ABSTRACT
The major objective of this study is to examine the combined influence of internal marketing and job satisfaction on quality health service delivery in Greater Iganga Local Government. A case study research strategy is used in which data are collected using self-administered questionnaire administered to 635 respondents. A sample of 127 health centres was drawn from a population of 205 health facilities from the Ministry of Health. Health directors, head of health facilities, district health inspectors, health educators, drug inspectors, laboratory administrators, human resource directors and drug inventory managers formed the unit of inquiry on internal marketing and job satisfaction while health service clients formed the unit of inquiry on the quality of health services offered. The responses were aggregated to the respective units of analysis. The time horizon of this study was two years spanning from 2016 to 2018. SPSS was used to perform correlation and regression analysis. The correlation results indicate that independently internal marketing and job satisfaction are positive and statistically significantly associated to quality health service delivery at r=0.695; p<0.001 and r=0.720; p<0.001 respectively. Furthermore, the combination between internal marketing and job satisfaction is positively and significantly associated with quality health service delivery (r=0.728; p<0.001). Results of the correlation analysis which showed that the relationship between the three study variables (internal marketing, job satisfaction and quality health service delivery) were positive and statistically significant were supported by results of the regression analysis. This resulted in the acceptance of the three research hypotheses.
Key words: Internal marketing, job satisfaction, service delivery, public health sector, local government.
All over the World, local governments are considered crucial centres for health service delivery. Owing to this mandate, local governments are required to rise to a high level in as far as the delivery of quality health services is
concerned (Sudhahar and Selvam, 2008). Service quality delivery in the health sector is associated with improved human participation capability in the social economic development process of the country (Kimenyi, 2013).
However, despite the fundamental role of quality health service delivery as articulated above, the quality of health service delivery in Uganda is poor and continues to deteriorate at an alarming level (MOH, 2013; Wane and Gayle, 2013; WHO, 2015). Limited access to skilled health care, perennial absence of drugs from health facilities, poor health infrastructure, and poor supervisory arrangements within the sector have combined in various ratios to worsen the health service delivery situation (MOH, 2013; Wane and Gayle, 2013). This situation has persisted despite numerous interventions and reforms such as improved resource allocation by the Central Government and other funding agencies, refurbished infrastructures in the health sector, drug inventory management techniques, health performance improvement plans, enhanced remuneration of health staff, and strengthened health framework like the health sector plan, community and health worker dialogue, and improved stewardship/governance (MOH, 2013; UNHCO, 2014). Health service provision in Uganda has always been guided by the Health Sector Strategic Plan (HSSP). The major aim is to ensure that all actions are aimed at improving the health of all people in a manner that is responsive to their legitimate health needs.
According to reports published in 2013 by the Ministry of Health (MOH) and the Uganda National Health Consumers Organisation (UNHCO), service delivery in the health sector is evidently poor. A study by UNHCO in 2013 as cited by Medicines Transparency Alliance (MeTA) in 2014 ranked Iganga District amongst the worst performing districts in as far as quality health service delivery (QHSD) is concerned. Inadequate drugs in health facilities, staff absenteeism, dilapidated health facilities, non-responsive and unreliable staff, and massive corruption among health workers were cited as the major causes of the decline in service quality. Consequently, there has been high level of mortality rate, low life expectancy, weak health conditions among others (MOH, 2013; WHO; 2015). Considering the above situation, internal marketing has been considered a unique attribute to improved service quality delivery (Wambugu, 2015). Similarly, job satisfaction has been considered a significant predictor of quality service delivery (Shabbir and Salaria, 2014).
The major objective of this research is to examine the combined influence of internal marketing and job satisfaction on quality health service delivery in the public sector within the context of Greater Iganga Local Government in Uganda. In line with this major objective, this research has two minor objectives: first, to establish the influence of internal marketing on quality health service delivery and second, to establish the influence of job satisfaction on quality health service delivery.
The empirical investigation is done using data drawn from 635 respondents in a sample of 127 health facilities drawn from a population frame of 205 health facilities for a period between 2016 and 2018.
This research contributes to literature in a way that it extends previous research but in a new and different context. Despite the usefulness of internal marketing and job satisfaction in fostering quality health service delivery in the health sector (Amjad and Alshurideh, 2012), this link has not been empirically tested in Uganda’s health sector. The closest was by Omagor et al. (2012), but this was in the in the airline service industry sector and Kakooza et al. (2015) who studied management practices and performance of public hospitals in Uganda.
The influence of internal marketing on quality service delivery
Internal marketing is defined as “a planned effort using a marketing-like approach directed at motivating employees for implementing and integrating organisational strategies towards customer satisfaction” (Ahmed and Rafiq, 2002).
