Jagannath University

INTERNSHIP REPORT ON

Factors Influencing Customer Satisfaction in Health Care

Services: A Study in Dhaka City

Submitted to:

Professor Dr. Md. Jakir Hossain

Department of Marketing
Jagannath University, Dhaka

Submitted by:

Rabby Islam Opu

ID: M-200204002
MBA Session 2021-2022 (11th batch)
Department of Marketing
Jagannath University

Date of Submission: 07 March 2023

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 Letter of Transmittal

Date: 7 March 2023

To
Professor Dr. Md. Jakir Hossain
Department of Marketing
Jagannath University, Dhaka

Subject: Submission of MBA Internship Report.

It is my great pleasure to submit the research proposal on “Factors Influencing

Customer Satisfaction in Health Care Services: A Study in Dhaka City” I expect
the research paper will be prepared as a partial requirement for completing the BBA
Program. I will try my best to organize this paper as per your instruction to make the
article worthwhile. I hope that your acceptance and appreciation will surely inspire me.
For any future explanations about the report, I will be glad to clarify the ins and outs. I
would like to request you accept this report.

With Regards

Rabby Islam Opu

ID. No: 2040002
11th Batch (2021-2022)
Department of Marketing
Jagannath University, Dhaka

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 Declaration
I do hereby declare that the internship report on “Factors Influencing Customer
Satisfaction in Health Care Services: A Study in Dhaka City” is my original work
and has been prepared under the guidance of Professor Dr. Md. Jakir Hossain,
Department of Marketing, Jagannath University, Dhaka. I have not submitted the report
for any other degree, diploma, title, or recognition before. I also declare that no part of
this report has been copied from anywhere without proper referencing.

So, I would like to request you to accept the report for evaluation and oblige thereby.

Rabby Islam Opu

ID. No: M 20004002
11th Batch (2020-21)
Department of Marketing
Jagannath University, Dhaka

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 Letter of Acceptance

This is to certify that the report titled “Factors Influencing Customer Satisfaction in
Health Care Services: A Study in Dhaka City” is done by Rabby Islam Opu, ID No-
M20004002, a student of the Master of Business Administration (MBA) Program from
the Department of Marketing, Faculty of Business Studies, Jagannath University,
Dhaka under my supervision. This report seems authentic to me and can be accepted
for evaluation.

I wish him every success and prosperity in his future endeavor.

Prof. Dr. Md. Jakir Hossain

Department of Marketing,
Jagannath University, Dhaka

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 Acknowledgment
First, I would like to thank the Almighty. I want to express my gratitude to all the
people involved, both directly and indirectly, in preparing this report. I apologize to the
people whose names I have not mentioned. I highly appreciate their contribution.

I have the immense pleasure to express my heartiest appreciation, a most profound

sense of gratitude, and best regard to my honorable teacher, Dr. Md. Jakir Hossain,
Professor of Jagannath University, for guiding me and for allowing initiating this
report. More specifically, I would like to thank him for helping me to prepare this
report.

I would like to thank the Department of Marketing, Jagannath University, for allowing
me to complete my report. I would like to convey my gratitude to all of them who
helped me by providing valuable time and intelligence.

Finally, my heartiest thanks go to others who were involved and helped to complete this
report. Without them, all these wouldn’t have been made possible.

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 Executive Summary

The aim of this research was to know the effect factor of participant satisfaction on
health insurance companies. By using quantitative methods with descriptive and
verification approaches. The test equipment used Structural Equation Modeling Partial
Least Square (SEM-PLS), and a questionnaire was distributed to 50 respondents. The
results obtained factors that affect participant satisfaction is the quality of service which
is also influenced by tangibility, reliability, responsiveness, empathy, and assurances by
testing the validity and reliability that meet the criteria. The results obtained are
expected to be a reference in increasing participant satisfaction with health care
services.

There are 3 serious problems in researching participant satisfaction, this is because

there are differences of opinion in testing participant satisfaction namely how to choose
an appropriate definition for the given study, operationalize the definition, and interpret
and compare empirical results. Basic structure and theory are influenced by these three
problems. When discussing and testing theories, it is important to explain conceptual
matters. Part of this process is defining an interesting construct and explaining why this
conceptualization is appropriate. However, if there are several theories that explain
different definitions, the researcher takes an understanding that approaches the truth
according to the field being discussed.

Patient satisfaction and its impact on healthcare and health outcomes date back to the
1950s when relationships between patients and healthcare providers were
examined.1 These relationships have become extremely complex as the healthcare
industry has grown, and there is now legislation in the form of the Affordable Care Act
(ACA) requiring that these relationships impact the business of healthcare in the form
of reimbursement and consumerism. Operating as a service industry, healthcare has
similarities to other firms whose goal is perfecting customer satisfaction and providing
superior services or products. The purpose of this paper is to discuss how there has
been a shift from the primary goal of medically treating patients to now treating them
as consumers, and how patient satisfaction is changing the structure of healthcare.
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 Table of Contents
Chapter- 01: Introduction .................................................................................. 1

1.1: Preface ............................................................................................................................ 1

1.2: Importance of the Study ................................................................................................. 3
1.3: Objective of the study ..................................................................................................... 4
1.4: Methodology of the Study .............................................................................................. 4
1.4.1: Research Design ...................................................................................................... 4
1.4.2: Sample Size ............................................................................................................. 5
1.4.3: Questionnaire Design and Sampling ....................................................................... 5
1.4.4: Data Collection........................................................................................................ 5
1.5: Literature Review ....................................................................................................... 5
1.6: Limitation of the Study ................................................................................................... 8
Chapter- 02: Overview of the Healthcare Industry ........................................ 9

2.1: Overview of the Health System ...................................................................................... 9

2.2: Historical Background of Healthcare Service in Bangladesh .......................................11
2.3: Health System Organization in Bangladesh ................................................................. 13
2.3.1: Administrative structure of the statutory health system ........................................ 13
2.3.2: Public sector health services ................................................................................. 15
2.3.3: Private sector health services ................................................................................ 16
2.3.4: Diagnostics ............................................................................................................ 17
2.3.5: NGOs..................................................................................................................... 17
2.3.6: Donors ................................................................................................................... 18
2.3.7 Professional groups ................................................................................................ 18
Chapter- 03: Market Analysis of the Healthcare Industry ........................... 19
3.1: Market Size and Growth of Healthcare ........................................................................ 19
3.2: Market Segmentation of Healthcare Service ................................................................ 22
3.3: Healthcare Sector Policies and Strategies .................................................................... 24
3.3: Factors driving patient satisfaction: the study framework ........................................... 27
3.3.1: Service factors ....................................................................................................... 27
3.3.2: Additional factors .................................................................................................. 30
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 3.4: Health Information System in Bangladesh ................................................................... 31
Chapter- 04: Findings of the Study ................................................................. 32

4.1: Demographic Characteristics of the Respondents ........................................................ 32

4.2: Age Distribution of the Respondents ............................................................................ 33
4.3: Gender of the Respondents ........................................................................................... 33
4.4: Occupation of the Respondents .................................................................................... 34
4.5: Family Monthly Income of the Respondents ............................................................... 35
4.6: I Often Visit Healthcare Services ................................................................................. 35
4.7: The Hospitals in Dhaka City's Overall Satisfaction are good. ..................................... 36
4.8: In Dhaka City's Hospital Convenience is good ............................................................ 37
4.9: In Dhaka City Hospital Facilities and Environment is good. ....................................... 38
4.10: In Dhaka City Medical Staff Services Technology is Good. ...................................... 39
4.11: In Dhaka City Medical Staff Services Attitude is good. ............................................ 40
4.12: In Dhaka City Hospital Expenses is Moderate. .......................................................... 41
4.13: In Dhaka City Hospital Registration Method is Very Easy. ....................................... 41
4.14: In Dhaka City Hospital Doctor Visit Promptly. .......................................................... 42
4.15: In Dhaka City Medical Cost Per Family is Expensive. .............................................. 43
4.16: In Dhaka City Hospital's Information Can Get from Websites Easily. ...................... 44
4.17: You are Satisfied with the Level of Customer Service Provided by Healthcare
Providers. ............................................................................................................................. 44
4.18: Overall Customer Attitude toward Healthcare Services. ............................................ 45
Chapter- 05: Recommendation and Conclusion ............................................ 47
5.1: Recommendation .......................................................................................................... 47
5.2: Conclusion .................................................................................................................... 49
References ........................................................................................................................... 50
Appendix ............................................................................................................ 53

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 List of Figures

2.1: Organization of Health Service System in Bangladesh…...…….…….… 10

2.2: Health Service Delivery Organization Structure in Bangladesh………. 15

4.1: Age of the Respondents………………...….........…….…….…….…….… 33

4.2: Gender Ratio of the Respondents…….…….…….…….…………....……. 34

4.3: Occupation of the Respondents…….…….…….………….….…….……. 34

4.4: Family Income of the Respondents……………….…….…….…….……. 35

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 List of Tables

4.1:
4.1: Demographic Characteristics of the Respondents……………………... 32
4.2:
4.2: Visiting Healthcare Services…………………………………………… 36
4.3: Getting Overall Satisfaction……………………………………………. 37
4.3:
4.4: Dhaka City’s Hospital Convenience…………………...............………
4.4: 37
4.5: Sufficient Facilities and Environment………………………………….
4.5: 38
4.6: Medical Staff Services Technology……………………….....................
4.6: 39
4.7: The Medical Staff Services Attitude…………………………………… 40
4.7:
4.8:
4.8: Hospital Expenses Are Moderate………………………………………. 41
4.9:
4.9: Hospital Registration Methods Are Easy………………………………. 42
4.10:
4.10: Hospital Doctor Visit Promptly………………………………………. 42
4.11:
4.11: Medical Cost Per Family Is Expensive……………………………….. 43
4.12:
4.12: Hospital’s Information Can Get from Websites……………………… 44
4.13:
4.13: Customers’ Satisfaction about Service Provided……………………... 45
4.14:
4.14: Overall Customer Attitude towards Healthcare Services…………….. 46

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 Chapter- 01: Introduction
1.1: Preface

