AN ASSESSMENT OF USER SATISFACTION WITH PUBLIC PRIVATE PARTNERSHIP (PPP) PROJECTS IN SELECTED UNIVERSITY TEACHING HOSPITALS

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ABSTRACT

Government at all levels are forced to prioritise and restrict public expenditures due to budget deficits and the inefficient management of large infrastructure projects. Due to
the shortage of resources for healthcare delivery leading to decline in the quality of care,
there is considerable interest in PPP initiatives for the provision of finance and
management of health care to ordinary people. The PPP option due to its complexities
has led to some projects failure leading to wastage of huge resources and time. Studies
have shown that majority of these project failures are as a result of public opposition
leading to outright cancellation of the projects. Due to the lack of empirical studies on
user satisfaction with PPP projects in Nigeria, this study assessed the satisfaction of users
of PPP projects from both employees and patients’ perspectives of two university
teaching hospitals in Nigeria. A total of 580 questionnaires were distributed to
Employees and Patients of University College Hospital, Ibadan (Oyo state) and Lagos
University Teaching Hospital, Lagos (Lagos state). The data received from these
respondents were analysed using both descriptive and inferential statistics with the aid of
SPSS to determine their levels of satisfaction with the facilities and services provided. It
was observed that the patients were more satisfied with the projects than the employees.
The patients rated the staff members the highest implying that they were quite confident
in the healthcare providers‟ reliability and expertise. The employees were most satisfied
with the reliability of the facilities in maintaining confidentiality. The study also
observed that there is a positive significant relationship between quality parameters and
overall satisfaction. The study therefore concluded that necessary improvement
adjustments need to be done in all areas of quality performance especially the facilities to
increase the satisfaction of the users of these projects.

TABLE OF CONTENTS
TITLE PAGE.. .. .. .. .. .. .. .. .. ii
DECLARATION.. .. .. .. .. .. .. .. .. iii
CERTIFICATION.. .. .. .. .. .. .. .. .. iv
DEDICATION.. .. .. .. .. .. .. .. .. v
ACKNOWLEDGEMENT.. .. .. .. .. .. .. .. vi
ABSTRACT.. .. .. .. .. .. .. .. .. vii
TABLE OF CONTENT.. .. .. .. .. .. .. .. viii
LIST OF TABLES.. .. .. .. .. .. .. .. .. xii
LIST OF FIGURES.. .. .. .. .. .. .. .. xiii
LIST OF APPENDICES.. .. .. .. .. .. .. .. xiv
1.0 CHAPTER ONE: INTRODUCTION.. .. .. .. .. 1
1.1. BACKGROUND TO THE STUDY.. .. .. .. .. 1
1.2. STATEMENT OF THE PROBLEM.. .. .. .. .. 5
1.3. N
EED FOR THE STUDY.. .. .. .. .. .. .. 6
1.4. AIM AND OBJECTIVES.. .. .. .. .. .. .. 8
1.4.1 Aim.. .. .. .. .. .. .. .. .. 8
1.4.2 Objective.. .. .. .. .. .. .. .. 8
1.5 SCOPE AND LIMITATION…. .. .. .. .. .. 9
1.5.1 Scope.. .. .. .. .. .. .. .. .. 9
1.5.2 Delimitation.. .. .. .. .. .. .. .. 9
1.5.3 Limitation.. .. .. .. .. .. .. .. 9
2.0 CHAPTER TWO: LITERATURE REVIEW.. .. .. .. 10
2.1 OVERVIEW OF PPP.. .. .. .. .. .. .. .. 10
2.1.1 Advantages of PPPs.. .. .. .. .. .. .. 11
2.1.2 Considerations for entering into a PPP option…. .. .. 12
2.1.3 Critical success factors as efficiency measures.. .. .. 13
2.1.4 Types of PPPs.. .. .. .. .. .. .. .. 16
2.1.5 Risks in PPP.. .. .. .. .. .. .. .. 17
2.1.6 Problems Faced in PPP Project Execution.. .. .. .. 21
2.1.7 Application of PPP in Nigeria.. .. .. .. .. 22
2.2 PAST EMPIRICAL RESEARCH ON PPPs.. .. .. .. .. 22
2.2.1 An Integrated Framework.. .. .. .. .. .. 25
2.3 QUALITY IN PPPs.. .. .. .. .. .. .. .. 26
2.3.1 The Product Dimension.. .. .. .. .. .. 26
2.3.2 The Services dimension.. .. .. .. .. .. 27
2.4 QUALITY PERFORMANCE IN RELATION TO CUSTOMER
SATISFACTION.. .. .. .. .. .. .. .. .. 29
2.5 QUALITY PERFORMANCE IN PPP HEALTHCARE DELIVERY.. 33
2.6 CUSTOMER/USER SATISFACTION.. .. .. .. .. 35
2.6.1 Effect of socio-demographic characteristics.. .. .. .. 35
2.7 USER SATISFACTION IN PPP PROJECTS.. .. .. .. 38
2.7.1 User Involvement.. .. .. .. .. .. .. 39
2.8 PPP IN HEALTHCARE DELIVERY IN NIGERIA.. .. .. .. 42
2.9 SUMMARY OF PPP PROJECTS FOR THE STUDY.. .. .. 45
3.0 CHAPTER THREE: RESEARCH METHODOLOGY.. .. .. 47
3.1 RESEARCH APPROACH.. .. .. .. .. .. .. 47
3.2 THE STUDY POPULATION.. .. .. .. .. .. .. 48
3.2.1 University Teaching Hospital (UCH), Ibadan (Project 1).. .. 48
3.2.2 Lagos University Teaching Hospital (LUTH), Lagos (Project 2).. 49
3.3 SAMPLING.. .. .. .. .. .. .. .. .. 50
3.4 INSTRUMENT FOR DATA COLLECTION.. .. .. .. 52
3.4.1 Questionnaire Design.. .. .. .. .. .. .. 52
3.5 DATA COLLECTION PROCEDURE.. .. .. .. .. 54
3.6 METHOD OF DATA ANALYSIS.. .. .. .. .. .. 55
4.0 CHAPTER FOUR: DATA ANALYSIS AND DISCUSSION OF RESULTS..
.. .. .. .. .. .. .. .. .. .. 56
4.1 DATA ANALYSIS.. .. .. .. .. .. .. .. 56
4.1.1 Socio-demographic Characteristics of Patients.. .. .. .. 56
4.1.2 Socio-demographic Characteristics of Employees.. .. .. 58
4.2 ASSESSMENT OF THE LEVEL OF USERS SATISFACTION WITH PPP
PROJECTS.. .. .. .. .. .. .. .. .. .. 60
4.2.1 Patients level of satisfaction with the PPP projects.. .. .. 60
4.2.2 Employees level of satisfaction with the PPP projects.. .. 62
4.3 EVALUATION OF THE RELATIONSHIP BETWEEN QUALITY
DIMENSIONS AND SATISFACTION.. .. .. .. .. .. 64
4.4 DISCUSSION OF RESULTS.. .. .. .. .. .. .. 67
5.0 CHAPTER FIVE: CONCLUSION AND RECOMMENDATION.. .. 71
5.1 SUMMARY OF FINDINGS.. .. .. .. .. .. .. 71
5.2 CONCLUSION.. .. .. .. .. .. .. .. 71
5.3 RECOMMENDATION.. .. .. .. .. .. .. 72
5.3.1 Recommendation for further studies.. .. .. .. .. 73
REFERENCES.. .. .. .. .. .. .. .. .. 74
APPENDICES.. .. .. .. .. .. .. .. .. 87

