Relationship Marketing Strategy Policy Formulation And Curricula Development To Enhance Quality Of.pdf

International Journal of Health Care Quality Assurance Relationship marketing strategy: policy formulation and curricula development to enhance quality of care in the health sector of Ghana Augustine Adomah-Afari, Theophilus Maloreh-Nyamekye,

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To cite this document: Augustine Adomah-Afari, Theophilus Maloreh-Nyamekye, "Relationship marketing strategy: policy formulation and curricula development to enhance quality of care in the health sector of Ghana", International Journal of Health Care Quality Assurance, https://doi.org/10.1108/IJHCQA-05-2017-0086 Permanent link to this document: https://doi.org/10.1108/IJHCQA-05-2017-0086 Downloaded on: 11 June 2018, At: 00:57 (PT) References: this document contains references to 0 other documents. To copy this document: [email protected] The fulltext of this document has been downloaded 9 times since 2018* Access to this document was granted through an Emerald subscription provided by emerald-srm:283794 []

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Title: Relationship marketing strategy: policy formulation and curricula development to enhance quality of care in the health sector of Ghana Author (s): Augustine Adomah-Afari, Ph.D, MA, MBA, BSc.1, Theophilus Maloreh-Nyamekye, Ph.D, MBA, MSC, MCIPS, PGDip, PGCert, BA2

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1. Lecturer, Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, P.O.Box LG13, Legon-Accra. Tel: 00233 (0) 265435294 Email: [email protected]; [email protected] 2. Lecturer, University of Ghana Business School, University of Ghana, P.O.Box LG78, Legon-Accra. Tel: 00233 (0) 202104480 Email: [email protected]; [email protected] Corresponding [email protected]

Author:

Augustine

Adomah-Afari,

[email protected];

Biodata Dr. Augustine Adomah-Afari, is currently, a lecturer in Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana. He received both MA and PhD from the Sheffield Business School, Sheffield Hallam University – UK. He had also graduated from the University of Ghana Business School with both BSc. (Admin) and MBA. He worked as a Health Services Administrator (District and Regional Hospitals-Ghana); Senior Health Services Administrator (HASS/GHS); Consultant (PHRplus-Ghana); and Administrator (Manor & Castle Development Trust Ltd.-UK). His research interests include health system reforms; health financing, policy, planning and management; quality of health care; relationship marketing; human resources management; and community-based organisations. Dr. Theophilus Maloreh-Nyamekye, is currently, a lecturer in Public Administration & Health Services Management, University of Ghana Business School, University of Ghana. He obtained PhD, MSc. and PG Cert. from the Robert Gordon University, Aberdeen, Scotland, UK. He has a PG Dip. in Marketing (CIM-Ghana). He had also graduated from the University of Ghana with both MBA and BA (Nursing with Psychology). His work experiences include: Part-Time Lecturer (Ghana Telecom University), Lecturer (Catholic Institute of Business and Technology), Consultant/Lecturer (GIMPA), Management Consultant (Ghana, Mali and Mozambique), Health Services Administrator (Effia-Nkwanta Regional Hospital and Tarkwa Government Hospital). He has also served as a Member, Staff Recruitment and Promotion Panel, Catholic Institute of Business and Technology (CIBT), Head, Department of Procurement and Supply Chain Management, CIBT, and Review Panelist (CIMG). His research interests include: health service marketing, impact of information, education and communication strategies related to malaria prevention and control during pregnancy, health systems evaluation, including management and mechanisms of malaria control programmes in Africa, poverty reduction, procurement and supply chain management and quality management, including customer satisfaction surveys in hospitals; and systematic review of evidence related to community health and healthcare. i

Abstract Purpose: The study explored how strategies were put in place to formulate policies regarding the introduction and implementation of relationship marketing in the health sector; and how relationship marketing strategies were designed as part of the curricula for the training of prospective health professionals in Ghana.