The health sector occupies an enormously important position in ensuring sustainable

overall socio-economic advancement in developing countries. In Bangladesh, the
government has begun to strategically integrate the health sector into its poverty
reduction plans. The alternative—an unhealthy nation—is destined to perpetuate a
vicious cycle of poverty. In this regard, the Commission on Macroeconomics and
Health (2001) asserts that ‘Improving the health and longevity of the poor is an end in
itself, a fundamental goal of economic development’ (see Executive Summary). The
efforts of the government, NGOs, and private service providers in the country’s health
sector have been rewarded with some success, especially in primary health care with its
focus on prevention. Presently, 73% of children are fully immunized in Bangladesh
(NIPORT 2004) and the child mortality rate has declined substantially to 88 per 1000
from 153 in the mid-1970s (Government of Bangladesh 2003). Maternal mortality, an
important indicator of well-being, has also declined, to 3.2 per 1000 in 2001 from 6 per
1000 in the 1980s, with the introduction of appropriate preventive measures (NIPORT
2003). While the efforts are in the right direction, the public health sector is plagued by
uneven demand and perceptions of poor quality. Countrywide, the underutilization of
available facilities is of significant concern. For example, one study shows that the
overall utilization rate for public healthcare services is as low as 30% (Ricardo et al.
2004). Moreover, the trend of utilization of public health care services has been
declining between 1999 and 2003, while the rate of utilization of private health care
facilities for the same period has been increasing (CIET Canada 2003). The
unavailability of doctors and nurses, as well as their negative attitudes and behaviors,
are major hindrances to the utilization of public hospitals. The situation is further
compounded by a lack of drugs, and long travel and waiting times (HEU 2003a). What
is particularly disturbing is the lack of empathy of the service providers, their generally
callous and casual demeanor, their aggressive pursuit of monetary gains, their poor

1
levels of competence, and, occasionally, their disregard for the suffering that patients
endure without being able to voice their concerns—all these service failures are
reported frequently in the print media. Such failures can play a powerful role in shaping
patients’ negative attitudes and dissatisfaction with health care service providers and
health care itself. The private healthcare sector (including unqualified providers) also
deserves scrutiny as about 70% of the patients seek medical care from this sector
(World Bank 2003). Between 1996 and 2000, private hospitals grew around 15% per
annum (HEU 2003b). Unfortunately, there are concerns that the quality of service is
being ignored here as well. Some of its main drawbacks include disregard of standard
treatment protocols, lack of qualified nurses and unnecessary diagnostic tests (World
Bank 2003). The Bangladesh Government and its development partners have also
acknowledged their concerns about the quality of health care services (Ministry of
Health and Family Welfare 2003): no privacy ...A good number of posts are lying
vacant at Upazila and below levels. Rural facilities need more budget to meet local
needs. Most of the time, providers are busy with other activities, including private
business. Unavailability of drugs is the single most important reason for people’s
dissatisfaction about public health facilities.’

These instances reflect the problems of the health service delivery system that must be
quickly and responsibly addressed. With the quality of services showing little signs of
improvement, many Bangladeshi patients who are able to afford it are going to foreign
hospitals, despite the financial costs and the cumbersome processes involved in getting
visas, obtaining foreign exchange, arranging for transportation, accommodation, and
food, and finding the right service providers. Clearly, the perceived benefits to them
exceed the costs. This also results in huge losses of foreign exchange for Bangladesh,
estimated at Tk.500 million a year (IHE 2002). Under these circumstances, this study
attempts to identify the factors that influence patients’ satisfaction with healthcare
services and examines their service experiences with public, private, and foreign
hospitals. A better understanding of the determinants of patient satisfaction with the
different types of hospitals should help policy- and decision-makers adopt and
implement effective measures to improve healthcare services in the country. The
following are the main objectives of this study:

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  Identify the key factors that affect patients’ satisfaction.
 Assess how these key factors are rated by patients.
 Determine the effects of these factors on patient satisfaction when applied to
users of public, private, and foreign healthcare services.

1.2: Importance of the Study

The study on factors affecting customer Trust in health service has importance in many
aspects. It is necessary from the marketer’s point of view and fruitful from the
customer's view. That importance can be classified with its consequences. Nowadays
many studies have been conducted on the healthcare service industry in our country,
but there is a scarcity of specific studies on customer Trust. So, it’s important to
increase the literature in this sector. It will also provide some advantages.

The study can provide insights into the key factors that influence customer trust in
health care services, which can help merchants to better understand their customers and
improve their online businesses. By identifying the key factors that influence customer
trust, the study can help merchants to provide a more satisfying experience for their
customers, which can lead to increased customer loyalty and repeat business.

The research will help to build knowledge about customers and facilitate serving and
will provide aid to the awareness about the growing healthcare service industry. As
privacy concerns continue to be a major issue in health care service, the study can
provide insights into how merchants can better address these concerns and increase
customer trust. It will provide a means to understand the customer’s psychology,
various issues, and public feedback.

Another importance of doing this research is it can be an aid to the healthcare service
business. Research is the tool for building knowledge and learning for that sector.
Customers can identify reliable sources, and businesspeople can define the factors they
should improve. Research also increases public awareness. People know about health
care services but sometimes they are unaware of the present situation of the market.

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Research also can be a way to prove the truths and support those. By improving
customer trust in health care service, the study can help to increase the growth and
competitiveness of the healthcare service industry.

This research can be a means to find, gauge, and seize the opportunities of health care
service both for the customers and businesspeople. It also creates an opportunity for
further investigation of the factors and covers the error of the previous study.

The report will initially offer an outline of the tasks completed throughout the period of
conducting research with technical details. Then the results obtained shall be explained
and analyzed. The research report shall also elaborate on the future works which can be
persuaded as an advancement of the current research work. I have tried my best to keep
the research paper simple yet technically correct. I hope I succeed in my attempt.

1.3: Objective of the study

The main objective of this study is to find out affecting factors of Customer Trust in the
healthcare service business. More especially the other objectives are as below:

1. To evaluate the scenario of healthcare service in Bangladesh.

2. To identify the factors that affect Customer Trust.
3. To investigate the level of influence of each of the factors on Customer Trust.
4. To put forward some suggestions in order to increase customer’s Trust in E-
commerce Business.

1.4: Methodology of the Study

The methodology is the process used for designing and conducting research. It includes
the way of organizing secondary data and collecting primary data from the source.

1.4.1: Research Design

The research paper has both exploratory and conclusive methods with quantitative
research methods for collecting primary data. Exploratory research will use to gain an
understanding of the underlying reasons, opinions, and motivations. Quantitative

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research will be employed to quantify the matter by means of generating numerical data
or information that may be remodeled into usable statistics.

1.4.2: Sample Size

Sample size depends on the average users and convenient users of e-commerce. The
sample size is based on the total population. As the convenient sampling method will
have been taken, the sample size is 50.

1.4.3: Questionnaire Design and Sampling

The survey of the research also related to developing the questionnaire, selecting the
sample number, and sampling method. The questionnaire will be designed with Likert
scale measurement in case of finding factors. The questionnaire will be divided into
two parts, demographic questions, and factor-wise questions.

1.4.4: Data Collection

The study on this research is mainly based on primary and secondary data. The
secondary information will be used to write the introduction part of the report. The
information will be gathered from the different E-commerce websites articles based on
E-commerce. The primary information will be gathered from a survey that I will
conduct on the customers of recent E-commerce websites via the internet, Facebook,
and everything else based on whatever I will collect for the research purpose.

1.5: Literature Review

A comprehensive model of patient satisfaction has many policy implications in regard
to identifying patient needs, developing standards, designing services systems and
processes, establishing employee and patient roles in service delivery, enhancing
training programs, managing demand and capacity, and delivering the needed quality of
services. To these ends, measuring service quality and satisfaction is very important. As
might be expected, the service orientation of doctors came out as the strongest factor
influencing patient satisfaction in all three types of hospitals. This is not surprising.
Usually in Bangladesh, patients’ experiences on this factor are not very positive. Since
most of the reputed physicians in the country serve multiple hospitals, they are
incapable of giving due time and attention to patients. Previous studies from Aldana et

5
al. (2001) and Rahman et al. (2002) also identified long waiting times and insufficient
consultation time as factors contributing to patient dissatisfaction in Bangladesh. Yet,
the overall ratings of doctors in our study are positive. Whether this represents a
positivity bias among patients evaluating the ‘exalted’ doctor, whether it is due to the
sample from Dhaka City, whether it is the reputed hospitals that were selected, or
whether it is because no better service is expected anywhere else in the country, the
higher-than-expected ratings have plausible explanations.

Given the important role of doctors in patient satisfaction, policymakers in Bangladesh

ought to initiate a professional development program (PDP) for physicians to provide
required technical and behavioral training. According to the World Bank (2003), there
is little documented evaluation of the quality of physician care in Bangladesh, in both
the public and the private sectors. PDP is a proven step in developed countries; thus,
customized versions of such programs have a place in Bangladesh that must be
vigorously pursued. Combining this approach with periodic certification requirements
ought to go a long way in improving health care provision in the country. The practice
of limiting the maximum number of patients to be visited by a physician in a day could
also be imposed in both the public and private hospitals. While this measure might lead
to an increase in costs per patient visit, the gains from quality treatment due to lower
patient loads should be reflected in fewer mistakes, fewer returns for additional service,
and hence lower overall costs. The significant contribution of nurses to patient
satisfaction in Bangladesh also ought to be noted. Unfortunately, the number of nurses
in Bangladesh today imposes serious constraints on health service delivery. Currently,
there are only eleven nurses for 100,000 people in Bangladesh compared to 94 in India
and 103 in Sri Lanka (Ministry of Health and Family Welfare 2004). In addition, the
nurses are also not equipped with the right behavioral and technical skills. Rahman et
al. (2002) indicate that patients were very dissatisfied with their behavior and
inefficiency. Our findings for urban areas do not support such a strong position: patients
were not ‘very’ dissatisfied with them. We hasten to add, however, that a larger sample
covering hospitals in rural areas may provide alternative insights. Bangladesh and its
development partners (e.g., the World Bank and WHO) have recently taken steps to
further the development of nurses by conducting behavioral change courses and
introducing nursing standards at different hospitals. However, much more needs to be

6
done. There is a general notion in Bangladesh that people entering the nursing
profession usually come from lower socio-economic strata. Coming with attitudes and
concepts from their world of struggle, their attitudes may be difficult to change. While
such a belief is debatable, there is no denying that the nursing profession should be
accorded more social status to attract others, especially from the upper strata, to provide
this vital service. This might be accomplished by offering a higher salary, fringe
benefits, free technical and behavioral training, free placement of their services in the
country and abroad and promoting their role and status more widely. The private health
sector is better resourced to actively pursue and promote higher nursing standards and
to guide the healthcare sector in this regard. It is also pertinent to note that healthcare
service providers and planners in Bangladesh are often more concerned about the cost
of healthcare rather than its quality. They feel that people in Bangladesh do not want to
pay more for higher service quality. This study suggests that cost is not a significant
contributor to patient satisfaction, especially for the private sector and for those
availing of foreign hospitals: instead, the quality of service is much more important.
Consequently, policymakers must recognize that a class of patients prefers quality
services to a cheaper but inferior solution that may add to future costs. It may be useful,
therefore, to look at health service delivery from a market segment perspective where
costs are emphasized to a specific segment and service is emphasized to others, but
with the right balance that meets minimum standards. The matter of Baksheesh
represents a double-edged issue for the health care system; while it increases the
efficacy of services received, it also serves as a disadvantage to those who are unable or
unwilling to accommodate this demand and thereby receive lower levels of services.
Hospitals could outlaw this practice, but only if they can make alternative arrangements
to better compensate service providers, especially the lower-level staff. A comment
about the measures we used in this study is also pertinent. The derived factors used in
the analysis are different from the ones originally proposed, yet they make clear sense
in that people apparently evaluate medical care not so much by service factors but by
personages or service providers when such personages are identified in the scales.
Since we used the terms ‘doctor’ or ‘nurse’ (instead of staff or personnel) in this study,
instead of assessing hospital services along the service quality dimensions initially
posited, respondents, assessed the personages and evaluated them comprehensively
along the service dimensions. This raises interesting questions about how service

7
recipients evaluate services (by provider categories or by service dimensions) that need
to be examined in future research. Finally, since the study was conducted in Dhaka
City, we caution against generalizing the results to the context of the entire country. The
models also compare the better hospitals in the city and the ones selected abroad. They
may be considered as benchmark hospitals against which services of others could be
compared and improved.

