guided the study:

1. What is the perceived quality of care at the various levels of care in Enugu?

2. What is the level of client satisfaction with health care professionals in the health facilities?

3. What are the predictors of perception of quality of care and client satisfaction in the health facilities?

1.5 Significance of the Study

This study holds significant implications for health policy, practice, and research in Nigeria. First, the findings will provide empirical evidence on the state of client perception and satisfaction with primary health care services in Enugu State, contributing to the evidence base that informs quality improvement programmes at the primary care level. Given the documented association between patient satisfaction, treatment adherence, and health service utilization (Jibril et al., 2024), improving satisfaction levels has direct consequences for health outcomes in the population.

Second, by identifying priority areas for service improvement from the clients’ perspective, this study will equip health facility managers and policymakers with actionable data to bridge the gap between client expectations and actual services received. This is particularly relevant in the context of Nigeria’s ongoing health system reforms and the drive towards Universal Health Coverage (UHC) (Nwanaji-Enwerem et al., 2022).

Third, the study will help health facilities to initiate policies and programmes aimed at improving client-provider relationships, which would result in increased facility utilization and revenue generation. Additionally, the study will serve as a baseline reference for future studies in Enugu State and similar settings, since no comprehensive study describing the quality of care across various levels of primary care has been conducted in the study area. Health professionals, facility administrators, and regulatory bodies will benefit from the study’s recommendations as they seek to entrench a culture of patient-centred care in primary health care delivery.

1.6 Scope of the Study

This study is limited to patient perception and satisfaction with health care professionals at primary health care facilities within Enugu State, Nigeria. Specifically, the study focuses on primary-level health facilities, including primary health care centres and clinics in selected communities within the state. The study examines key service quality dimensions physician care, nursing care, access, and ancillary services as experienced by clients who accessed outpatient services at these facilities during the study period.

The study is geographically confined to Enugu State and does not extend to secondary or tertiary health care facilities. It covers clients who were 18 years of age and above or caregivers of patients below 15 years of age at the time of the study. The study covers one health centre and one clinic owing to resource constraints. The scope is further limited by the cross-sectional nature of the design, which provides a snapshot of client satisfaction at a specific point in time and cannot capture longitudinal changes in satisfaction levels.

1.7 Definition of Terms

Patient Perception: The way in which a patient interprets and makes sense of their health care experience, including the quality of services received, interactions with health professionals, and the physical environment of the health facility.

Patient Satisfaction: A multidimensional construct that reflects the degree to which patients’ expectations about health care are met or exceeded by the services they receive. It encompasses technical quality, interpersonal care, access, continuity, and physical environment (Jibril et al., 2024).

Primary Health Care (PHC): The first level of contact between individuals, the family, and the community with the national health system, bringing health care as close as possible to where people live and work. It forms the foundation of the health system and provides essential, accessible, and community-based services (Endalamaw et al., 2023).

Healthcare Professional: Any individual who is trained and licensed to provide health care services to patients, including medical doctors, nurses, pharmacists, laboratory scientists, and community health workers, among others.

Quality of Care: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Dimensions include technical quality, interpersonal quality, and amenities (Endalamaw et al., 2023).

Service Quality: A measure of how well health care service delivery meets client expectations across five dimensions reliability, responsiveness, assurance, empathy, and tangibles as defined by the SERVQUAL model (Hammanjoda & Singh, 2024).

Client/Patient: In the context of this study, these terms are used interchangeably to refer to individuals who have visited a primary health care facility and received or sought health care services during the study period.

Health Facility: A physical location where health care services are delivered, including primary health care centres and clinics as defined within Nigeria’s three-tier health care system.

1.8 Limitations of the Study

The major limitations of the study were:

Interviews and Focus Group Discussions (FGDs) were held on the health facility premises. This may have caused clients to provide higher satisfaction ratings for fear of victimisation, even though they were assured of confidentiality. Response bias of this nature is a recognised limitation in facility-based satisfaction surveys (Aljohani, 2026).

Interviewing caregivers of patients below 15 years of age rather than the patients themselves may not reflect the true experience of the patients, as caregivers’ perceptions may differ from those of the patients.

Only one health centre and one clinic were sampled due to resource constraints, which limits the generalisability of the findings to other primary care facilities in Enugu State and Nigeria broadly.

REFERENCES

Akafa, T. A., & Iseko, K. I. (2024). Factors determining satisfaction with service delivery at family medicine clinics of a tertiary hospital in North Central Nigeria. Nigerian Medical Journal, 65(2), 132–141. https://doi.org/10.60787/nmj-v65i2-393

Aljohani, M. (2026). Three-year trends and seasonal variation in patient satisfaction with primary health care services in Saudi Arabia: Results from the national patient experience measurement program (2022–2024). Frontiers in Public Health, 13, 1727345. https://doi.org/10.3389/fpubh.2025.1727345

Endalamaw, A., Khatri, R. B., Erku, D., Nigatu, F., Zewdie, A., Wolka, E., & Assefa, Y. (2023). Successes and challenges towards improving quality of primary health care services: A scoping review. BMC Health Services Research, 23(1), 893. https://doi.org/10.1186/s12913-023-09917-3

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Hammanjoda, K., & Singh, A. G. (2024). The effect of healthcare service quality dimensions on patient satisfaction among primary care settings in Nigeria. Global Social Welfare, 11, 327–342. https://doi.org/10.1007/s40609-023-00329-z

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Nwanaji-Enwerem, J. C., Nwanaji-Enwerem, U., & Gyamfi, J. (2022). Patient satisfaction with the Nigerian National Health Insurance Scheme two decades since establishment: A systematic review and recommendations for improvement. African Journal of Primary Health Care & Family Medicine, 14(1), 3221. https://doi.org/10.4102/phcfm.v14i1.3221

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Parasuraman, A., Zeithaml, V. A., & Berry, L. L. (1988). SERVQUAL: A multiple-item scale for measuring consumer perceptions of service quality. Journal of Retailing, 64(1), 12–40.

Persai, D., Balu, R. K., Singh, K., Prabhu, R. R., Lahoti, S., Rout, S., & Panda, R. (2022). Patient satisfaction with quality of primary care health services Findings from India. International Journal of Health Planning and Management, 37(4), 2256–2265. https://doi.org/10.1002/hpm.3467

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