Health Care Marketing and Public Relations in Not for Profit Hospitals in Nigeria

Government Hospitals are largely Not for Profit Organisations, because the purpose of establishing them is to provide Health services to the community, mostly the needy; at little or no cost. Their services are invaluable and essential. It is therefore, imperative that the Government subsidized the services of these Health Care Organisations, for people to be able to reap the benefits of its services. However, there are many challenges faced by these Health Care Organisations like, rise in expectation of patients about their poor service delivery and increased competition from Private or For Profit Health Care Organisations. This is in addition to the fact that Health Care Industry is now experiencing a new dawn, where the patients have become more informed about their Health needs and are no longer submissive to their Physician’s instruction only but play more active role in their health care related decisions. Thus, Health Care Providers have realized that one of the ways to manage these challenges is the use of Hospital Marketing and have also discovered that it is easier and less expensive to retain old patients than to find new ones. The objective of this paper therefore, is to examine how marketing and Public Relations activities have contributed to the realization of the organizational objectives of Not for Profit Health Care Organisations in developing country, most especially Nigeria. The study was carried out in ten out of the sixteen Local Government Areas of Kwara State of Nigeria. The data for the Research was obtained through Proforma type Questionnaire administered to both Health Care Marketing Staff and Patients from twenty out of the one hundred and thirty five government hospitals in the state. The test stastic used for the study are Pearson Correlation and Regression Analysis. The Correlation analysis was employed to determine the relationship between the Incomes received from Patient and the estimated Marketing budget for the Health Care Organisations. Regression Analysis was used to explained the effect of education, age, and work experience of Health Care Marketing Staff on their salaries. Regression was also used to examine the effect of Marketing and Public Relations activities on quality of service delivery by the Health Care Providers to the People. Results of the study indicate that there exists a significant relationship between the income received from Patient and Marketing budget for the Health Care Organisation. The Model fit for the effect of education, age and work experience on salary is significant at 99 percent while similar result was obtained for the effect of marketing activities on Hospital Services at 99 percent significant level. The suggested Recommendations for the study were discussed. Finally, the study concludes that Marketing and Public Relations now emerge as important Management function not only in Not for Profit Health Care Organisation but also Private or For Profit Health Care Organisation. The coldness and aloofness normally associated with the Hospital and Medical Community have given way to a more vibrant one which requires Marketing for sustainability.


Introduction
There was little focus on marketing by Health Care Providers before the mid 1900's because they did not realized the need for it.Most Hospitals are "Monopolies" or "Oligopolies" in their Markets.(Thomas, 2005).This means hospitals determine both the price and supply for services.The Patients have little or no say in the whole matter.Thomas (2005) further said that by mid 1990's Hospital became focused on providing quality health care and as part of its responsibility to the community with its constituents using Public Relations Practices.At this time Health care Industry saw only the Physicians and donors as worthy audiences, so little or no attention was given to Patients who are the consumers.However, with government involvement, governmental relations became an essential function for the Health Care Public Relations and Marketing Staff (Burdette, 2007).
Government became involved in health care by establishing hospitals and introducing various reforms to the Industry.Health care is something everyone needs and is also vital to human existence.Government Hospitals are mostly Not for Profits and are set up to provide humanitarian services to the community.This makes it different from those set up by individuals, known as Private Hospitals or For Profit Hospitals.Private Hospitals though also perform humanitarian services, does not see this function as its prerogative.Not for Profit Hospitals now faced several challenges amongst which includes: Over capacities, increased competition, lack of facilities, inadequate funding and increased complaint from Patients about quality of health care delivery from Not for Profit Hospitals.All these challenges must be managed for Not for Profit hospitals to be able to achieve its organizational objectives.Health care Providers have realized that one of the ways to manage these challenges is the use of Hospital Marketing.Burdette (2007) wrote that with the shift to consumerism, Health Care Marketers quickly adopt traditional marketing methodologies, focusing on the 4 Ps -the Product, Place, Price, and Promotion.She noted that consumers sought for information before purchasing appliances and other product, it is natural to expect them to do the same thing for health care which is something vital.There are few meaningful methods for distinction and differentiation by marketers because Patients did not play active role in marketing.Patients based their opinions on superficial factors such as the appearance of hospital facilities, amenities and tastiness of the hospital food.(Thomas,2005 ).The use of print advertising , bill boards, television, and radio by Health Care Marketers therefore gave way to a more informed and demanding consumers.With employers and consumers now emerging as buyers of health care services, the focus on Physician has taken a back seat to consumer directed marketing (Thomas, 2005).