CHAPTER ONE
1.0 INTRODUCTION
1.1 BACKGROUND TO THE STUDY
Endemic budget deficits and the inefficient management of large infrastructure projects
and services within the public sector are a few reasons why the traditional procurement
method of governments funding infrastructure projects through fiscal budgets is
increasingly considered unviable (Alitheia, 2010).
In the past few decades, developed economies (e.g. the United Kingdom) have modelled
a variety of public private partnerships (PPPs) for the delivery of infrastructure, public
utilities and large services projects, achieving significant successes from harnessing the
competences and expertise from both sectors. Emerging markets such as India and South
Africa are also recording successes using tried and tested PPP templates to create,
expand and modernise infrastructure (Workshop Report, 2008). It is apparent that these
dynamic partnerships between the public and private sectors have become inevitable
across the globe.
Nigeria’s infrastructure challenge is huge. Reports suggest that the country requires
between US$12 billion to $15 billion annually for the next six years to meet the
infrastructure requirements (Izuwah, 2010). The World Bank estimates that every 1% of
(government) funds invested in infrastructure leads to an equivalent 1% increase in gross
domestic product (GDP). Nigeria has not had a consistent history of investment in
infrastructure; however, government agenda show that infrastructure development is
gaining momentum. In the past 10 years, over 25 major infrastructure projects have been
rolled out through PPPs. The Federal Government of Nigeria, state and local government

2
areas (LGAs) have contributed over N10 trillion ($66 billion) to these. However, the total
investment required to meet the vision 2020 target for infrastructure projects is N32
trillion ($210 billion) (Izuwah, 2010).It has become evident that the government alone
cannot muster the resources (finance and expertise) to meet this need and the
involvement of the private sector is not just desirous, but necessary.
Governments at all levels are forced to prioritize and restrict public expenditures to
health. Leading to some government (owned and operated) hospitals in dire financial
state and having shortage of resources for health care delivery. These include meeting
patients’ expectations in terms of demand for modern medical facilities; the need to
provide care for an aging population; improve quality of care; and also invest in
expensive medical technology. Therefore, there has been considerable interest in PublicPrivate Partnership (PPP) initiatives in the health sector in light of the challenges the
public sector is facing in financing, managing and providing health care to ordinary
people (Alitheia, 2010; Asoka, 2014; Anyaehie, Nwakoby, Chikwendu, Dim, Uguru,
Oluka and Ogugua, 2014).
The concept of Public Private Partnership (PPP) is underpinned by a government’s desire
to resolve financial constraints by joining forces with the private sector to increase
efficiency and effectiveness in the delivery of public services and facilities, whilst
ensuring better risk management and increasing certainty of outcomes. PPPs are also
often aimed at accelerating economic growth, development and infrastructure delivery;
and achieving quality service delivery and good governance (Akintoye, 2006), especially
in developing countries.
The structure of PPPs are built around two main types – in one case, the cost of providing
the facility/service is borne exclusively by the users of the service and in the other, the