Concern over the quality of health care services in Bangladesh has led to loss of faith in
public and private hospitals, low utilization of public health facilities, and increasing
outflow of Bangladeshi patients to hospitals in neighboring countries. Under the
circumstances, assessment of the country’s quality of health care service has become
imperative, in which the patient’s voice must begin to play a greater role. This study
attempts to identify the determinants of patient satisfaction with public, private, and
foreign hospitals. A survey was conducted involving inpatients in public and private
hospitals in Dhaka City and patients who have experienced hospital services in a
foreign country. Their views were obtained through exit polls using probability and
non-probability (for foreign hospital patients) sampling procedures. Regression models
were derived to identify key factors influencing patient satisfaction in the different
types of hospitals. Doctors’ service orientation, a composite of 13 measures, is the most
important factor explaining patient satisfaction. Policy implications are discussed.

1.6: Limitation of the Study

It is important to stress several limitations of the method used for this research –

 Limitation of time
 Unwillingness of the people to fill up the survey was a problem.
 There are vast amounts of information and write-ups relating to the topics of
this research are present on the internet and various other sources, but it was not
possible to gain access to much such information.
 A minimal sample size is selected for this research. If a larger sample was taken
into consideration the research would have been more accurate.

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Chapter- 02: Overview of the Healthcare
Industry
2.1: Overview of the Health System

The provision of basic health services in Bangladesh is a constitutional obligation of

the Government (IGS, 2012). Article 15 of the Constitution stipulates that it shall be a
fundamental responsibility of the State to secure for its citizens the provision of the
necessities of life, including food, clothing, shelter, education and medical care. In
addition, Article 18 of the Constitution asserts that the State shall raise the level of
nutrition of its population and improve public health as some of its primary duties. In
line with this broad legal framework, the health sector has developed policies and
programs which are implemented through the central control of the Ministry of Health
and Family Welfare. Despite the constitutional obligation to secure health services for
the people, in practice, this responsibility has been significantly shared with the private
sector. The country has an entrepreneurial health system, i.e., access to health services
is considered the individual’s responsibility depending on his or her economic
condition. The health system of Bangladesh is pluralistic, referring to the existence of
multiple actors performing diverse roles and functions through a mixed system of
medical practices. There are four key actors that define the structure and functioning of
the broader health system: Government, the private sector, NGOs, and donor agencies.
The government, the private sector and NGOs are engaged in service delivery,
financing and employing health staff; donors play a key role in financing and planning
health programs. The public sector is mandated not only to set policies and regulations
but also to provide comprehensive health services and to manage e financing and
employment of health staff. The Government regulates the functions of public, private,
and NGO providers through various acts and legislation. It delivers services through its
nationwide infrastructure by employing doctors, dentists, nurses, pharmacists, and a
huge number of auxiliary health workers. Public sector care includes curative,
preventive, promotive, and rehabilitative services, while the private sector provides
mostly for-profit curative services and not-for-profit curative services to a limited
extent at the national and sub-national level. NGOs, on the other hand, provide mainly

9
preventive and basic care. The private sector, with its limited infrastructure, employs
more providers than the public sector, including traditional healers, unqualified
allopath’s, and doctors who are already employed by the Government. On the other
hand, NGOs provide mostly not-for-profit services to the underserved population. The
Ministry of Health and Family Welfare regulates both public and private sector health
services. As per Schedule I of the Rules of Business, the Ministry has been empowered
to act as the central body for policy formulation and planning, regulating the medical
profession and standards, managing, and controlling drug supply, administering
medical institutions, providing health services and much more. The Ministry, with its
two wings of Health and Family Planning, manages public sector health services
ranging from primary to tertiary care (excluding urban primary care), stretching from
the central level to the grassroots and covering both rural and urban areas. It is worth
noting that although the Ministry is the leading agency for institution-based health care
delivery at the national level and in rural areas, primary health care in urban areas is the
responsibility of respective local government institutions (municipalities and city
corporations) which are under the Ministry of Local Government, Rural Development
and Cooperatives. Private sector infrastructure, on the other hand, is limited to medical
colleges, hospitals, clinics of various natures and qualities, pharmacies, and untrained
healers. Service coverage by the private sector is wider than the public sector
(http://uphcp.gov.bd/Responsibilities). A figure (Figure 2.1) of organization of health
service system in Bangladesh:

10
 Figure 2.1: Organization of health service system in Bangladesh

Source: Asia Pacific Observatory on Health Systems and Policies

2.2: Historical Background of Healthcare Service in

Bangladesh

Modern health systems evolved in Bangladesh, as in many developed countries, within

the premises of Government-owned health-care establishments largely funded by
government tax revenues. Bangladesh was a part of India when it was a British colony
and later became the eastern province of Pakistan (East Pakistan) at the time of the
partition of British India on 14 August 1947. Thus, Bangladesh inherited a highly
centralized healthcare system from the former British colonial power, which was then
influenced by health policies in Pakistan until its independence in 1971 (Mahmood,
2009). In 1946, a Health Survey and Development Committee was formed, popularly
known as the “Bhore Committee”, with the objective of exploring conditions and health
service provision and putting forward recommendations for further development. The
Committee proposed a comprehensive healthcare service provision system; inter alia,
integration of curative and preventive services, production of basic doctors for rural
health institutions, and the establishment of rural health centers. During the early
1960s, several initiatives were undertaken to strengthen health systems. Important

11
among them were (i) the scheme of Rural Health Systems, comprising one rural health
center and three subcenters for every 50 000 people; (ii) the Malaria Eradication
Program; and (iii) the Family Planning Program that over time turned into a department
under the Ministry of Health and Family Welfare. After independence in 1971, the
country inherited a healthcare delivery system comprising eight medical college
hospitals, 19 district hospitals, several sub-divisional hospitals, and rural and urban
health centers (dispensaries). In the early days of independence, overpopulation was
recognized as the major obstacle to national development. Accordingly, a separate
division for family planning activities under the Ministry of Health was created. In
1975, the Ministry of Health was bifurcated into two wings and population control
received new impetus in health sector planning. The First Five Year Plan (1972–1978
and then extended to 1980) emphasized primary health care (PHC) as the key to
improving health care, as stated in the Alma-Ata Declaration of 1978 (Anwar, Islam et
al., 2012). The plan established 31-bed Upazila Health Complexes (UHCs) in most
rural subdistricts, while the second and third Five Year Plans (1980–1990) strengthened
human resources for health (Anwar, Islam et al., 2012). During the third and fourth
planning periods (1986–1998), the Government implemented a number of child health
programs including the Expanded Program on Immunization (EPI), Control of
Diarrheal Diseases (CDD), the Acute Respiratory Infection (ARI) Control Project and
the Night Blindness Prevention Program (Anwar, Islam et al., 2012). These health
development projects were impressive in reducing mortality and morbidity. Since the
late 1990s the health sector has gone through massive institutional reform to promote
greater equity and efficiency in resource use under the influence of external donors. In
1996, the World Bank and other consortium members indicated to the Government that
they would not proceed with further credits until a comprehensive, sector-wide strategy
had been adopted (Vaughan, Karim, et al., 2000). This included substantive structural
and organizational reforms by the Ministry of Health and Family Welfare (Buse,
Gwinn, 1998). Accordingly, the Health and Population Sector Strategy (HPSS)
approved in 1997 gave the health sector a new direction towards efficiency and cost-
effectiveness through advocating certain institutional and governance reforms in the
health sector. The HPSS fed into two consecutive policy documents – the Fifth Five-
Year Plan (1997–2002) and the National Health Policy approved in 2000. As a result,
these three documents advocated for a common set of institutional reform strategies,

12
including the provision of primary health services in an ESP, introduction of the Sector
Wide Approach (SWAp), one-stop services through community clinics at the village
level, unification of the Health and Family Planning Directorates, administrative
decentralization, and the creation of static clinics (community clinics). Accordingly, in
1998 the first-ever five-year operational program, called the Health and Population
Sector Program (HPSP) (1998–2003) was designed and implemented. With the
termination of HPSP, the Health Population and Nutrition Sector Program (HPNSP) for
2003–2010 was launched, with similar strategies but an added emphasis on nutrition.
With its expiry in 2011, the country has designed another operational program called
the Health, Population, and Nutrition Sector Development Program (2011–2016), with
a renewed emphasis on improving nutrition by streamlining this service at various
levels of the health system (MOHFW, 2011).

2.3: Health System Organization in Bangladesh

2.3.1: Administrative structure of the statutory health system

The Ministry of Health and Family Welfare implements its programs and provides
services through different executing and regulatory authorities. The executing
authorities include five Directorates of the Ministry and some other organizations. The
Directorates are the Directorate General of Health Services (DGHS); Directorate
General of Family Planning (DGFP); Directorate General of Drug Administration
(DGDA); Directorate of Nursing Services (DNS); and the Health Engineering
Department (formerly known as the Construction Management and Maintenance Unit).
The DNS and the DGDA are attached to the health wing of the Ministry of Health and
Family Welfare. The DNS is responsible for nursing education and nursing services,
while the DGDA implements drug regulations. Other executive organizations
accomplishing significant tasks of the Ministry include the Transport and Equipment
Maintenance Organization, National Electro-medical and Engineering Workshop, and
the Essential Drugs Company Limited. The regulatory bodies of the health sector are
the Bangladesh Medical and Dental Council (BMDC), Bangladesh Nursing Council
(BNC), State Medical Faculty (SMF), the Ayurvedic, Homeopathy and Unani Board,
and the Bangladesh Pharmacy Council.