According to Amjad and Alshurideh (2012), internal marketing dimensions include: employee motivation and reward, effective communication, employee recruitment, employee selection, employment development, support system, and a healthy work environment. This concept emerged from the development of business structures and services marketing (Varey and Lewis, 2000). In particular, internal marketing has been perceived as a means of creating a sustainable competitive advantage in the market through the provision of high service quality (Cronin and Taylor, 1992). Although originating within the services marketing literature, internal marketing is now viewed as applicable in all industry contexts (Cahill, 1995).
Internal marketing supports a great role of service organisations in achieving quality service delivery. Owing to this, managers in organisations should employ strategic plans to enhance internal marketing if service quality is to be achieved (Sadeghloo and Tirgar, 2013). Kotler and Armstrong (2006) developed a Service Marketing Triangle which explains the relation between organisations, its employees and its customers. In this triangle, they propose three forms of marketing each of which is considered a main factor in the success of an organisation. These forms are: External Marketing, Interactive Marketing, and Internal Marketing.
Reaching customers and winning their satisfaction is achieved through reaching a level of quality required in all marketing relations between organisations and customers. Lings (2000) explains that workers’ satisfaction is a basic condition and first step to achieve customers’ satisfaction. He further points out that customers’ feeling of quality of service provided to them by individuals working in organisations with which they become in contract is affected by the level of those workers’ performance.
The influence of job satisfaction on quality service delivery
Spector (1985) suggested that there are nine constituents of job satisfaction namely: salary, promotion, benefits, bonus, operating procedures, colleagues, work, communication and relationship with supervisor. The Job Satisfaction Survey (JSS) conducted by Spector in 1985 focused on examining employees of human resource companies, public companies, and non-profit organisations. Snipes (1996) added customer satisfaction as a factor to JSS because many studies revealed that employees’ perception of customer satisfaction will ultimately affect service quality and job satisfaction. Brown et al. (1993) classified all factors affecting job satisfaction into the following four constructs: job consequences, personal differences, role awareness and organisational factors.
A previous study carried out by Yoon and Suh (2003) shows that satisfied employees are more likely to work harder and provide better services. Employees who are satisfied with their jobs tend to be more involved in their organisations, and more dedicated to delivering services with a high level of quality. Previous studies have also suggested that loyal employees are more eager to and more capable of delivering a higher level of service quality (Loveman, 1998; Silvestro and Cross, 2000; Wambugu, 2015; Amjad and Alshurideh, 2012).
Some researchers argue that service quality is influenced by the job satisfaction of employees (Bowen and Schneider, 1985; Hartline and Ferrell, 1996 and Wambugu, 2015). Other researchers have also found evidence that job satisfaction is associated with service quality. These include: Hartline and Ferrell (1996) and Kakooza et al. (2015).
Quality service delivery
According to Parasuraman et al. (1988), service quality unveils the totality of the overall judgement of a service to ascertain whether it meets customer’s satisfaction. Zeithmal et al. (1990) defined service quality as the difference between client expectation and the outcome (achievement). In view of this, there are incidences where clients expectation exceed service performance hence the revelation of dissatisfaction is experienced (Parasuraman et al., 1985).
Wambugu (2015) points out that researcher do not agree upon the essence of service quality dimensions because it is difficult for service organisations to put forward observational procedures to define standards of service quality provided to customers. However, according to Parasuraman et al. (1988), service quality has the following ten dimensions: credibility, responsiveness, reliability, security, understanding, tangibles, accessibility, courtesy, competence and communication. Studies have shown that both internal marketing and job satisfaction improve quality service health delivery (Omagor et al., 2012; Shabbir et al., 2014; Wambugu, 2015; Kakooza et al., 2015).
The conceptual framework shown in Figure 1 is based on the literature review. This study has two independent variables namely: internal marketing and job satisfaction. The dependent variable is quality health service delivery. The control variables are gender, education, age and tenure. The dimensions used for each variable are drawn from previous research. The gist captured in the above figure is three fold: first, it is postulated that internal marketing influences quality health service delivery. Second, job satisfaction is assumed to influence quality health service delivery, and lastly internal marketing and job satisfaction jointly influence quality health service delivery.