3
private company invests alongside government to provide a service and the cost of
providing the service is wholly or partly carried by the government (Alitheia, 2010).
Overwhelming evidence in the past 50 years of the use of PPP structures indicate that
these arrangements are relatively cost efficient, foster best practices for sharing and
transfer of risk, assure superior value for money, saves time, streamline contracts and
simplifies procurements, facilitates innovation through public-private cohesion,
eradicates bureaucratic and political processes, encourages technology transfer and acts
as vehicles which adopt life cycle approaches to delivering infrastructure and services
(Alitheia, 2010).
PPP is rapidly becoming the preferred method for public procurement for delivering
infrastructure projects throughout the world, thus gaining importance as a vehicle to
finance much-needed public infrastructure across the globe (Gunnigan and Rajput, 2010),
despite the conspicuous absence of systematic evaluations of quality improvement and/or
customer satisfaction in the PPP context (Jamali, 2007), thereby leading to a number of
unsuccessful projects reported as a result of users dissatisfaction (Levy, 1996; El-Gohary,
Osman and El-Diraby, 2006; Gunnigan and Rajput, 2010).
The fierce competition in the wake of globalization is pushing companies to improve
continuously in order to stay in the business. It is a very challenging task to meet the
ever-increasing and diversified customer (user) requirements. To tackle this challenge
effectively and efficiently, the alignment of the business processes with the customer
requirements is vital (Jochem, Menrath and Landgraf, 2010).
El-Gohary
et al. (2006) stated that stakeholders are individuals or organisations that are
either affected by or affect the development of the project. Therefore, capturing their

4
input is a crucial component of the project development process. It is important to gauge
stakeholder opinion and concerns to better facilitate the development of a project that
will meet the needs of those stakeholders.
Tangkitsiri, Ogunlana, Oyegoke and Oladokun (2013) opined that customer satisfaction
begins when the customers’ service expectations are met i.e. when the level of service
provided by the service provider meets the expectations of the users. The importance of
customer satisfaction in a PPP project is based on the assumption that the private sector
can be more efficient in service delivery than the public sector. And also, if citizens are
now being expected to pay for services they have been delivered free-of-charge in the
past; they should have the right to expect better quality services.
In order to measure levels of stakeholders’ satisfaction, it is necessary to study the real
benefits from existing projects (Tangkitsiri
et al., 2013) that is, project monitoring. They
further described Project monitoring as a tracking process, comparing actual outcome to
predicted outcome, analysing impact, and making appropriate adjustments.
Positive attitudes towards bringing users’ ideas into the product development process of
design, delivery and after-care can change the whole situation. Innovative approaches
such as this can lead to new and more user-friendly forms of products and services which
reflect user requirements. Specific requirements of end-users have to be captured in order
to achieve a maximum level of customer satisfaction, which ultimately will contribute to
the success of the business. Therefore, we need to know who the users are, what their
requirements are and how they can be involved in the product development and design
process. Various users need to be part of not only the image and vision of the project, but
also the physical design, which should reflect the way they work. The new culture,

5
images and visions need to be fully shared among all the stakeholders during the
consultation, rather than only after the implementation (Ozaki and Yoshida, 2007).
El-Gohary
et al. (2006) opined that PPP infrastructure projects vary in the level of
contention that they raise among stakeholders. Moreover, the involvement of the private
sector – with its profit-making mindset – usually raises concerns that are not usually
likely when the asset is publicly owned (e.g. quality assurance, safety, rate hikes, transfer
agreement, etc.).
There are many studies that have been carried out in various aspects of PPP projects both
nationally and internationally. Some of these studies have shown that the dissatisfaction
of users of some PPP projects have led to the cancellation of some projects which has led
to loss of time and resources (Levy, 1996; El-Gohary
et al., 2006; Gunnigan and Rajput,
2010).
1.2 STATEMENT OF THE PROBLEM
Alienation of actual users of the asset and lack of public support have increased project
costs, delayed project completion, and ultimately jeopardized the sustainability of public
services. Lack of communication and poor stakeholder management could become dealbreakers: a predominant reason for this is lack of effective communication with the
principal stakeholders of the project (Levy, 1996; El-Gohary
et al., 2006; Asian
Development Bank, 2007; Gunnigan and Rajput, 2010). Users are critical to the
sustainability of PPP projects they need to communicate their ability and willingness to
pay for the service, express priorities for quality and level of service and also identify
existing strengths and weaknesses in services provided (Inter-American Development
Bank, 2014)

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