13
To facilitate research and training in medical science, different public sector institutions
under the control of the Ministry of Health and Family Welfare operate at the national
level. There are 21 government medical colleges, six postgraduate institutes, three
specialized institutes, two institutes of health technology, and five medical assistant
training schools in Bangladesh (DGHS, 2012). For research, there are two institutions,
the Bangladesh Medical Research Council (BMRC) and the National Institute of
Population Research and Training (NIPORT). In addition, there are a few public health
research and training institutions, including the Institute of Epidemiology, Disease
Control and Research (IEDCR), Institute of Public Health (IPH), Institute of Public
Health and Nutrition (IPHN), and National Institute of Preventive and Social Medicine
(NIPSOM).

Additionally, the Government of Bangladesh delivers healthcare services in partnership

with NGOs. The Urban Primary Healthcare Services Delivery Project (UPHCSDP)
covers all seven city corporations and five municipalities (Bogra, Comilla, Madhabdi,
Savar and Sirajgonj) in Bangladesh (UPHCSDP, 2014). The goal of the project is to
improve the health status of the urban population, especially the poor, through
improved access to and utilization of efficient, effective, and sustainable PHC services.
The Ministry of Local Government, Rural Development and Cooperatives is
responsible for managing this project through a Project Management Unit established
in the six city corporations and the five selected municipalities.

At least 30% of the total services provided by this project are targeted to the poor free
of cost. UPHCSDP service providers are contracted to deliver an agreed “Essential
Services Package +” (ESP+) through partnership agreements with a focus on access for
the poor. The services are provided through Comprehensive Reproductive Health-care
Centers, Primary Health-care Centers and PHC Outreach Centers (satellite clinics) in
24 Partnership Areas. The centers are generally managed and run by 12 partner NGOs.
UPHCSDP provides services for reproductive healthcare, child health care,
communicable disease control, limited curative care, management and
prevention/control of reproductive tract/sexually transmitted infections, voluntary
confidential counseling and testing for HIV/AIDS, management of violence against

14
women, primary eye care, TB control and treatment, behavior change communication,
and diagnostic services.

2.3.2: Public sector health services

The Ministry of Health and Family Welfare has an extensive health infrastructure. The
service delivery structure follows the country’s administrative pattern, starting from the
national to the district, upazila, union and finally to the ward levels. It provides
promotive, preventive, and curative services such as outdoor (outpatient), indoor
(inpatient), and emergency care at different levels – primary, secondary, and tertiary.
The chart below (Figure 2.2) summarizes the organization of the Ministry of Health and
Family Welfare service delivery structure.

“The healthcare system of Bangladesh relies heavily on the government or the public
sector for financing and setting overall policies and service delivery mechanisms”
(Islam & Biswas, 2014, p. 366). The governmental healthcare services are rendered
through the Ministry of Health and Family Welfare (MOHFW) and Ministry of Local
Government, Rural Development and Cooperatives (MOLGRDC).

Primary healthcare services include general health and family planning services for the
people in rural areas. There are 421 Upazila Health Complexes accommodating 15958
beds (DGHS, 2021), 3900 Union Health and Family Welfare Centers, and 13000
Community Clinics at ward level across the country for delivering primary healthcare
services. “Bangladesh has established more than 13,000 community clinics (CCs) to
provide primary healthcare with a plan of each covering a population of around 6,000”
(Riaz, et al., 2020). In addition, the Ministry of Local Government, Rural Development
and Cooperatives manage the provision of urban primary care services. Furthermore,
“providing the primary healthcare in urban areas is the responsibility of respective local
government institutions namely municipalities and city corporations which are under
the Ministry of Local Government, Rural Development and Cooperatives” (Ahmed et
al., 2015). A figure (figure 2.2) of Health service delivery organizational structure in
Bangladesh

15
 Figure 2.2: Health service delivery organizational structure in Bangladesh

Source: Asia Pacific Observatory on Health Systems and Policies

2.3.3: Private sector health services

In the private sector, providers can be grouped into two main categories. First, the
organized private sector (both for-profit and nonprofit) which includes qualified
practitioners of different systems of medicine.

Apart from modern medicine, traditional medicine is widely practiced in the private
sector. Second, the private informal sector, which consists of providers not having any
formal qualifications such as untrained allopath’s, homeopaths, kobiraj, etc., known as
Alternative Private Providers. These informal/traditional private service providers
mostly serve the poor in rural areas. On the other hand, formal, for-profit, or nonprofit
service institutions are mostly located in urban areas. Private facilities including
medical colleges, hospitals, clinics, laboratories, and drug stores are being established
in increasing numbers in the capital city as well as other divisional headquarters. This
causes geographic inequity in health service provision. The private facilities are often
staffed with public sector health personnel. Many health professionals hold two jobs.

16
The growth of the private sector compared to the public sector is significant. Along
with the increasing number of hospitals and hospital beds, over the last few years, the
private sector has witnessed tremendous growth in teaching institutions. For instance,
in 1996 there were no medical colleges or any teaching institutions in the private sector,
but by 2011 the private sector had 44 medical colleges (MOHFW, 2013).

2.3.4: Diagnostics
Along with private clinics and hospitals, the number of diagnostic centers in the private
sector is growing. In 2000, approximately 838 laboratories and other diagnostic centers
were registered with the Ministry of Health and Family Welfare. This number has risen
to 5122 in 2012 (MOHFW, 2012). In the private for-profit sector, there are some large
diagnostic centers in the cities (Lab-aid, Popular Diagnostics) providing laboratory and
specialized radiological tests. Some of these facilities maintain a high standard. In the
nonprofit private sector, there are centers like the International Centre for Diarrhoeal
Diseases and Research, Bangladesh, located in Dhaka, which has a modern laboratory
providing research facilities and extending laboratory services to the general
community.

2.3.5: NGOs
The NGO sector has emerged as the third sector, providing new options and
innovations. Bangladesh is known worldwide for having one of the most dynamic NGO
sectors, with over 4000 NGOs working in the population, health and nutrition sector
(Perry, 2000). NGOs have been active in health promotion and prevention activities,
particularly at the community level, and in family planning, maternal and child health
areas. The role of NGOs is growing as donors are channeling significant and increasing
amounts of funding directly to them. In 2007, 9% of total health expenditures were
managed by NGOs, up from 6% in 1997; upwards of 80% of NGO funding comes from
donors (Health Economics Unit, 2010). The larger national NGOs (BRAC,
Gonoshasthaya Kendra, Grameen Bank) have strong organizations and the management
capacity to provide both preventive and curative services. These NGOs are well-
equipped with training and research facilities and information management systems.

17
NGO partners provide services for the Expanded Program of Immunization across the
country, in urban and rural areas.

There is generally a good working relationship between the government and NGOs, as
exemplified by the number of public-private partnerships. The Fifth Five Year Plan
(1997–2002) encouraged promotion of the role of the private sector and NGOs in
health development. In later years, health sector diversification was emphasized,
implying a shift from Government’s role being as a “provider “of services towards
being a “purchaser” of services. This established formal collaborations between the
public and private sectors –public-private partnerships.

2.3.6: Donors
Multiple donors, both multilateral and bilateral, have been actively engaged in
healthcare financing and planning. The main bilateral donors to the health and
population sector in Bangladesh are the governments of Australia, Belgium, Canada,
Germany, Japan, Netherlands, Norway, Sweden, the United Kingdom and the United
States (Vaughan, Karim et al., 2000). The multilateral donors include the World Bank,
European Union, UNICEF, ADB, Global Fund to Fight AIDS, Tuberculosis and
Malaria (GFATM), and the GAVI Alliance.

2.3.7 Professional groups

In Bangladesh there are several professional organizations who address the rights of
medical professionals at different levels, such as the Bangladesh Medical Association
(BMA), Bangladesh Private Medical Practitioners Association (BPMPA), Public Health
Association of Bangladesh, Bangladesh Pediatric Society and the Nephrology Society
of Bangladesh. However, there is no organized body, either in the public or private
sector, for overseeing the interests of patients. The Consumers Association of
Bangladesh is an NGO addressing the rights of consumers in general and does not have
a separate agenda on health focusing on the rights of consumers as patients (Consumers
Association of Bangladesh, 2014)

18
 Chapter- 03: Industry Analysis
3.1: Market Size and Growth of Healthcare
In the last five decades, the health conditions of people in Bangladesh have improved
due to the growth of our healthcare service sector. Our average life expectancy has
grown from only 52 years in the 70s to the current 72 years. This has been
accompanied by a reduction in infant and maternal mortality rates, growing access to
healthcare and education, and progress in various social indicators. In 1990, 534
women used to die among one lakh pregnant women, which has come down to 173 in
2016. The infant mortality rate was 9.4 percent in 1981, which has come down to 1.9
percent in 2019. The Extended Immunization Program (Penta V) has been developed to
fight various infectious diseases such as diphtheria, polio, whooping cough, hepatitis B,
rubella and, above all, the BCG vaccine is now given six weeks after birth. Many
hospitals in rural or semi-urban areas are working with local women to create
awareness on maternal health and nutrition, family planning, prenatal maternal
healthcare, etc. Other healthcare organizations and NGOs are also playing a significant
role in raising awareness about primary healthcare and nutrition.

While communities working together in this way for their wellbeing are a sign of hope,
there is a need to specifically look at the growth of the rural health system over the last
five decades. At present, one-third (36.6 percent) of the 170 million people in
Bangladesh live in cities, meaning that most of the country's population are still living
in rural areas. But the major modernization of the country's healthcare management has
been city centric. As a result, people are rushing to metropolitan areas for treatment and
the city's hospitals are struggling to cope. The urban middle class are also travelling to
neighboring countries for better health treatment. According to the Center for Research
and Information (CRI), there are around 600 government hospitals in Bangladesh at
present, of which 482 primary service hospitals are upazila based. There are about 75
secondary hospitals in the districts and 15 hospitals where specialized medical services
are provided. In addition, more than 15,000 community clinics and satellite clinics have
been officially established for primary and child, and maternal healthcare.

19
Despite having so many healthcare centers, community clinics and satellite clinics, why
are people from rural areas rushing to big cities like Dhaka or Chattogram for medical
treatment? According to government information, the number of public and private
hospital beds in Bangladesh is about 1.5 lakh, and the number of private hospitals is
almost double that of government hospitals. According to this calculation, the number
of beds allocated for every 1000 patients in Bangladesh is less than one (only 0.87),
whereas the World Health Organization (WHO) recommends a minimum of three beds
per 1,000 patients for ensuring access to healthcare. In other words, there is no
allocation of hospital beds for two-thirds of the patients in Bangladesh at present,
despite the existence of a network of clinics for primary healthcare.