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Methodology: Data were gathered using interviews and documentary review. A purposive sampling technique was used to recruit policy makers and health educationists in Accra for in-depth interviews. Qualitative interviews were analysed using framework analysis. Findings: The findings revealed that currently, there is no policy framework on relationship marketing in the health sector nor included in the curricula of health training institutions in the country. Research Limitation(s): Due to limited time and funding constraints, the study could not include many policy makers, educationists, health providers, facilities and regions outside the Greater Accra region of Ghana. This means that we missed out on useful insights from other relevant policy makers/educationists who would have added to the knowledge that this study contributes. There were still some areas that this study could not cover, including lack of an exploration of the perceptions of health providers and patients. Practical Implication(s): Evidence from the current research provides the basis for scaling up of a similar study to the whole country to address the perennial relationship marketing or quality of care/patient satisfaction issues persisting in health facilities in the country. The outcome of this large scale study would help to confirm the findings of the current study on the adoption and incorporation of relationship marketing into both policy framework and curricula of health training institutions in Ghana. The findings would culminate in the preparation and utilisation of guidelines on relationship marketing for client-centered service delivery in the health sector of the country. Social Implication: This paper argues that relationship marketing orientation could enable health professionals to improve upon their health care service performance and quality of care so as to enhance patient satisfaction. Originality: The study recommends that relationship marketing should be adopted by health policy-makers and designers of curricula for health training institutions.

Key words: relationship marketing orientation/strategies, customer policymaking, quality healthcare, training institutions, and curricula.

ii

service/care,

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Relationship marketing strategy: policy formulation and curricula development to enhance quality of care in the health sector of Ghana

INTRODUCTION There is the need to develop a suitable and more humane approach to healthcare service delivery to enhance quality care and patient satisfaction (Alrubaiee and Alkaa'ida, 2011). Some analysts anticipate that paying attention to the perspectives of clients, improving the competencies and skills of providers, working environment and motivating staff among others could help improve quality of care (Bannerman et al., 2002; Turkson, 2009). The lack of these attributes is why there is perceived poor delivery of health care services in hospitals and clinics in Ghana. Even under the current National Health Insurance Scheme (NHIS) dispensation, healthcare providers are perceived to be rude, uncaring, disrespectful and unfriendly (Turkson, 2009). These, coupled with other factors, have created the assumption that healthcare providers are not customer-friendly, giving rise to self-medication and other unethical means of healthcare service consumption (Gyasi et al., 2011). Relationship Marketing (RM) strategy on the part of healthcare providers can resolve some of these problems (Berry, 1983; Sorce, 2002). The primary goal of RM is to build and maintain a base of committed customers who are profitable for the organisation. The concerns include attracting, developing and retaining customer relationships (Berry and Parasuraman, 1991). RM is within the framework of services marketing (Gronroos, 2000b); a branch of the marketing discipline (Kotler, 2000). Kotler (2000) argued that marketing deals with profitably identifying and meeting human and social needs. That is, marketing people are involved in marketing ten types of entities: goods, services, experiences, events, persons, places, properties, organizations, information and ideas. ‘Service’ has been defined as the application of specialised competencies (skills and knowledge) through deeds, processes and performances for the benefit of another entity or the entity itself (self-service) (Gronroos, 2000b). However, ‘services marketing’ has been defined differently including the fact that it is the marketing of activities and processes (rather than objects) (Solomon et al., 1985) and as a process or performance (rather than a thing) (Lovelock, 1991). In addition to the traditional four ‘Ps’ of marketing (product, price, place and promotion (distribution)), Rust et al. (1996a) identified another three ‘Ps’ of services marketing― people, physical evidence and process. RM, which is the focus of this study, takes a cue from services marketing (Rust et al., 1996a; Rohrer et al., 1999; Rohrer, 2000). Thus, Berry (1995) explains that RM is an old idea with a new focus. It has taken the forefront of services marketing practice and academic research. The impetus for its development has come from the maturing of services marketing with emphasis on quality, increased recognition of potential benefits for the firm and customer and technological advances. Undeniably, the notion of RM sub-sits on long-term relationships (MacNeil, 1981). Thus, the firm/hospital will have to focus on the attraction, retention and enhancement of customer relationships (Berry, 1983). In doing this, Khurana et al. (1993) proposed eighteen novel ways to get more patients. Berry (1995) argues that RM aims to target profitable customers using the strongest possible strategies for customer bonding, marketing to employees and other stakeholders and building trust as a marketing tool.