Literature Review
There have been very few works in the area of Hospital Marketing; an attempt has been made in considering some of the Scholars' contributions in the Introduction.The works of Burdette (2007); Thomas (2005); Fastenmeier and Leuca (2006); and Anand and Chakravarti (1981) have proved to be good sources of materials for this study.Their contributions serve as foundation upon which this research is built, effort have therefore been made to acknowledge their contributions appropriately.

Definition of Concept -Marketing
Marketing have been defined in various ways but effort would be made to consider few of these definitions that are relevant to this study.In this regards Kotler and American Marketing Association's definition would be considered.
American Marketing Association (2007) defined Marketing as "an organizational function and a set of processes for creating, communicating, and delivering values to customers and for managing customer relationships in ways that benefit the organization and its stakeholders."Kotler (1975) described Marketing as "an umbrella term", Marketing refers to any means of promotion devoted to the ends indicated in the definition.

Public Relations
The word Public is not very easy to define but according to Anand and Chakravarti (1981) Public in the case of hospital includes Staff Members, Patient and Relative and the governing board.Scott and Center (1964)

Methodology
The data in this study were collected through Survey method and the instrument used was the Proforma type questionnaire administered to both Health Care Marketing Staff and Patients in twenty out of the One hundred and thirty five Government Hospitals in the Kwara State.The breakdown of the total one hundred and thirty five Government Hospitals is presented in Table 1 in  Correlation and Regression analysis were the Statistic used to test for the hypotheses mentioned above.The Correlation analysis was employed to determine the relationship between the Incomes received from Patients and the estimated Marketing budgets for the Health Care Organisations.Regression was also used to examine the contribution of Marketing and Public Relations activities to the success of these Not for Profit Hospitals.The construct and encoding of the variables were measured via several indicator variables.This has been operationalised on Likert Like Scale ranging from "1" (representing Poor) to "6" (representing Excellent) and "1" (representing Strongly Disagree) to "5" (representing Strongly Agree).Other measures include "1" for Available and "2" for Not Available; "1" for Adequate and "2' for Not Adequate and "1" for Adequately Provided, "2" for Not Adequately Provided and "3" for Not Available.The operationalisation of the constructs and wording of the respective indicator variables are displayed in the Appendix.