According to the World Bank, there is also less than one doctor for every 1,000 patients
in Bangladesh (0.6), whereas the WHO recommends one doctor for every 1,000
patients. The proportion of doctors and nurses in Bangladesh is also very skewed—
while there should be at least three nurses per doctor, there is currently less than one. In
other words, the number of nurses is alarmingly low at present. Over the last five
decades, there has been a significant lack of focus on the importance of the nursing
profession for the healthcare sector, although finally in 2016, the government upgraded
the nursing profession to second class and established several nursing colleges.
However, the quality of education in most nursing colleges needs improvement.

Intensive care unit (ICU) beds in the country is something else in which we are lagging
far behind; there are currently not more than 1,200—of which 450 are in government
hospitals and 750 in private ones—less than one per 100,000 patients. The number of
high quality multi-disciplinary tertiary care hospitals is also negligible and most of
these hospitals are in Dhaka. On top of that, patient pressure on specialist physicians is
increasing due to the absence of a system of referrals in healthcare management. If this
were properly implemented, patients at the primary and secondary level could get
treatment from general practitioners so that specialist doctors could focus on the
treatment of critical patients.

20
And it is not just ICUs—many district Sadar hospitals lack CCU facilities and even
elevators. There is often a shortage in power supply, and even if there is a generator, the
allocation of fuel oil is not enough to run it properly. These problems are more evident
at the upazila level. In some cases, the lists of medicine stored at the hospital are not
drawn up or updated regularly. Although there are medicine counters in many upazila
health complexes, there is often an inadequate supply of medicine, irregular supply etc.
Most of these hospitals lack the necessary medical equipment, especially digital X-rays,
CT scan, ultrasonogram and echo-cardiac machines, microscopes, etc. Most hospitals
do not have operational ambulances.

At present Bangladesh ranks 88th in the latest rankings released by the WHO on the
quality of healthcare around the world. Among the SAARC countries, only Sri Lanka is
ranked 76th above Bangladesh. India is 112th, Pakistan is 122nd and Nepal is 150th.
According to this ranking, the health system of Bangladesh appears to be better than
that of India; yet Bangladeshi patients spend about USD two billion a year seeking
treatment in India. We need to really get to the root of this issue.

Currently, Bangladesh is lagging other countries in health spending. Bangladesh spends

2.3 percent of GDP on the public health sector, whereas Nepal spends 5.6 percent, Sri
Lanka 3.8 percent and India 3.8 percent. Developed nations like the UK tend to spend
around 10 percent of GDP on healthcare. In Bangladesh, 65 percent of the allocation is
spent on salaries and allowances, while the rest is meant to be on development.
However, this allocation is clearly not fully utilized due to the lack of overall capacity
of the health sector. It is not enough to increase the budget of the health sector—we
must have good governance and proper healthcare management to ensure that the
growth of the health sector is more uniform and equitable.8

It is said that education is the backbone of the nation and health is the root of all
happiness. Therefore, there is an urgent need to focus on improving the quality of
healthcare in Bangladesh. A few recommendations can be made to bring the health
sector under a robust structure—increase the number of beds and intensive care units
by constructing quality secondary hospitals with individual incentives at the district and

21
upazila levels; introduce patient referral system through digital connectivity in primary,
secondary and tertiary hospitals; introduce health care insurance system and most
importantly, prevent misuse of allocated budgets. We also need to encourage people to
seek medical treatment in government hospitals, as well as set up public-private
partnerships and encourage foreign investment in order to modernize these hospitals.
Government hospitals can also outsource cleaning and support services to be better
developed, and there is also a need to initiate health fairs and health camps in the
villages and remote areas. Finally, we must aim for a better score on the Healthcare
Index, which is an estimation of the overall quality of the healthcare system, healthcare
professionals, equipment, staff, doctors, costs, etc. Currently, Taiwan is scored at
86.42, whereas Nepal is 57.44 and Bangladesh is 43.08.

Our health sector has a huge potential for good. However, we need skilled resources
who will establish good governance with innovative strategies and build a vibrant
health sector in the coming years.

3.2: Market Segmentation of Healthcare Service

The market segmentation of healthcare services typically involves dividing the market
into different groups based on various characteristics such as age, income, gender,
location, health needs, and preferences. Here are some common market segments in
healthcare services:

1. Age-based segmentation: Healthcare services can be segmented based on the age of

the patients, such as pediatric care for children, geriatric care for the elderly, and
general medical care for adults.

2. Geography-based segmentation: Healthcare services can be segmented based on

the location of the patients, such as urban, suburban, and rural areas.

3. Income-based segmentation: Healthcare services can be segmented based on the

income level of the patients, such as low-income, middle-income, and high-income
groups.

22
4. Health-based segmentation: Healthcare services can be segmented based on the
health needs of the patients, such as chronic disease management, preventive care, and
mental health services.

5. Preference-based segmentation: Healthcare services can be segmented based on

the preferences of the patients, such as alternative medicine, home healthcare, and
telemedicine.

By segmenting the healthcare market, healthcare providers can better understand the
needs and preferences of their patients, and tailor their services to meet those needs.

Segmentation of the contraceptive market in Bangladesh already exists with the public
and private sectors playing crucial roles. Using the Demographic Health Survey (DHS)
data to highlight each sector’s efforts to reach contraceptive users, this report will help
guide policymakers and other stakeholders in resource allocation decisions. Analysis of
the users by income, region, and other characteristics has helped determine which
methods are being used, by whom, and from which source. Opportunities have been
identified that will help both the public and private sectors focus their attention on
potential and existing clients. This report is the first step in the consultative process.
The second step, a workshop in Bangladesh for donors and stakeholders, will be to
develop policy to maintain market segmentation.

The market segmentation analysis is supporting the policy process to improve resource
allocation by addressing the contraceptive security challenge in Bangladesh. This final
report has been shared with key stakeholders from the public and private sectors; and
has stimulated discussions about their respective roles, information needs, and interests
in specific market segments. The feedback obtained from stakeholders during the May
2003 market segmentation workshop has helped tailor the analysis to address specific
information needs and has also identified potential opportunities for each sector. This
final report should inform subsequent discussions among stakeholders about
appropriate strategies to improve efficiency and effectiveness of the national family
planning program. This collaborative approach will facilitate identification of
appropriate roles for the public and private sector, allowing each sector to maximize its
contribution and impact.

23
In many countries, a limited resource for family planning is a primary obstacle to
contraceptive security. Sources of funding for family planning include government,
donors, and the private sector. The GOB contributes significantly to the national family
planning program. What is the GOB’s ability to meet the increased funding required as
both contraceptive demand rises while donor funding decreases? Donor funding for
contraceptives is declining. This means that the private sector needs to contribute
significantly to meet the funding gap. In Bangladesh, as in most developing countries,
virtually all private sector spending for family planning comes from households. The
challenge is to increase payments from households without putting an unfair burden on
the poor families of Bangladesh. Therefore, an efficient use of resources means that
payments from households reflect what those households are able to pay, as a way to
maximize private sector resources. Such segmentation, however, requires coordination
among public and private sector stakeholders.

3.3: Healthcare Sector Policies and Strategies

Important health sectors and policies include National Health Policy 2011, Health,
Nutrition and Population Sector of the 7th Five-year Plan, (National Nutrition Policy
2015), 4th (Health, Population and Nutrition Sector) Program (HPNSP) 2017-2022,
Healthcare Financing Strategy 2012-2032: Expanding Social Protection for Health
towards Universal Coverage, Bangladesh Health Workforce Strategy 2016–2021 and so
on (Health Bulletin, 2019).

National Health Policy

2011 Bangladesh did not have any health policy before 2000 when the first National
Health Policy was passed in the Parliament. In the absence of a formal health policy, all
the health-related planning and programming were guided by the health sector
components of successive Five-Year Plans (Chowdhury and Osmani, 2010). The new
National Health Policy (NHP) was passed in Parliament in 2011. The NHP sets out
nineteen goals and objectives, sixteen principles and thirty-nine strategies.

24
According to Murshid & Haque (2020), the specific aims of the Bangladesh National
Health Policy 2011 include “to ensure accessibility of primary health care and
emergency care for all; to ensure quality health-care services for all based on equity; to
extend the coverage of quality health-care services; and to increase community demand
for health care considering rights and dignity.”

The National Health Policy 2011 includes, inter alia, the following as the primary goals
(Murshid and Haque, 2020) “Establishing health care as a right in all layers of society
by ensuring essential elements of care, nutrition, and public health improvement; and
providing quality and easily accessible care, irrespective of an urban and rural
community, mainly focusing on the poor and disadvantaged population.”

The National Health Policy has defined the term health in a broader sense as it
enshrines in the preamble that ‘health’ is not only limited merely within medical care,
but it also includes pure water, nutritious food, healthy environment and so on. A
concerted effort of stakeholders is required with a view to securing good health to
people as envisaged in NHP.

National Nutrition Policy 2015

The National Health Policy 2015 has categorically underscored that ‘health’ is not
limited merely within the medical care, but it also includes pure water, nutritious food,
healthy environment and so on. Nutrition also is a basic human right, with both equity
and equality related to eliminating malnutrition and ensuring human development
(NNP, 2015). The NNP (2015) aims at improving “the nutritional status of the people,
especially disadvantaged groups, including mothers, adolescent girls and children;
preventing and controlling malnutrition; and accelerating national development through
raising the standard of living”.

(Healthcare Financing Strategy 2012-2032: Expanding Social Protection for

Health towards Universal Coverage)

25
One of the major hindrances to access health care service is financial. Health care
services in Bangladesh are received out-of-pocket expenditure to a great extent.
“Globally, such expenditures account for about 32% of total expenditure on health but
for Bangladesh, it makes up to 64% of the total health expenditures” (MOHFW, 2012).
“Such high out of pocket expenditures on health can lead to loss of productive assets
(selling items to pay for medicines) and threaten economic survival, especially in
countries with high rates of catastrophic illnesses, such as Bangladesh” (MOHFW,
2012). The Healthcare Financing Strategy 2012-2032 sets out a framework for
formulating a healthcare financing policy in Bangladesh. The strategy has been drawn
up in line with the objectives as envisaged in the Health, Population and Nutrition
Sector Development Program (HPNSDP) 2011-2016, the Universal Health Coverage
(UHC) as prescribed by the World Health Organization (WHO), and the National
Health Policy, 2011 that underscores the necessity of dedicating more funds in health
sector development. However, in a country like Bangladesh, there are several
challenges in the financing health sector so as to offer access to health for all, e.g. (i)
inadequate health financing; (ii) inequity in health financing and utilization; and (iii)
inefficient use of existing resources.