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Without a doubt, RM strategy has become important in the delivery of health services due to the introduction of cost and risk sharing policies in Ghana (Badasu, 2004). Naidu et al. (1999) contend that RM has been gaining momentum as business entities realize that shortterm sales/transaction orientation has several pitfalls for building customer loyalty and continued patronage. The reason is that RM has the potential to improve marketing productivity (Sheth and Parvatiyar, 1995a). Naidu et al. (1999: 207) examined the nature of RM practices adopted by hospitals in the United States and how they correlated with the performance of such hospitals. These researchers concluded that development and implementation of customer retention programmes, partnering with customers, suppliers and competitors and other RM practices had become a way of life. Hasan et al. (2014) recognize that customer loyalty is important for many competitive organisations and that retail firms will need to make investments (in RM) towards building and maintaining loyal relationships with their existing and potential customers. In spite of the benefits derived from an RM strategy, there are certain impediments to its implementation (Grönroos, 1995). Grönroos (1995:252) observe that as service firms like banks, insurance firms, transportation companies and retailers have grown, the masses of customers have made the establishment of true relationship more difficult. What seemed to have happened was that, in growing service businesses, the customer was turned from a relationship partner into market share statistics. This analyst provides two obvious reasons for this. Firstly, there is a difficulty to administer a relationship-oriented customer contact when the number of customers is increasing. Secondly, there is a growing influence from popular consumer goods-based, nonrelational marketing approaches. Of particular mention was when the marketing mix management paradigm and its flagship (the 4Ps model) established itself as the dominating marketing paradigm. Supporting this perspective, Hibbard et al. (2001) suggest that though building trust, commitment and the other components of RM continue to have a positive effect on the performance of business partners, the positive effect could diminish over time. The authors suggest that managers need to identify the true cost of building relationships so as to judge whether the diminishing returns justify the effort; and to vary their handling of each relationship because standardized RM practices are unlikely to be effective (Hibbard et al., 2001: 29). Confirming this, Leverin and Liljander (2006) observed no significant differences between the segments on customers' evaluations of the service relationship or their loyalty to the bank. Thus, managers should invest resources to stimulate customer gratitude in order to build strong customer–seller relationships (Hasan et al., 2014). Indeed, firms can do this by organising what is termed as a service-influenced marketing so as to create a customer focus among all employees beyond conventional marketing (Grönroos and Gummerus, 2014). Recognising the deficiencies, Berry (1995) indicates that although RM is developing, more research is needed before it reaches maturity. To do this, Gummerus et al. (2017) suggest that there is the need to look for a common ground in RM thinking, assessing the extent to which the different literature streams add to marketing research and when they do not; testing/deploying the learnings in new settings. In spite of its applicability, no study using qualitative interviews has yet explored how strategies were being put in place to formulate policies regarding the introduction and implementation of RM in the health sector or has examined how relationship marketing strategies were designed as part of the curricula for the 2