HYPOTHESES DEVELOPMENT
Based on the literature review and conceptual framework, the following research hypotheses were formulated:
(i) H1: There is a positive and significant relationship between internal marketing and quality health service delivery
(ii) H2: There is a positive and significant relationship between job satisfaction and quality health service delivery
(iii) H3: The combined effect between internal marketing and job satisfaction positively and significantly influences quality health service delivery
Sample and data selection
Data for this study were collected using self-administered questionnaires from 635 respondents in 127 health facilities drawn from a total population frame of 205 health facilities in Greater Iganga Local Government using simple random sampling technique. The responses were aggregated to the respective unit of analysis. Greater Iganga Local Government is composed of the following districts: Mayuge, Bugiri, Namutumba, Luuka, Namayingo and Iganga. Greater Iganga Local Government health sector is layered along a continuum of four levels: health centre II, health centre III, health centre IV and a referral hospital. These formed the units of analysis. The respondents comprised the following: District Directors of Health Services, Head of Health facilities, District Health Inspectors, Health Educators, Drug Inspectors, Laboratory Administrators, Human Resource Directors, Drug Inventory Managers and Health Clients. The time horizon for this research was two years.
Measurement of variables
In order to tap the domain of internal marketing, the model used by Amjad and Alshurideh (2012) was adopted. Accordingly, internal marketing dimensions include the following: employee motivation and reward, effective communication, employee recruitment, employee selection, employment development, support system and a healthy work environment.
In order to tap the domain of job satisfaction, Spector’s model was adapted. Spector (1985) suggested that there are nine constituents representing job satisfaction namely: salary, promotion, benefits, and relationship with supervisors, bonus, operating procedures, colleagues, work and communication. To unearth the domain of service quality, three different service quality models were reviewed. The SERVQUAL model by Parasuraman et al. (1988), the SERPERF model by Gronroos (1984) and the P-C-P model by Philip and Hazlett (1997). Notably, all the items/dimensions/constituents from the study variables were anchored on a five point Likert scale (1-5) ranging from Strongly Disagree to Strongly Agree.
Data processing and analysis
The study employed quantitative techniques in data analysis. Data from the questionnaires were subjected to the Statistical Product and Service Solutions, SPSS, an IBM software (Hejase and Hejase, 2013). SPSS was used for coding, editing and analysis. Descriptive statistics arising from SPSS manipulation of data from questionnaires are presented. Correlation analysis was done to generate correlation coefficients in order to determine the direction and extent of association of the study variables. Regression analysis was performed to ascertain the predictive potential of the independent variables (internal marketing and job satisfaction) on the dependent variable (quality health service delivery).
Presentation of results
The reliability of the three scales of internal marketing, job satisfaction and quality health service delivery were determined by Cronbach alpha coefficient as generated by SPSS. The results indicate that for all the three variables, the coefficients are above the threshold of 0.70 as recommended by Nunnally (1978). Accordingly, it was concluded that the scales for measuring internal marketing, job satisfaction and quality health service delivery were reliable (Table 1).
Correlation analysis
Pearson’s product moment correlation coefficient was calculated to determine the extent/degree and direction of relationship between the study variables. A summary of the results is displayed in Table 2. The results presented
in the above table indicate the following:
(i) The relationship between internal marketing and quality health service delivery is statistically significant and positive (r=0.695; p <0.01).
(ii) The relationship between job satisfaction and quality health service delivery (r=0.720; p <0.01) is statistically significant and positive.
(iii) There is a positive and statistically significant relationship between internal marketing and job satisfaction (r=0.897; p<0.01).
(iv) There is a positive and statistically significant relationship between the combined influence of internal marketing and job satisfaction on quality service delivery (r=0.728; p<0.01)
Multiple regression analysis
The results of the multiple hierarchical regression analysis are shown in Tables 3, 4 and 5.
Correlation analysis
The result in Table 2 indicate a positive and statistically significant relationship between internal marketing and quality health service delivery which is consistent with Balemba and Bugandwa (2016) who posit that effective internal marketing can enhance desired service quality. Similarly, a study by Amjad and Alshurideh (2012) earmarked internal marketing as a significant predictor to quality service delivery.
The results also show a positive and statistically significant relationship between job satisfaction and quality health service delivery is in line with the study of Wambugu (2015) who argued that service quality is influenced by job satisfaction of employees. Similarly, Hartline and Ferrell (1996) and Kakooza et al. (2015) found evidence that job satisfaction is associated with service quality. The results also depict a positive and statistically significant relationship between internal marketing and job satisfaction. This is in line with several previous studies which have shown that adopting internal marketing through specific techniques like: training and development, autonomy, motivation, communication, empowerment, healthy working environment and reward will all have a positive impact on employee job satisfaction. These studies include the following: Al-Hawary et al. (2013) and Amjad and Alshurideh (2012). Lastly, the results portray a positive and statistically significant relationship between the combined influence of internal marketing and job satisfaction on quality health service delivery which is in line with the findings of Omagor et al. (2012).