As per MOHFW (2012), “the goal of the national health financing strategy is to
strengthen financial protection and extend health services and population coverage
especially to the poor and vulnerable segments of the population, with a long-term aim
to achieve universal coverage”. Further, MOHFW (2012) provides that “the role of
health financing is to: (i) provide all the people with access to necessary health services
including prevention, promotion, treatment and rehabilitation of sufficient quality to be
effective; and (ii) ensure that the use of these services does not expose the user to
financial hardship”.

26
3.3: Factors driving patient satisfaction: the study framework

Studies in the developing world have shown a clear link between patient satisfaction
and a variety of explanatory factors, among which service quality has been prominent
(Rao et al. 2006; Zinedine 2006). We believe this link is important also in the health
care sector in Bangladesh. Earlier studies suggest that service quality can be adequately
measured using the SERVQUAL framework (Parasuraman et al. 1991, 1993), and its
refined version in the context of Bangladesh (Andaleeb 2000a, 2001), to help explain
patient satisfaction.

The framework, further embellished based on focus group discussions, is as follows

3.3.1: Service factors

Reliability

Reliability refers to providers’ ability to perform the promised service dependably and
accurately. In Bangladesh, reliability of the provider is often perceived as low for
various reasons, such as the accusation that doctors recommend unnecessary medical
tests, there is an irregular supply of drugs at the hospital premises, supervision of
patients by care providers is irregular, and specialists are unavailable. Perceptions of
reliability are also attenuated when doctors do not provide correct treatment the first
time. In view of these reliability drivers, we felt that the more reliable the health care
providers, the greater the patients’ satisfaction.

Responsiveness

Patients expect hospital staff to respond promptly when needed. They also expect the
required equipment to be available, functional, and able to provide quick diagnoses of
diseases. In addition, patients also expect prescribed drugs to be available and properly
administered, as other indicators of responsiveness. Thus, we posit that the greater the
responsiveness of healthcare providers, the greater the satisfaction of patients.

27
Assurance

Knowledge, skill and courtesy of the doctors and nurses can provide a sense of
assurance that they have the patient’s best interest in mind and that they will deliver
services with integrity, fairness, and beneficence. For a service that is largely credence
based (Zeithaml and Bitner 2000), where customers are unable to evaluate the quality
of the services after purchase and consumption, the sense of assurance that is
engendered can greatly influence patient satisfaction. In the health care system,
assurance is embodied in service providers who correctly interpret laboratory reports,
diagnose the disease competently, provide appropriate explanations to queries, and
generate a sense of safety. Nurses also play an important part in providing additional
support to patients’ feelings of assurance by being well-trained and by addressing their
needs competently. Thus, the greater the perceived assurance from the health care
providers, the greater will be the satisfaction of patients.

Tangibles

Physical evidence that the hospital will provide satisfactory services is very important
to patient satisfaction judgments. Generally, good appearance (tangibility) of the
physical facilities, equipment, personnel, and written materials create positive
impressions. A clean and organized appearance of a hospital, its staff, its premises,
restrooms, equipment, wards, and beds can influence patients’ impressions about the
hospital. However, in Bangladesh, most of the hospitals/clinics are lacking in many of
the above attributes, thereby attenuating patient satisfaction. We posit that the better the
physical appearance (tangibility) of the health care service facility and the service
providers, the greater will be the patients’ satisfaction.

Communication

Communication is also vital for patient satisfaction. If a patient feels alienated,

uninformed, or uncertain about her health status and outcomes, it may affect the healing
process. When questions of concern can be readily discussed and when patients are

28
consulted regarding the type of care they will be receiving, it can alleviate their feelings
of uncertainty. Also, when the nature of the treatment is clearly explained, patients’
awareness is heightened, and they are better sensitized to expected outcomes.
Appropriate communication and good rapport can, thus, help convey important
information to influence patient satisfaction. In particular, patients expect doctors and
nurses to communicate clearly and in a friendly manner regarding laboratory and other
test results, diagnoses, prescriptions, health regimens, etc. Similarly, nurses are
expected to understand patient problems and to communicate them to the doctor
properly. It is proposed that the better the quality of communication perceived by the
patient, the greater will be their level of satisfaction.

Empathy

Health care providers’ empathy and understanding of patients’ problems and needs can
greatly influence patient satisfaction. Patients desire doctors to be attentive and
understanding towards them. Similarly, patients expect nurses to provide personal care
and mental support to them. This reflects service providers’ empathy. We posit that the
more empathy received from the service provider, the greater the satisfaction of the
patients.

Process features

Process features refer to an orderly management of the overall health care service
process. This constitutes patients’ expectation that doctors will maintain proper visiting
schedules and that there will be structured visiting hours for relatives, friends, etc.
Updated patient records and standard patient release procedures also facilitate patient
care. The practice of paying ‘Baksheesh’ (an informal but small facilitation payment),
on the other hand, is an indication of process failures that can sometimes go out of
control. We feel that the better the process features at the hospitals, the higher will be
the level of satisfaction of the patient.

29
3.3.2: Additional factors

Cost

In addition to service factors, perceived treatment cost is another factor that patients
may perceive as excessive. In the more affluent Western world, Schlossberg (1990) and
Wong (1990) suggest that health care consumers have become much more sensitive to
costs, despite health insurance coverage. Wong also predicts that consumers will shop
for the best value. In the developing world, especially Bangladesh, cost is a perennial
concern among those seeking health care service, given their low earnings. Such costs
include consultation fees, laboratory test charges, travel, drugs, and accommodation.
While basic health care service is supposed to be free in public hospitals, patients end
up bearing the costs of medicine and laboratory tests, as well as some additional unseen
costs. Private hospitals are not free, but their costs vary markedly across hospitals. We
posit that the lower the perceived overall cost of health care services, the higher will be
the level of patient satisfaction.

Availability/access

Availability of doctors, nurses and hospital beds round the clock is of concern to
patients in defining the level of access they have to health care. Scarcity of beds and
cabins in the government hospitals sometimes forces patients to choose private
hospitals, often non-reputed ones. To access a foreign hospital, visa processing matters
and arranging for accommodation and food are major concerns; patients usually prefer
countries with minimum hassle in this regard. Therefore, it is hypothesized that when a
hospital has easy physical access, where doctors, nurses, beds/cabins, etc. are available
and when visa processing (for those seeking care abroad) is simple, patients will be
more satisfied. In other words, the greater the patients’ access to hospitals, the greater
will be their satisfaction.

30
3.4: Health Information System in Bangladesh

The Ministry of Health and Family Welfare comprises nine executing authorities
(directorates). As noted, two are directly involved with provision of health and family
planning services, namely the Directorate General of Health Services and the
Directorate General of Family Planning. Four have routine Management Information
Systems (MIS):

• MIS Health (DGHS) and its subsystems.

• MIS Family Planning (DGFP) and its subsystems.
• MIS National Nutrition Program (NNP); and
• MIS 2nd Urban Primary Health-care Program (UPHCPII).

MIS-Health and MIS-FP are being implemented by the DGHS and the DGFP
independently. There is poor linkage between them (both at peripheral and central
level), although both provide summarized data to the Ministry of Health and Family
Welfare regularly. There is also little coordination with the national statistics office, the
Bangladesh Bureau of Statistics.

31
 Chapter- 04: Findings of the Study
4.1: Demographic Characteristics of the Respondents

The survey statistics and secondary data are described after assessing them considering
the study goals. In addition, customers’ thoughts were investigated about healthcare
services in Dhaka and their expectations. 50 respondents were randomly selected for
the survey online. The following table (Table- 4.1) shows the demographic
characteristics of the respondents:

Table- 4.1: Demographic Characteristics of the Respondents

Descriptive Variables Frequency Percentage

Gender:
34 68
Male
16 32
Female
50 100.00
Total

Age of the respondent:

21 42
15-25 Years
24 48
25-35 Years
3 6
35-45 Years
1 2
45-55 Years
1 2
Above 55 years
50 100.00
Total

Occupation:
24 48
Student
14 28
Job holder
4 8
Businessperson
8 16
Others
50 100.00
Total

Monthly Family Income (Tk.):

Below 50000

32
 50000-75000 24 48
75000-100000 7 14
Above 100000 11 22
Total 8 16
50 100.00
Source: Survey

4.2: Age Distribution of the Respondents

According to my survey, the majority 21 respondents are of 15 and 25. Moreover, this
age group has the greatest proportion of taking service. But, in most cases, they are
most concerned with things like quality, cost, and delivery time. Next majority 24
respondent are the client whose age range is from 25 to 35. Following figure (Figure-
4.1) shows the age of the respondents:

Figure-4.1: Age Distribution of the Respondents

4.3: Gender of the Respondents

The gender of healthcare service visitors was my next discovery. I was interested in the
ratio of male to female service takers. From the survey it has been found out that only
32% of women participated in the poll and the number is 16, compared to
approximately 68% of men the number is 34. According to this information, more men
than women visit healthcare service, or more men are visited healthcare service. The
following figure (Figure- 4.2) indicates the ratio of male and female respondents:

33
 Figure- 4.2: Gender Ratio of the Respondents

4.4: Occupation of the Respondents

Getting known about the profession of the healthcare visitor has a great importance.
From that idea I wanted to know about the profession of the visitors. From the survey it
was revealed that 53% of the respondents were students and they were 26 in number.
The next most respondents were job holders who were 25% and 12 in number. The
following (figure- 4.3) shows the occupation of the respondents:

Figure-4.3: Occupation of the Respondents

34
4.5: Family Monthly Income of the Respondents
In the survey, there were different types of people with different sorts of family
income. In the survey, the maximum number of people was 16 who had the income of
50000-75000. The second most respondents were both below 50000 and above 100000
with 12 respondents each. The figure (Figure- 4.4) below is showing the ratio of the
family income of the respondents:

Figure- 4.4: Family Income

4.6: I Often Visit Healthcare Services

Another question I had was whether customers actually go to the healthcare service. I
spoke with several people both inside and outside the organization when I was drafting
my report. I learned from that exchange that not everyone consistently visits healthcare
service. So, it was quite clear to determine whether they visited healthcare or not. From

35
the following table (Table- 4.2) will get to know how much people visit healthcare
service:

Table - 4.2: Visiting Healthcare Services

Number of Respondents
Factors

Disagree

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)
Strongly

Total
(1)

Visiting Healthcare services 07 15 16 07 04 50 3.22

Source: Survey

From the above table (Table- 4.2) through the weighted average we can see that, the
total weighted average on this aspect of the 50 respondents is 3.22 which is
satisfactory. Dhaka city has a healthy number of people visiting healthcare services.