Discussion and Results
The findings of Hypothesis 1(H 1) specify that Income received from patients positively correlates with the Hospital Marketing Budget.The correlation is significant at the 0.01 level, and the coefficient of correlation equals to 0.853.This shows a high level of correlation (Table 2 Appendix).Hence, we reject the Null Hypothesis that Income from Patient does not positively correlates with the Hospital Marketing Budget.This result confirms that increase in Hospital spending on Marketing and Public Relations will bring about corresponding increase in Income received from Patient.Table 3(Appendix) shows the Cross Tabulation for the various types of Hospital and their Estimated Marketing Budgets.In the table 200 respondents gave their estimated marketing budget to be between the range of N750000 and N3 Million per annum, 140 respondents indicated that their Hospital estimated marketing budget is between above N3 Million to N4.5 Million and 160 respondents gave their estimated Hospital marketing budget to be above N4.5 Million.This represents 40%, 28% and 32% of the total respondent survey respectively.There are 180 respondents who agreed that the Income received from Patient for Medical treatment by their hospital falls within N1 Million to N4 Million, while 160 respondents agreed that their own Income falls between the range of above N4 Million to N6 Million and also 160 respondents agreed that their Hospital received above N6 Million Income from patient per annum.This represents 36%, 32% and 32% respectively.This Information is provided in Table 4.There are 100 respondents selected for Small Hospital and 200 respondents for both Medium and Large Hospitals.It is further shown in Table 3 that none of the Small and Medium sized Hospital's Marketing budget exceed N4.5 M and Table 4 also indicated that none of the Small and Medium sized Hospital Income exceed N6 Million per annum.We can therefore, conclude that 80% of Large Hospital's Income falls within the range of above N6 Million while only 20% of the Large Hospital's have their Income falling within the range of above N4 Million to N6 Million.This clearly shows that those Hospitals with large marketing budget estimate also received more Income than those with lesser marketing budget.In determining the Coefficient of determination for this study we have: Coefficient of determination (ESTMARBUDG, PATESTINC) = Corr (ESTMARBUDG, PATESTINC) 2 = (0.853) 2 = 0.7276 or 72.3 % This simply means that 72.3% of one variable can be explained by the other one or 72.3%of estimated marketing budget can be explained by variation in Income received from Patients.The issue of examining the effect of education, age, and work experience on salary of Health Care Marketing Staff involved the use of Pearson Correlation analysis.A look at the Model fit for underlying data indicated that it is highly significant at 99% level.Table 5 (Appendix) provides information about the model fit.The model summary also shows that R squared is 0.679, adjusted R squared is 0.677 and Standard error of the estimate is 0.62518.This shows that 67.9% of the data is explained.The standard error of the estimate gives the dispersion of the dependent variable estimate around its mean.The model summary is shown in Table 6 Appendix.The coefficient explains the effect of the individual variables on the dependent variable and the confidence with which we can support the estimate for each such estimate.In Table 7(Appendix) the value of coefficient is significant, we assume estimate in column B can be asserted as true at 95% confidence level.A look at age indicates that B (0.08) lies within (0.018 and 0.142) the lower and upper bound.This suggests therefore that the null hypothesis that education, age and work experience does not have significant effect on salary is not true, hence is rejected.The alternative hypothesis that education, age and work experience have significant effect on salary of Health Care Marketing Staff is therefore accepted.The Collinearity Diagnostic (Table 8 Appendix) for the model is 11.412 which are significant.Gupta (1999) suggested that condition index greater than 30 is severe collinearity which may result to breakdown of classical assumptions.The Model fit for Hypothesis 3 (H 3 ) is highly significant at 99% level, similarly like Hypothesis 2 (H 2 ).The model summary for the data indicated that R Square is 0.485 and Adjusted R Square equals to 0.472.This shows that 48.5% of the variation in the data is explained.The standard error of the mean is 0.55637.Therefore, we can conclude that the null hypothesis stating that Marketing and Public Relations activities contribute to the success of not for Profit Health Care Organisation is true and therefore accepted.The study considered twelve of the services performed by Health Care Organisations and these include: (1) Level of Sanitation, Cleanliness and Physical comfort: This service is very important for Hospital whether Profit or Not for profit.Most Patient are normally attracted to a good and clean environment before even considering the quality of medical services offered to the Public.Therefore, most Hospital tries to make their environment attractive to the people.
(2) Parking Space: We have separate and not separate parking space, where there is Separate Park the Hospital Staff and Patient have different parks.This further provide for driving convenience and orderliness within and around the Hospital's vicinity.
(3) Waiting and Seating room: This serves as a point of first contact by the patient to the Hospital.An excellent waiting and seating room will serve as an advantage for Hospital over other Competitors.
(4) Public Toilet: This also form part of what determines the level of sanitation of an Hospital.Most Patients believe hospitals with clean toilets are good and efficient.This also creates good public image for Hospital.
(5) Public Tap: Availability of efficient Public Tap is part of the infrastructural facilities that the Patient expects to find in a good Hospital.
(6) Cafeteria facilities: Patients in most cases believe their Medical bills cover not only their medical treatment but payment for feeding.Therefore, they always expect good diet and absence of it lead to complain.(9) Information about Patient: Most relatives expect Nurses and Doctors to furnish them information about their Patient's illness.This will enable them know the state of health of their Patient so as to determine whether there is improvement or deterioration in the health of their Patient.In some hospitals such information are not readily made available to Patient's relations, this action can have negative effect on public image of Hospital.
(10) Patient's Privacy: Most Patients especially the rich and Public figure want a reserved place where they can get their treatment without being exposed.This is probably why some Patients prefer Private Hospitals where such service is available.
(11) Complain and Suggestion: Patients have numerous complains, where there is no immediate response that serves as a minus for the Hospital.Hospitals sometime put Suggestion Box in Strategic Point to enable them know some of these complains.
(12) Mortuary and Chaplain Facility: Patient expects the corpse of their dead relative to be giving last respect.Therefore, hospital where there is no excellent facility will definitely not attract Patients.(2005) explained that Health Marketing is different from Marketing in other Industries.He said "In Health Care your marketing message must contain an element of mission, goodwill, and community service … in other Industries, it sounds a bit phony".Therefore, it is necessary for Marketing and Public Relations activities in the Government Hospitals to address the issue of community service, this should also be part of its mission and vision.Government Hospital should also ensure that it offers quality service to the Patient.According to Clarke (2004) "Quality to a Patient in health care system is access and timeliness of service …."In a similar word, Repert and Babacus (1996) wrote that "In an era of increasing competition and potential additional government regulation, a strong quality orientation can serve as a means by which a hospital differentiates itself from its competitors".The following recommendations are therefore suggested:

Wanless
Government Hospital should recruit effective Health Care Marketers that would bring desired turn around in the system.
Hospital should cut their cost so as to have more money for Marketing most especially advertising, staffing, equipment and research.
Employee morale should also be improved in order to get better result from them.
Hospital should focus on key opportunities in their environment.They should monitor the environment for any potential threats and convert such threats to opportunities and where it is not possible to do so capitalize on the threats.
The choice of location for Government Hospital should be accessible and visible.This will definitely serves as an advantage for Hospital over its competitors.
Revenue base of Government Hospital should be increased through marketing new point of differentiation.This will definitely make them have edge over their competitors.
This study therefore concludes that Marketing and Public Relations though appear as emerging phenomenon in Health Care Industry, is one of the important function of managements.Health Care Organisations should therefore direct their effort towards employing it for the realization of their goals.
the Appendix.The questionnaire was distributed randomly to both the Patients and Health Care Marketing Staff in these Hospitals.The Health Care Marketing Staff were questioned about the implementation of Marketing and Public Relations activities in their Health Care Organisations.Specifically they were asked about their work experience in the Health Care Marketing Field, current role in the Health Care Organisation, types of Hospital they are working, estimated annual Marketing Budget, Income received from Patient for Medical treatment per annum, and assessment of their Health Care Organisation's Marketing and Public Relation's function.The Patients were asked to provide their assessment of the Hospital performance of Marketing and Public Relations activities.The questionnaire was designed to provide information about the Patient's background, physical and environmental situation and various services performed by the Hospital.One thousand one hundred questionnaires were administered but only One thousand questionnaires were returned.The hundred not returned are mainly from the Six hundred questionnaires originally given to the Patients; while one hundred percent returned was recorded for the Five hundred questionnaires given to the Health Care Marketing Staff.The following hypotheses were tested: H 1: Income received from Patient does not positively correlates with the Hospital Marketing Budget.H 2 : Education, age, and work experience does not have significant effect on the salary of Health Care Marketing Staff.H 3 : Marketing and Public Relations activities contribute to the success of Not for Profit Health Care Organisations.

( 7 )
Ward Reception: Hospital where Receptionists are not friendly will lose not only their old and loyal Patients but find it also difficult to win new Patients.(8) Public Telephone: Communication is very important to every organization and therefore Hospitals need to provide adequate communication facilities for both its Staff and Patient.Public phone are sometimes cheaper and effective.It enable Patient contact their relative, friends and business colleague at economical and efficient manner where available.
defined Public Relations as Management function which evaluates public attitudes and procedure of an individual and organization with the public interest, and executes programmes of action to carry Public understanding and acceptance.A critical look at the definitions of Marketing and Public Relations revealed that the two concepts are same.Public Relations is one of the Promotional mix, while Promotion is one of the Marketing mix.Therefore, it can be argued that Promotion is the communication aspect of Marketing.Marketing is very essential for Organisations either Profit or Not for Profit Ones.Most Non Profit Organisations, not only Hospitals but others like Charitable organizations, Churches and other religious bodies have begun to realized this in recent time.Hospital Marketers now required special skills about Patient confidentiality and Privacy Act, Community and Health Care Administration, Knowledge of how Profit and Non Profit Hospital operate, Hospital funding, developing an efficient Hospital Media Relations and manage Hospital Publications and Special events.The overall mission and vision of Hospital can only be achieved when there is effective performance of these roles

Table 3 .
Estimated Marketing Budget by Hospital Types

Table 4 .
Estimated Income Received from Patients by Hospital Types