Regression analysis
It was hypothesized that there is a significant and positive relationship between internal marketing and quality health
service delivery. Table 3 depicts that Model 1 which controlled for gender, age, educational level and tenure (demographic variables) explained 3.2% of the total variation in quality health service delivery. This implies that the contribution of demographic variables to quality health service delivery in Greater Iganga Local Government is statistically insignificant (R2=0.032, p>0.05).
However, the regression analysis results displayed in Model 2 revealed that 52.7% of the total variation in quality health service delivery is explained by the variation in internal marketing (R2=0.527, p<0.001). The regression coefficient of change in quality health service delivery due to a change in internal marketing was significant (β=0.713, t=11.260, p<0.001). The positive and significant correlation between internal marketing and quality health service delivery (r=0.0695, p<0.001), and the regression coefficient (β=0.713, t=11.260, p<0.001) led to the acceptance of hypothesis H1.
This finding is consistent with a previous study by Sadeghloo and Tirgar (2013), suggesting that internal marketing supports a great role of service organisations in achieving quality service delivery. Owing to this, organisations need Strategic Plans to enhance internal marketing if service quality is to be achieved. It was also hypothesized that there is a significant and positive relationship between job satisfaction and quality health service delivery. Table 4 depicts that Model 1 which controlled for gender, age, educational level and tenure (demographic variables) explained 3.2% of the total variation in quality health service delivery. This implies that the contribution of demographic variables to quality health service delivery in Greater Iganga Local Government is statistically insignificant (R2=0.032,
p>0.05).
The correlation analysis results in Table 2 indicate a positive and statistically significant relationship between job satisfaction and quality health service delivery (r=0.720, p<0, 01). This finding is strengthened by the regression results shown in Table 4 for Model 2 which indicates that 54.8% of the total variance in QHSD was explained by the variation of job satisfaction (R2=0.548, p<0.001). The regression coefficient of change in quality health service delivery due to a change in job satisfaction was significant (β=0.731, t=11.747, p<0.001). Based on this, hypothesis H2 was accepted. These results are consistent with Yoon and Suh (2003) showing that satisfied employees are more likely to work harder and provide better services.
Lastly, it was hypothesized that there is a significant and positive relationship between the combined influence of internal marketing and job satisfaction on quality health service delivery. Correlation analysis results in Table 2 depict a positive and statistically significant relationship between the combined influence of internal marketing and job satisfaction on quality health service delivery (r=0.728, p<0.01). This finding is strengthened by the hierarchical multiple regression results shown in Table 5 for Model 2 which indicates that 56.3% of the total variance in quality health service delivery was explained by the combined influence of internal marketing and job satisfaction (R2=0.563, p<0.001). The regression coefficient of change in quality health service delivery due to a combined change in internal marketing and job satisfaction was significant (β=0.739, t=12.129, p<0.001). The correlation and regression analysis results led to the acceptance of hypothesis H3.
This result is in consonance with Omagor et al. (2012) who argued that internal marketing and job satisfaction improve service quality delivery. This is due to the enhancement of training with an emphasis on the specific service tasks that employees have to accomplish, employee empowerment, sharing information pertaining to customer needs and rewarding employees based on the customer service level they offer as well as prompt payment of employees and promotion (Amjad and Alshurideh, 2012; Shabbir and Salaria, 2014).
The major objective of this research is to examine the combined influence of internal marketing and job satisfaction on quality health service delivery in Greater Iganga Local Government. In line with this major objective the study had two minor objectives. Firstly, to examine the influence of internal marketing on quality health service delivery in Greater Iganga Local Government; secondly, to examine the influence of job satisfaction on quality health service delivery in Greater Iganga District Government.
Based on the results of the correlation and regression analysis, this study has empirically demonstrated the following: Firstly, that internal marketing is a predictor of quality health service delivery in Greater Iganga Local Government; secondly, that job satisfaction is critical for quality health service delivery. Thirdly, that internal marketing is an antecedent for job satisfaction. The research has implications for local governments through the Ministry of Health. Local governments should review and update the existing marketing practices and strengthen them through policy implementation. The Ministry of Health through local governments should promote and sensitize effective employee satisfaction. It should also promote effective internal marketing practices to ensure a high level of job satisfaction.
Despite the fact that this study has made some contributions to literature, it has some limitations that provide avenues for future research. The study’s findings were accrued from a cross sectional research strategy. Future studies should consider using other research strategies. Since the study was carried out in public sector health organisation (Greater Iganga Local Government) valuable information relating to the private health sector was not captured. It is therefore proposed that future studies should consider incorporating private sector health facilities as units of inquiry.
The authors have not declared any conflict of interests.
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