4.7: The Hospitals in Dhaka City's Overall Satisfaction are

good.
There are so much health care in Dhaka city now which are too much complicated to
explore. Users sometimes face a lot of difficulties during visiting, and they failed to get
their desired results. Therefore, I asked people that whether healthcare services are user
friendly or not. In the following table (Table- 4.3) it is shown that how much the
respondents are getting overall satisfaction. Here we can see 11 people agree that the
website is user friendly, 16 people stayed neutral and 15 people disagreed:

36
 Table- 4.3: User Friendly Website/App

Number of Respondents

Weighted Average
Factors

Strongly Agree
Disagree (1)

Disagree (2)

Neutral (3)

Agree (4)
Strongly

Total
(5)
Overall satisfaction 5 11 16 15 03 50 3.00
Source: Survey

From the above table (Table- 4.3) through the weighted average we can see that, the
total weighted average on this aspect of the 50 respondents is 3.00 which is not positive
nor negative. Healthcare service in Dhaka city must improve their services and make it
more satisfaction able.

4.8: In Dhaka City's Hospital Convenience is good

It is difficult to determine the overall convenience of hospitals in Dhaka city. However,
the studies suggest that there are some challenges in the healthcare system in
Bangladesh, such as a shortage of a healthy workforce, increasing out-of-pocket
payment for healthcare, and low patient satisfaction with the quality of care provided.
These factors may impact the convenience and accessibility of healthcare services in
Dhaka city. In the table (Table- 4.4) below the number of respondents is shown who
agreed and disagreed with the convenience of Dhaka city’s hospital:

Table - 4.4: Dhaka City’s Hospital Convenience

Number of Respondents
Factors
disagree
Disagree

Weighted Average
Disagree (2)

disagree (4)
Neutral (3)
Strongly

Strongly

Total
(1)

(5)

Convenience is good 05 15 13 13 04 50 3.08

37
Source: Survey
From the above table (Table- 4.4) we can see that 15 people responded agreed and 13
people are neutral. And over the 50 respondents, the weighted average is 3.08 which is
more than the neutral zone which is positive. So, it can be said that convenience is
good.

4.9: In Dhaka City Hospital Facilities and Environment is

good.
The hospital facilities and environment in Dhaka city vary depending on the hospital.
Some hospitals in Dhaka, such as Square Hospital and Evercare Hospital Dhaka, are
described as world-class with state-of-the-art infrastructure and professional medical
teams. However, there are also challenges in the healthcare system in Bangladesh, such
as a shortage of healthcare workers, poor upkeep of facilities, and unexplained hospital
costs. Patient satisfaction with hospital services in Dhaka varies, with some studies
reporting high levels of satisfaction among admitted patients, while others suggest that
patient satisfaction in Bangladesh is generally low. Overall, the quality of hospital
facilities and environment in Dhaka city may vary depending on the hospital and
individual experiences. The table (Table- 4.5) indicates whether the respondents get
sufficient facilities and environment:

Table 4.5: Sufficient Information is provided about the Product in Website

Number of Respondents
Factors
Disagree

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)
Strongly

Total
(1)

Dhaka city’s hospital 03 13 19 15 00 50 3.08

facilities and
environment

Source: Survey

38
According to the preceding (Table- 4.5) the cumulative weighted total of the responses
on this topic is 3.08, which is more than neutral. Dhaka city’s hospital should put up
sufficient facilities and healthy environment. Hospitals should put extra thoughts on
putting the proper information for better facilities to share the information and the
knowledge of the hospital environment.

4.10: In Dhaka City Medical Staff Services Technology is

good.
The use of technology in hospitals, such as the implementation of smart technologies
like AI to improve patient care, there are also studies that highlight challenges faced by
healthcare providers in Bangladesh, such as inadequate training on how to use personal
protective equipment (PPE) during the COVID-19 pandemic. It is important to note
that the use of technology in healthcare services can vary depending on the hospital and
individual experiences of patients and medical staff. The table (Table- 4.6) shows us
whether the customer service people contact the customers on time after placing the
order:

Table- 4.6: Medical Staff Services Technology

Number of Respondents
Factors
Disagree

Disagree

Weighted Average
Disagree (4)
Neutral (3)
Agree (2)
Strongly

Strongly

Total
(1)

(5)

Customer service people contact on time

05 12 14 18 01 50 3.04
after placing the order.

Source: Survey

According to the preceding (Table- 4.6) the cumulative weighted total of the responses
on this topic is 3.04, which is lightly neutral. Hospital should train their medical staffs
to service people.

39
4.11: In Dhaka City Medical Staff Services Attitude is good.

There is some evidence to suggest that the attitude of medical staff towards patients in
Dhaka city can vary depending on the hospital and individual experiences. For
example, a study conducted among Bangladeshi doctors found that while most doctors
were aware of COVID-19 symptoms, transmission, and prevention measures, over 50%
of doctors expressed that they would send suspected COVID-19 patients to be
designated hospitals without providing treatment. This suggests a lack of willingness to
engage with patients and provide care. However, a study exploring the perceptions and
experiences of patients receiving mental health care services at the National Institute of
Mental Health in Bangladesh found that patients had a generally positive perception of
the quality of care, although some expressed dissatisfaction due to a lack of resources
and functional medical equipment. Overall, the attitude of medical staff towards
patients in Dhaka city may vary depending on the hospital and individual experiences.
(Table- 4.7) it is shown that the medical staff services attitude:

Table- 4.7: The Medical Staff Services Attitude

Number of Respondents
Factors
Disagree

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)
Strongly

Total
(1)

The Medical Staff

04 08 15 14 09 50 2.68
Services Attitude

Source: Field Survey

According to the preceding (Table- 4.7) the cumulative weighted total of the responses
on this topic is 2.68, which is negative. So, the medical staff team of Dhaka city’s
hospital should show some gratitude towards the customers.

40
4.12: In Dhaka City Hospital Expenses is Moderate.

In any healthcare services, the cost of health service is crucial. Customers won't choose
that services if they discover that the service or operation costs are excessive. In the
following table (Table -4.8) customers’ perception towards the service expense is
shown:

Table- 4.8: Hospital Expenses Are Moderate

Number of Respondents
Factors
Strongly Disagree (1)

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)

Expenses are moderate 08 20 08 12 02 Total

50 2.60

Source: Field Survey

According to the above table (Table- 4.8) the cumulative weighted total of the
responses on this topic is 2.60, which is negative. So, Hospital in Dhaka city should
lower the healthcare services cost to satisfy their customer.

4.13: In Dhaka City Hospital Registration Method is Very

Easy.

For customers, registration method is crucial. Customers understand the time because it
is previously mentioned on the facilities of a hospital. Customers wait for the
emergency operations on that time frame. I have questioned the customers to find out if
they think the hour of registration method is appropriate. In the following table (Table-
4.9) it is shown that whether customers are pleased with the registration method:

41
 Table- 4.9: Hospital Registration Methods Are Easy

Number of Respondents
Factors

Strongly Disagree (1)

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)

Total
Are you pleased with the delivery 02 16 15 15 02 50 2.98
time?
Source: Field Survey

According to the above table (Table- 4.9) the cumulative weighted total of the responses on
this topic is 2.98, which is neutral. So, healthcare service should improve their registration.

4.14: In Dhaka City Hospital Doctor Visit Promptly.

Doctors in Dhaka city visit patients promptly. One study published in the British medical
journal BMJ Open found that physicians in Bangladesh, including Dhaka city, see patients
for an average of only 48 seconds, which suggests a lack of time spent with patients.
However, another study suggests that a doctor's ability to elicit a patient's detailed history is
related to their ability to be cordial, sympathetic, and trustworthy to patients. It is important
to note that the promptness of doctor visits in hospitals in Dhaka city may vary depending
on the hospital and individual experiences. The table (Table- 4.10) below showcases
whether doctors meet with their patients:

Table 4.10: Hospital Doctor Visit Promptly

Number of Respondents
Weighted Average

Factors
Strongly Agree
Disagree (1)

Disagree (2)

Neutral (3)

Agree (4)
Strongly

Total
(5)

Doctor visit promptly 01 15 16 13 05 50 3.12

Source: Survey

42
According to the above table (Table- 4.10) the cumulative weighted total of the
responses on this topic is 3.12, which is positive. So, Doctor should improve their
visiting time to meet their clients or patients.

4.15: In Dhaka City Medical Cost per Family is Expensive.

Medical costs in Dhaka city can be expensive for families. A study published in the
Journal of Health, Population, and Nutrition found that healthcare in Bangladesh is
mostly financed through out-of-pocket payments, which can be a significant financial
burden on households. It is important to note that the cost of medical treatment in
Dhaka city may vary depending on the hospital and type of services received. However,
the evidence suggests that medical costs in Dhaka city can be a significant financial
burden on families, particularly those with low incomes. The following table (Table-
4.11) show in Dhaka city medical cost per family is expensive:

Table- 4.11: Medical Cost per Family Is Expensive

Number of Respondents
Factors
Strongly Disagree

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)

Total
(1)

Product looking same as the picture 00 05 04 18 23 50 4.18

Source: Survey
According to the above table (Table- 4.11) the cumulative weighted total of the
responses on this topic is 4.18, which is positive. So, healthcare services should provide
the services to their customer at lower expenses.

43
4.16: In Dhaka City Hospital's Information Can Get from
Websites Easily.
It is very important to know about the hospital’s information and about the price of the
services from the hospital websites. The table (Table- 4.12) under shows whether
customers getting the information of prices and the services:

Table 4.12: Hospital’s Information Can Get from Websites

Number of Respondents
Factors
Strongly Disagree (1)

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)

Total
Getting information from websites 7 10 13 18 02 50 2.96
Source: Survey

According to the above table (Table- 4.12) the cumulative weighted total of the
responses on this topic is 2.96, which is below neutral. So, hospitals should give their
proper services information to their websites for their customers.

4.17: You are Satisfied with the Level of Customer Service

Provided by Healthcare Providers.

The next question that has been asked to the consumers are they pleased with the level
of customer services provided by healthcare providers? Service level has always been a
headache for the customers to get services from healthcare. In the table (Table- 4.13)
below it is shown whether customers are satisfied with the level of service provided by
healthcare:

44
 Table 4.13: Customers’ Satisfaction about Service Provided

Number of Respondents
Factors

Strongly Disagree (1)

Weighted Average
Strongly Agree (5)
Disagree (2)

Neutral (3)

Agree (4)

Total
Are customers pleased with the 05 14 13 15 03 50 2.94
service level
Source: Survey

According to the above table (Table- 4.13) the cumulative weighted total of the
responses on this topic is 2.94, which is below neutral. So, customers are not so much
satisfied with the level of services provided by the healthcare service provider.

4.18: Overall Customer Attitude toward Healthcare Services.