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training of prospective health professionals in Ghana (Derbile and van der Geest, 2012). This paper provides more understanding and argues that the introduction of RM strategy into the policy framework and curricula of health training institutions could help to address the perennial RM issues persisting in the health facilities in the country. LITERATURE REVIEW RM orientation can enhance patients’ satisfaction with the reception they receive from health personnel (Palmatier, 2008). RM strategy provides the basis for a business entity to realise that any attempt to underestimate the supremacy of the customer (patient) will lead to other competitors having competitive advantage (Palmatier, 2008). In the healthcare environment, patients consider the time spent with the doctor/health personnel as very crucial due to consumerism (Fang et al., 2008). RM strategy to healthcare service delivery will ensure the appreciation of the exchange relationships that must exist between healthcare providers and clients/patients of health care services (Enyeart and Weaver, 2005). Patients take into account the attitude of staff in assessing quality of care. Hence, RM skills will enable staff to appreciate the urgent need to be customer-friendly (Ngo-Metzger et al., 2006). Patients are satisfied with less waiting time at the various departments of a health care institution (Jennings et al., 2015). Designing an RM strategy in this direction must consist of the health sector as a whole (MacAdam, 2008). This will create new opportunities, customerfriendly health service environment and engender competition (Debono and Travaglia, 2009). Greer (1985) noted that the media could influence people’s perception of medical technology as well as reflect community perception of the local hospitals. Such perceptions play an important part in determining whether local community members would support a hospital financially as well as use its services (Asadi-Lari et al., 2004). The key gaps identified in the literature include the reality that even though RM is considered a paradigm change in both academic and practitioner literature, it has yet to evolve into becoming a discipline in the health training institutions in Ghana (Thoreli, 1986; Sheth and Parvatiyar, 2000). This justifies the reason RM must be considered as a strategic policy framework and included in the training curricula to be taught by health training institutions (Zeithaml and Bitner, 1996). This will arouse the interest of student health professionals to accept RM as an integral part of the delivery of quality healthcare service (Morgan, 1998; Yoon and Lee, 2005). Conceptual Analysis The study sub-sits on the framework of relationship, trust, collaboration, commitment, quality of care and satisfaction (Morgan and Hunt, 1994). These are important elements for effective and efficient management and delivery of quality healthcare services. Commitment is a variable believed to be central in distinguishing social from economic exchange; and commitment and trust lead directly to cooperative behaviours that are conducive to RM success (Moorman et al., 1993). A few analysts argue that collaborative efforts between the private health sector, public health sector and community members could enhance social relationships (Molinari et al., 1998). These can promote the health of residents as there is a positive relationship between community health service, quality and health status (House et al., 1988; Sturchio and Goel, 2012). Wright (1994) points out that human evolution depends on relationships that enable reciprocal altruism. RM has a positive relationship with commitment and trust ― successful RM requires relationship, commitment and trust (Rotter, 1967). Invariably, the efficiency, 3

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adjustment and even survival of any social group depend upon the presence or absence of trust (Fu, 2004). This is why true marketing companies are held by means of norms of sharing and commitment based on trust (Morgan and Hunt, 1994; Kozlowski and Ilgen, 2006). Walt and Gilson (1994) developed a policy analysis framework specifically for health but its relevance extends beyond this sector. These researchers note that health policy research focuses largely on the content of the policy, neglecting actors, context and processes. The content of the policy looks at the following factors: educational qualification, knowledge and experience, skills and abilities. The process factors include: legal framework, institutional influences and external influences. The contextual factors include: situational/political, socio-cultural and economic. This framework was used to assess the policy makers’ knowledge and readiness to institute and implement RM strategy as a new policy direction in the health sector under the health sector reforms. Donabedian (1988) discusses three phases of quality of care measures in healthcare institutions: structure, process and outcome. The structure indicates characteristics of the resources in the health delivery system. For example, number of qualified staff and policy guidelines and management systems including RM strategies. The process involves an examination of care in terms of what is actually done to and for the patient. Process measures include factors such as waiting time, examining patients properly and appropriateness of treatment. The outcome measured includes patient satisfaction, coverage and attendance levels (Donabedian, 1988). The three phases of quality of care measures were used to measure heads of health training institutions’ level of knowledge of the contribution of RM orientation towards achieving quality of care for patients in health institutions. METHODS Data were gathered using qualitative and documentary reviews between June and September, 2015. Study design and strategies Ghana is located on the west coast of Africa with a population of 24,658,823. There are ten administrative regions (GSS, 2011). The health sector in Ghana has been decentralised to the district level (Ministry of Health, 1996). The study was conducted in Greater Accra which had a population of 4,010,054 in 2010 (GSS, 2011). Using the interpretivist approach (Schwandt, 1998), purposive sampling strategy (Creswell and Clark, 2007) was used in selecting ten participants based in Accra, the capital city of Ghana. Creswell (1998) suggests a sample size of between five and twenty-five. This sample size was determined based on saturation. This was explained by Polite and Beck (2008) as the point in data collection when new data no longer brought additional insight to the research questions. Interviews The ten policy makers and educationists interviewed were selected from the Ministry of Health, Ghana Health Service, health regulatory bodies and health training institutions. They had varied years of experience in their respective positions. Using a semi-structured interview guide, the following questions were addressed: 1. What are the strategies put in place to formulate policies regarding the introduction and implementation of relationship marketing in the health sector? 4

2. How can relationship marketing strategies be designed as part of the curricula for the training of prospective health professionals?

