Roger A.

Atinga a

Abstract
Objective

To examine differences in patient-centred care among private and

public inpatients in public hospitals and whether satisfaction with
patient-centred care differ between the patient groups.
Method

Cross-sectional data collected from inpatients in private wards

(n = 300) and public wards (n = 520) in Ghana, using a structured
questionnaire modelled on four dimensions of patient-centred care:
respect and dignity, emotional support, interpersonal relations and
information sharing.
Results

Patient-centred care differed significantly among private and public

patients (p < 0.001), with an effect size ranging from medium to large.
Private patients rated patient-centred care higher than public patients
in all the items of the four dimensions. Satisfaction with patient-
centred care discriminated between the patient groups. Satisfaction
was significantly high for private patients who are aged 50+
(p < 0.001), had high education (p < 0.05) and high income
(p < 0.001) compared to the same category of public patients.
Conclusion

Physicians behaviour is stereotyping and less favourable to public

patients, suggesting inequitable access to patient-centred care for
inpatients from high and low socioeconomic backgrounds.
Practice implications
Hospitals with private and public wards should be compelled to
properly coordinate and regulate the activities of physicians to avoid
fragmented care for inpatients.

Introduction
In spite of the global call for people of all socioeconomic status to
have access to needed care that is effective, efficient, safe, timely and
patient-centred [1], differential treatment and access to quality care
between patients from high and low socioeconomic status remain a
problem [2], [3]. Low caste people and the poor still face multiple
barriers getting needed attention and appropriate care in their
healthcare encounter [4], [5]. In the healthcare setting, some patients
are recognised as more equal than others [6], [7], which is a
symptomatic of differential care for patients based on social
inequalities [5]. Differential care is even more pronounced in two-tier
ward systems of inpatient care [8].
A two-tier inpatient ward system is a practice in which a public hospital
maintains a mix of public and private inpatient wards with
differentiated amenities to offer related or unrelated medical care to
patients. Under this arrangement, the hospital complements existing
traditional public wards with private wards that have private rooms
offering premium services at high fees based on willingness to pay
among the well-off [9]. Public wards are often distinguished from
private wards by their low fees, less privacy and ambience.
The operation of two-tier ward systems differs across countries and
hospitals. In some hospitals, identical medical services are available
to patients in private and public wards; while for others, private
patients have more options to choose from [10]. Second, whereas in
some settings, private patients pay full cost out-of-pocket that include
room charges, services and medical bills [10], [11], in other settings,
medical care is billed separately, so that the private patient pays out-
of-pocket for only accommodation. Patients with insurance cover, for
example, can opt for private ward, pay for accommodation alone while
insurance agents pay for the medical bills.
The primary reason for which hospitals operate two-tier inpatient ward
system is to mitigate funding gaps. It is often argued that additional
revenue generated from private patients can be used to cross-
subsidise hospital-wide operations [9]. However, one of the key
concerns of this system is that equity of access to quality care across
the board is not guaranteed [8]. Because hospitals rely on fees from
private patients to increase their revenue base, there is the potential
that attention and medical resources will be diverted to these patients.
Besides hospitals may strategically use the system to widen
differences in amenity levels, comfort, privacy and clinical care
between private and public wards [11], so as to increase demand for
the former. A recent study found private patients were treated
differently to the extent that they experienced less waiting days and
assigned higher urgency of admission [12]. Another study found no
discrepancy in the quality of care offered to private and public
patients, but noted that shifts in market forces was likely to stimulate
changes in physicians behaviour over time [13]. What remains unclear
is whether patient-centred care differ between private and public
patients in two-tier systems and if so what is the magnitude of such
differences.
Patient-centred care or patient-centredness is a measure of how the
physician honours and responds to every patient’s needs and
preferences [14] and engage in quality interpersonal relations with the
patient [15]. Patients traditionally looked to the physician to use both
medical and social oriented tools to treat diseases and health related
concerns [16]. Physicians in turn have a professional obligation to
exhibit patient-centred behaviour; dignify, respect, comfort and provide
emotional and psychosocial care to every patient [14].
We argue that this obligation to care can and must remain
uninfluenced by the forces of patients’ socioeconomic status and the
ward of admission. Moreover, as patients derive maximum utility and
experience better therapeutic outcome when care is patient-centred
[17], [18], it is expected that physicians employ a more egalitarian
approach to care delivery, so that all patients benefit from equal
opportunity to achieve good health. In view of this, our study is driven
by two key research questions: (1) Do patients on admission in private
and public wards receive differential patient-centred care? (2) Does
satisfaction with patient-centred care differ between patients on
admission in private and public wards? Empirical answers to these
questions will significantly aid in monitoring activities of private and
public wards and foster a healthy interaction between them.

Section snippets
Conceptual framework
The boundary of patient-centred care has not been clearly delineated.
Different interpretations of the concept abound in the literature [19],
[20], [21]. Mead and Bower [15] whose work upon whom many
authors often quote identified the constituents of patient-centred care
to include: the biopsychosocial care (the physician looks beyond the
narrow biomedical care and tackles the patient’s problem from the
psychological and social perspective); the patient as person
(recognising the patient as a

Study area and hospitals

The study was conducted in Accra, one of Ghana’s most populous
cities with a high population density and accommodating about 17.7%
of the country’s total population [37]. Within the last decade Accra has
experienced rapid sociodemographic changes and epidemiological
transition to chronic communicable and non-communicable diseases,
many of which are socially patterned [38]. In terms of healthcare
delivery, public hospital infrastructure, doctors and nurses have high
concentration in Accra than

Patient characteristics
The socio-demographic characteristics of the patients are shown in
Table 3. The mean age of the patients in private wards was 38 (SD:
14.83; range: 22–90) while that of public wards was 35 (SD: 15.16;
range: 20–82). The majority of the patients in both private and public
wards was respectively females (55.3% vs 58%), employed (78.7% vs
65.0%) and had at least senior high education (76.3% vs 58.1%). The
mean number of days that patients spent on admission in both wards
was well balanced (mean:

Discussion
Findings show that physicians’ approach to dignity and respect
differed significantly across the two groups of patients. Compared to
patients in public wards, those in private wards were more likely to be
revered, experienced no discrimination and felt exalted. The
magnitude of the difference was shown to be large. We attribute this
to the socio-demographic differences between the two groups of
patients. Because patients in private wards were relatively well-off,
they were more likely to

Conclusion
Studies have evaluated patient-centred care from the inpatient and
outpatient settings [17], [32], [47] and its importance to the patient in
improving health outcomes [55]. This is one of the few studies
comparing patient-centred care in two-tier inpatient ward hospitals.
Our findings are that physicians’ relationship orientation, interaction
behaviour, emotional support and dignity for the patient differed
considerably between patients in private and public wards. The
difference was shown to

Practice implications
In view of the importance of patient-centred care in patient activation,
treatment adherence, patient satisfaction, trust in clinicians and patient
safety, it would be important for health managers in Ghana and
elsewhere to develop policy tools that compel hospitals with private
and public wards to properly coordinate and regulate the activities of
physicians in order to avoid fragmented care and attention for
patients. Also didactic training programmes focusing on building the
skill of

Conflict of interest
None declared.

Author contribution
RAA conceived the study and contributed to the design, data
collection and analysis of results. JNB and AN-B contributed to the
review of literature. All authors read and approved the final
manuscript.
“I confirm all patient/personal identifiers have been removed or
disguised so the patient/person(s) described are not identifiable and
cannot be identified through the details of the story”.

Acknowledgement
This study received funding from the faculty support grant of
the University of Ghana Business School, which played no role in the
preparation, data collection and publication of this paper.