Customer satisfaction can be measured through various methods, including survey,
feedback, and ratings. We measured customer satisfaction of healthcare services
through a survey. According to survey, based on different factors overall customer
satisfaction of healthcare services is 3.07 out of 5.00 which is shown at table 4.14. The
pleasure expressed by consumers in answering to some question through questionnaire
is shown in the table (Table- 4.14) below:

45
 Table- 4.14: Overall Customer Attitude towards Healthcare Services

Factors Customer Satisfaction out of 5.00

Visit healthcare services. 3.22
Overall satisfaction is good. 3.00
Hospital convenience is good. 3.08

Facilities and the environment are good 3.08

Staff services technology is good 3.04
Staff services attitude is good. 2.68
Hospital expenses are moderate. 2.60
Registration method is very easy. 2.98
Doctor visit promptly. 3.12
Cost per family is expensive. 4.18
Information can get from websites easily. 2.96
Level of customer service provided by 2.94
healthcare
Total 3.07

From the above table (Table- 4.14) overall customer attitude towards healthcare
services is 3.07 out of 5.00 which slightly neutral position. In this situation healthcare
services need to improve the factor which has gain low outfit on this survey to satisfied
customer.

46
 Chapter- 05: Recommendations and
Conclusion
5.1: Recommendations

A comprehensive model of patient satisfaction has many policy implications regarding

identifying patient needs, developing standards, designing services systems and
processes, establishing employee and patient roles in service delivery, enhancing
training programmers, managing demand and capacity, and delivering the needed
quality of services. To these ends, measuring service quality and satisfaction is very
important. As might be expected, service orientation of doctors came out as the
strongest factor influencing patient satisfaction in all three types of hospitals. This is
not surprising. Usually in Bangladesh, patients’ experiences on this factor are not very
positive. Since most of the reputed physicians in the country serve multiple hospitals,
they are incapable of giving due time and attention to patients. Previous studies from
Aldana et al. (2001) and Rahman et al. (2002) also identified long waiting time and
insufficient consultation time as factors contributing to patient dissatisfaction in
Bangladesh. Yet, the overall ratings of doctors in our study are positive. Whether this
represents a positivity bias among patients evaluating the ‘exalted’ doctor, whether it is
due to the sample from Dhaka City, whether it is the reputed hospitals that were
selected, or whether it is because no better service is expected anywhere else in the
country, the higher-than-expected ratings have plausible explanations.

Given the important role of doctors in patient satisfaction, policy makers in Bangladesh
ought to initiate a professional development program (PDP) for physicians to provide
required technical and behavioral training. According to the World Bank (2003), there
is little documented evaluation of the quality of physician care in Bangladesh, in both
the public and the private sectors. PDP is a proven step in developed countries; thus,
customized versions of such programs have a place in Bangladesh that must be
vigorously pursued. Combining this approach with periodic certification requirements
ought to go a long way in improving health care provision in the country. The practice
of limiting the maximum number of patients to be visited by a physician in a day could
also be imposed in both the public and private hospitals.

47
The significant contribution of nurses to patient satisfaction in Bangladesh also ought
to be noted. Unfortunately, the number of nurses in Bangladesh today imposes serious
constraints on health service delivery. Currently there are only eleven nurses for
100,000 people in Bangladesh compared to 94 in India and 103 in Sri Lanka (Ministry
of Health and Family Welfare 2004). In addition, the nurses are also not equipped with
the right behavioral and technical skills. Rahman et al. (2002) indicate that patients
were very dissatisfied with their behavior and inefficiency. Our findings for urban areas
do not support such a strong position: patients were not ‘very’ dissatisfied with them.
We hasten to add, however, that a larger sample covering hospitals in rural areas may
provide alternative insights. Bangladesh and its development partners (e.g., the World
Bank and WHO) have recently taken steps to further the development of nurses by
conducting behavioral change courses and introducing nursing standards at different
hospitals. However, much more needs to be done. There is a general notion in
Bangladesh that people entering the nursing profession usually come from the lower
socio-economic strata. Coming with attitudes and concepts from their world of
struggle, their attitudes may be difficult to change. While such a belief is debatable,
there is no denying that the nursing profession should be accorded more social status to
attract others, especially from the upper strata, to provide this vital service. This might
be accomplished by offering a higher salary, fringe benefits, free technical and
behavioral training, free placement of their services in the country and abroad and
promoting their role and status more widely. The private health sector is better
resourced to actively pursue and promote higher nursing standards and to guide the
health care sector in this regard. This study suggests that cost is not a significant
contributor to patient satisfaction, especially for the private sector and for those
availing of foreign hospitals: instead, the quality of service is much more important.
Consequently, policy makers must recognize that a class of patients prefers quality
services to a cheaper but inferior solution that may add to future costs. It may be useful,
therefore, to look at health service delivery from a market segment perspective where
costs are emphasized to a specific segment and service is emphasized to others, but
with the right balance that meets minimum standards.

48
5.2: Conclusion

We contend that improving medical care in Bangladesh requires attention to service

features that are regularly rated by patients. These features include doctors, nurses,
tangibles, process features, etc. However, additional organizational and extra
organizational issues that play a vital role must also be addressed to improve the health
care system. For example, studies are needed to examine the influence of political
elements, the commitment of the higher authorities of the MOHFW (especially those in
the Directorate of Health), the cooperation and coordination achieved with affiliated
ministries such as the Ministry of Establishment (for recruitment purposes) and the
Ministry of Finance (which makes funds available), and the role and quality of
involvement of the development partners (e.g. the World Bank, USAID, WHO,
UNFPA, etc.). Changes in attitudes and practices at these higher tiers of the health
design and delivery system, where human, financial, technical and policy matters are
negotiated, are essential for the health care system to respond optimally and provide the
needed services to deliver patient satisfaction. More specifically, the influence of party
politics (who gets hired, who approves purchases), corruption at the MOHFW and
Directorate of Health (who gets foreign or local training, who gets posted where, who
is recommended for promotion, etc.), conditions imposed by the Ministry of
Establishment and Ministry of Finance (in matters of recruitment, purchase of
expensive diagnostics equipment and related budgetary attars), and the purported
interfering, imposing and intransigent nature of the development partners also need to
be examined. Failures at these levels have significant ramifications for any
improvements at the service delivery level. An example is the recent imbroglio in
Bangladesh between the development agencies and the MOHFW in regard to the right
approach to health care service delivery, which has led to much bickering, conflict and
stoppage of funds for staff salaries and purchases of essential drugs (The Daily Star
2006). Many feel this has seriously undermined the health and family planning program
in Bangladesh. Unless these intertwined and networked structures of power and
influence see eye-to-eye and demonstrate a spirit of collaboration and goal orientation
to fulfill their mission of alleviating Bangladesh’s health challenges, changes at the
service delivery level may remain seriously encumbered.

49
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Cambridge, MA: Mathematica Policy Research Inc. Makoul G, Arnston P, Schofield T.

1995. Health promotion in primary care: physician-patient communication
and decision making about prescription medication. Social Science and
Medicine 41: 1241–54.

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Ministry of Health and Family Welfare. 2003. Health, Nutrition and Population Sector
Program, July 2003-June 2006. Dhaka:

Planning Wing, Ministry of Health and Family Welfare, Government of Bangladesh.

Ministry of Health and Family Welfare. 2004. Poverty Reduction Strategy
Paper, Bangladesh. Thematic Group on Health including Population
Planning, Nutrition and Sanitation. Dhaka: Government of Bangladesh.

Aldana et al. (2001) and Rahman et al. (2002) also identified long waiting times and
insufficient consultation time as factors contributing to patient dissatisfaction
in Bangladesh

Rahman, M. O., Ali, N. A., Khatun, A., & Rasheed, S. (2002). Patient satisfaction with
health services in Bangladesh. Health Policy and Planning, 17(3), 264-271.

World Bank. (2003). Bangladesh Health Sector Review: Financing and Sustainability.
Retrieved from https://openknowledge.worldbank.org/handle/10986/15120

Ministry of Health and Family Welfare. (2004). Health and Family Welfare Statistical
Pocket Book of Bangladesh 2004. Dhaka, Bangladesh: Ministry of Health
and Family Welfare, Government of Bangladesh.

Rahman, M. O., Ali, N. A., Khatun, A., & Rasheed, S. (2002). Patient satisfaction with
health services in Bangladesh. Health Policy and Planning, 17(3), 264-271.

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 Appendix
Survey Questionnaire
Dear Sir/Madam

I would like to introduce myself as a student of Department of Marketing, Jagannath

University. I am conducting research on “Factors Influencing Customer Satisfaction
in Health Care Services: A Study in Dhaka City” as a part of my MBA internship. It
will be helpful for me if you kindly spend time and provide the information requested
in the following questionnaire. I can assure you that the information provided you will
keep secret and be only used for academic purpose. Thanks in advance for your sincere
cooperation.

A. General Information
(Put the right mark on the most appropriate one of the following answers)

1. Gender of the Respondent: (A). Male (B). Female

2. Age of the Respondent (in years): (A). 15-25(B) 26-35
(C).36-45 (D) 46-55 (E). Above 55
3. Occupation of the Respondent: (A). Student (B). Jobholder
(C). Business (D) Others
4. Monthly Family Income of the Respondent (in Tk.)
(A). Below Tk. 50,000 (B) Tk. 50,000 to 75,000 (C). Tk. 75,000 to 100,000
(D). Above 100,000

Influencing Factors Questionnaire

Put the tick marks on the most appropriate one of the following statements where
strongly Agree (1), Agree (2), Neutral (3), Disagree (4) Or Strongly Disagree (5).

53
 Strongly Disagree Neutral Agree Strongly
Disagree (2) (3) (4) Agree
Statements (1) (5)

1. Visiting healthcare. 1 2 3 4 5

2. The hospital in 1 2 3 4 5
Dhaka city's overall
satisfaction is good.

3. In Dhaka city's hospital 1 2 3 4 5

convenience is good.

4. In Dhaka city 1 2 3 4 5
hospital facilities and the
environment is good

5. In Dhaka city 1 2 3 4 5
medical staff services
technology is good

6. In Dhaka city 1 2 3 4 5
medical staff services attitude
is good.

7. In Dhaka city 1 2 3 4 5
hospital expenses are
moderate.

8. In Dhaka city 1 2 3 4 5
hospital registration method
is very easy.

9. In Dhaka city 1 2 3 4 5
hospital doctor visit promptly

10. In Dhaka city 1 2 3 4 5

medical cost per family is
expensive.

11. In Dhaka city 1 2 3 4 5

hospital's information can get
from websites easily.

12. You are satisfied 1 2 3 4 5

with the level of customer
service provided by
healthcare providers

54