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The interviews, which were conducted in the English language, were held in their respective offices during working hours. Attempts were made to minimise interruptions and interferences. Each interview lasted between 15 and 30 minutes and was tape recorded using a digital voice recorder. Data Analysis The interviews were transcribed and analysed using suitable theories and techniques including framework analysis and Nvivo software. The interpretative perspective was used in the data analysis because there was the need for thematic emphasis on understanding and interpretation (Bernstein, 1983; Lincoln, 1990). The interview transcripts were read over and over, developing patterns and themes based on frequently occurring issues raised by the participants. Codes were used to identify respondents of each organisation. PM means Policy Maker. HTIP means Health Training Institution Personnel. Ethics, access and quality assurance A pre-test of the semi-structured interview was done with some officials with similar characteristics within the health sector. Ethical clearance was granted by the Ethics Committee for Humanities (ECH), University of Ghana-Legon, under certificate number: ECH 074/14-15. Another ethical clearance was granted by the Ethics Review Committee, Ghana Health Service under Ethics Approval ID No. GHS-ERC 01/09/15. Introductory letters were sent to appropriate authorities/institutions. Participants' consent was sought using an approved participant’s consent form. Confidentiality and anonymity of participants was guaranteed. ANALYSIS OF FINDINGS Analysis of the findings based on the themes that emerged from the interview data in respect to the objectives of the study are presented below; Strategies toward formulating policies regarding the introduction and implementation of relationship marketing in the health sector The first objective, which focused on the policy makers, was achieved by using the framework for policy analysis to assess the policy makers’ knowledge and readiness to institute and implement RM strategy as a new policy direction in the health sector. Content The analysis revealed that although health professionals are somewhat trained in different aspects of customer services and that there was the existence of ‘work-in-progress manual’ on ‘customer services’ for the health sector, there was no specific policy framework, training manual or inclusion of RM in the curricula: […] I think that we have some modules on staff-patient relationship but I wouldn’t call that one RM because marketing is another terminology for a new concept […]…PM-3.

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The absence of strong emphasis on marketing and RM in the health sector could also be related to the orientation of health providers. Sometimes, quality of healthcare measures are adopted: […] Clearly, we recognise the technical perspective in terms of ‘quality’, and we recognise the user ‘satisfaction’ as another important dimension […]…PM-4.

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Processes The perspective of policy makers was that all stakeholders in the health sector should encourage, coordinate, collaborate and support the institution and training of health personnel in the health sector in RM: […] So one way to actually carry out the process is advocacy with the professional regulatory bodies so that they see the need for incorporating RM into the course syllabus of the training institutions […] PM-2. Participants discussed the seeming absence of accountability in terms of performance to demonstrate invested resources in the public health sector compared with the private health sector. This could account for the lack of good customer/patient relationship. Context Participants believed that introduction of RM would give the public health sector a new look within the context of the health sector reform: […] After your research findings come out in a positive direction and based on what the findings are, we’ll be making a presentation and we will adopt that (RM) and then quickly put them in a form as a policy […] Now, we are moving away from just putting policies in a vacuum […]…PM-1. The policy processes and procedures that RM would need to go through before it could become a national policy were discussed. There are however, attitudinal issues and certain cultural behaviours of health providers that should be addressed: […] We all know that people complain about attitude of health workers - it is the culture of Ghanaians […] RM will help change the mindset of people […]…PM-1. Introducing RM will require some financial commitment from both government and other stakeholders in the healthcare environment. Designing relationship marketing strategies as part of the curricula for the training of prospective health professionals The three phases of quality of care measures were used to measure heads of health training institutions’ level of knowledge of the contribution of RM orientation towards achieving quality of care for patients in healthcare institutions. Structure The health training institutions make enormous efforts to inculcate in trainees different good attitudes so as to encourage good relationship between them and their clients on completion of their courses. However, there is no specific topic on the concept of RM: 6

[…] In our training, we teach some courses like behaviour change under health promotion - we expect them to learn some things about change of attitude […]…HTIP-2. Efforts are also made outside the curriculum, to introduce courses that help trainees to understand relationship-specific issues.

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Process It is important that healthcare training institutions inculcate into students the habit of establishing a long-term stable relationship with their stakeholders. Participants revealed the areas serving as the basis of such an orientation while in training. Training on relationship with clients The health training schools ensure that students develop the idea of how health personnel provide quality relationship between them and their patients/clients by even instilling discipline: […] When they’re coming in at first with their admission letter, we have an undertaking - academic work and behaviour […]…HTIP-4. They teach the students how to even do community entry, how to meet the chiefs, how to pay homage among others. Training on relationship with government Respondents described how they talk to students about how to improve relationship between health institutions and government: […] During administration, we teach them a lot about the pillars of government: the Ministry of Health and the Ghana Health Service where we work basically […]…HTIP-2. Training on relationship with competitors The training institutions introduce students to the idea of improving the relationship between their institutions and the competitors in the competitive healthcare environment: […] We tell them ‘when you finish and you’re in the hospitals, you should be ambassadors of your school’ […] ‘You should work hard, learn and be singled out among the lot’ […]…HTIP-3. Training on relationship with media Educating nurse trainees on their relationship with the media upon completion is approached from a point where they have to establish cordial working relationships; to ensure continuous public education: […] We encourage them to work hand in hand […] Most of them even do TV programmes - they are called upon to talk to the public on health education […]...HTIP-2. Outcome 7

Respondents recommended training in RM for tutors of health training institutions to achieve the most desirable patient-provider related outcomes in the health sector: […] I will also approve of the training of the tutors […] A curriculum needs to be developed, then the tutors can be taken through RM, and they will in turn teach the students both the theory and practicals […]…HTIP-2.

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Despite the few challenges such as attitude of health providers and financial constraints likely to confront the introduction of RM into the policy framework and curricula of health training institutions, there was overwhelming support from all participants. DISCUSSION The study argues that there is a difference between customer service/care and RM. Customer care/service is a temporary interaction with patients; the current ‘work in progress’ concept being promoted in the public health sector. RM is a long term/sustained relationship. The difference can be seen in the ability of RM to attract, establish, maintain and enhance a longterm relationship between healthcare providers and patients in the health sector (Berry, 1983). Using this premise, the key findings of the study are discussed in relation to the concepts of collaboration and commitment; and relationship and trust. Promoting policy formulation and implementation of RM in the health sector ― Collaboration and commitment to enhance quality of care and patient satisfaction Studies show that RM emerged from dissatisfaction with existing paradigms ― many marketing theories tend to focus on exchange as adhoc transactions based on conflict (Cannon and Sheth, 1994). The study argues that quality of care and health status of people would be improved when partners in the healthcare market environment coordinate, cooperate and collaborate with each other. This can promote the health of residents as there is a positive relationship between community health service, quality and health status (House et al., 1988; Sturchio and Goel, 2012). Policy adoption pathways for RM Morgan (2012) argues that academics and managers have struggled for many years to understand and delineate the role of marketing in explaining business performance differences between firms. This study shows the view that the process towards the adoption and implementation of RM is based on some assumptions shown in figure I that: 1. The content, processes and context are crucial regarding policy implementation. 2. The three dimensions are intertwined. 3. Each dimension may operate in isolation in certain instances. Walt and Gilson (1994) note that health policy research focus largely on the content of policy, neglecting actors, context and processes. However, the findings of this study show that when RM is implemented with the requisite regulatory framework, it will be adopted for implementation by healthcare providers. This supports Eiriz and Wilson’s (2006) suggestion that future research into RM should focus on the rationale, processes and structures involved. Promoting strategies toward curricula development in relationship marketing for health training institutions― Relationship and trust to enhance quality of care and patient satisfaction 8

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Rotter (1967) notes that successful RM requires relationship, commitment and trust. The study found that this was a prerequisite since participants agreed on the need to include RM strategy in the curricula of health training institutions. The fact is that RM reflects a strategy and process that integrates customers, suppliers and other partners/stakeholders into the company’s design, development, manufacturing and sales processes (Sheth and Parvatiyar, 1993; Cannon and Sheth, 1994). Thus, the study revealed the interrelationship between the structure, process and outcome in figure II. The figure shows that training is a key aspect of education that ensures that students receive knowledge of RM strategies as part of curricula for prospective health professionals. However, this process can only be successful in an enabling environment where structures and systems such as the readiness of the health ministry to institutionalise RM strategies as part of the students’ curricula are available. Hopefully, when the process is supported by the appropriate structures, health professionals’ knowledge of RM would be enhanced. This would lead to enhanced quality healthcare. Storey and Hughes (2013) observe that there are different pathways to new service development performance depending on existing organizational conditions. Thus, the study argues that there is the need to inculcate the tenets of RM into prospective students before they graduate to join the healthcare delivery institutions. The relevance of RM in the curricula of health training institutions is paramount because academics and practitioners have become increasingly dissatisfied with traditional marketing theory and practice (Cannon and Sheth, 1994). However, this study found that marketing/RM as a discipline was not included in the curricula of health training institutions. Thus, managers require faculty to provide them with knowledge that is relevant and able to guide their decisions. The need for collaboration between the health training institutions and health care industry is also paramount. Additionally, students desire that the pedagogy will help them to develop skills and provide them with hands-on experience. The curricula for the training of students in RM should be designed taking cognisance of the socio-cultural parameters of the country. This will sit with the observation that RM has emerged as a big new idea for many Western companies ― there is emphasis on relational as opposed to transactional exchange (Palmer, 1997). Notably, attitudinal/behavioural changes are necessary to engender confidence and trust of the patients in the healthcare providers as documented (Zeithaml and Bitner, 1996). CONCLUSION This study explored how strategies were put in place to formulate policies regarding the introduction and implementation of RM as a policy in the health sector; and how RM strategies were designed as part of the curricula for the training of prospective health professionals. Generally, the findings showed that there was no policy framework on RM in the health sector nor was it included in the curricula of health training institutions. Although a large body of research theoretically asserts a positive association between RM orientation and business performance, a valid measure of RM orientation has not yet been proposed and systematic analysis of its effect on business performance has thus far not been possible as indicated (Sin et al., 2002). Nonetheless, attempts were being made to introduce ‘customer service’ in the health sector. This could be used as a basis to develop the policy and curricula frameworks for RM towards improving quality of care, patient satisfaction and performance in the health sector. 9

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Evidently, RM orientation was positively and significantly associated with overall performance in other studies (Sin et al., 2002). The process of adopting RM strategy as a policy framework may be seen as developing an understanding of the communicator’s intentions and qualities (ethos) and the communication climate (pathos), both of which are necessary for engaging in constructive dialogues with customers (logos) (Houman, 2001:167). Equally, participants agreed on the crucial need to include RM strategy in the curricula of health training institutions (Achrol, 1991). This would help inculcate into prospective students the tenets of RM before they graduate to join the healthcare delivery institutions. Patient satisfaction would be enhanced with the service received in hospitals through RM orientation as indicated (Morgan and Hunt, 1994). Implications for policy, practice and management Ravald and Grönroos (1996) suggest that it is possible to establish and maintain mutually profitable customer relationships which are of prime concern in RM. Consequently, the suggestion is that option ‘D’ in figure I should be adopted. For an effective implementation of a policy on RM in the health sector of Ghana and elsewhere, the content, context and process factors must interact concurrently. A similar result led to the acceptance of a model which indicated that change context mediated the relationship between individual differences and change process and content (Walker et al., 2007). Indeed, RM processes in public health sector institutions can only survive if policy makers, led by political leaders (of the day), are ready to embrace the concept. There has to be a policy in place to guide the implementation process. The context of such a policy must be clearly understood by health educational institutions whose role is to impact knowledge of RM orientation. However, this policy if established will be only relevant when it has the backing of political leaders and embraced by technocrats at all levels. Walker et al. (2007:761) reported that even though an organization's prior change history (i.e. context) has the potential to negatively influence change success, change agents should concentrate on clearly communicating the change details (i.e. process) to employees in order to counteract these effects. Similarly, the study argues that the extent to which employees perceive an organizational change as justified will be influenced by their perceived organizational support (an organizational context variable) (Self et al., 2007). Ravald and Grönroos (1996) suggest that the ability to provide superior value to customers is a prerequisite when trying to establish and maintain long-term customer relationships. This study observes that since the process dimension essentially focuses on actual implementation of RM orientation in healthcare institutions, participants suggested that lecturers and tutors in training institutions must have the required knowledge, skills and readiness to teach the concept and passion to use students to effect change in healthcare delivery following completion of studies ― the value concept is a basic constituent of RM as indicated in other studies (Ravald and Grönroos, 1996). This is because organizational change (an employee outcome variable) is strongly related to the impact of the change on employees (a content variable) and organizational communication media (a process variable) (Self et al., 2007). Limitations and future research There were few challenges in the overall success of the study. Due to funding constraints, it was not possible to include many policy makers, educationists, health providers, facilities and regions outside the Greater Accra region of Ghana. This study could not explore the perceptions of health providers and patients. Therefore, attempts should be made by future 10

researchers to mitigate similar challenges. Crucially, the evidence from the current research provides the basis for scaling up a similar study to the whole country to address the perennial RM or quality of care/patient satisfaction issues persisting in health facilities in the country (Wall et al., 2009). The outcome of this large scale study would help to confirm the findings of the current study on the adoption and incorporation of RM into both policy framework and curricula of health training institutions. The findings would culminate in the preparation and utilisation of guidelines on RM for client-centered service delivery in the health sector of Ghana and beyond.

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Acknowledgement This research was funded by the Office of Research, Innovation and Development (ORID), University of Ghana, with Project Reference Number: URF/8/Sf-018/2014/2015. We appreciate this financial support.

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Processes

B

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E

A

G D F

C

Content

Context

Figure 1: Strategies towards formulating policies regarding the introduction and implementation of relationships marketing in the health sector

Legends The legends and grids in figure 1 have been explained below. ‘A’ - represents that aspect of policy content that may never be implemented because it has no bearing on or with contextual factors. ‘B’ - represents that aspect of policy process, which cannot be implemented unless it is based on policy content and context. ‘C’ - stands for policy context, which involves the contextual factors related to realities on the ground, but meaningless unless it is linked up with policy content and process. ‘D’ - shows that for an effective implementation of a policy on RM in the health sector, the content, context and process factors must interact concurrently. For example, RM processes in public health sector institutions can only survive if policy making led by political leaders (of the day) are ready to embrace the concept. On the other hand, there has to be a policy in place to guide the implementation process. The context of such a policy must be clearly understood by health educational institutions whose role it is to impact knowledge of RM orientation. However, this policy if established, is only relevant when it has the backing of political leaders and embraced by technocrats at all levels. This leads us to the process dimension, which essentially focuses on actual implementation of RM orientation in health care institutions. For instance, lecturers and tutors in training institutions must have the required knowledge, skills and readiness to teach the concept and the passion to use students to effect change in healthcare delivery following completion of studies.

‘E’ - shows that policy content is embraced by those involved in policy implementation. These include such implementers as health service managers, lecturers, principals and tutors of health training institutions. However, without contextual factors such as health care providers’ belief in patients as valued customers, health care practitioners’ readiness to be customer-focus and the understanding that health care institutions only exist because of patients, no headway can be made.

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‘F’ - shows an interaction between policy content and context. It means that aspect of the policy content has a link with reality. However, this is not enough because without it being embraced by political authorities and technocrats at the helm of affairs, implementation is meaningless. ‘G’ - represents a situation where process factors intersect with contextual factors in the absence of policy content. Contextual and process factors are meaningless if policy content is absent. Thus, the best scenario is, ‘D’, which provides an ideal platform for policy implementation success.

Structure Institutionalising RM in the recognition of schemes / enabling environment

Process • Training on relationship clients • Training on relationship stakeholders • Training on relationship government • Training on relationship competitors • -Training on relationship media

with with with with with

Outcome • Implementing quality outcomes in the training of healthcare providers • Delivery of patient centred/customer focused care

Figure 2: Designing relationship marketing strategies as part of the curricula for the training of prospective health professionals