Study area and period

A facility based cross sectional study was conducted in the selected public health facilities at Gamo zone, which is geographically located in southern region of Ethiopia. The study was conducted in public health facilities at Gamo zone from June 1 to 30, 2023. There are fifty-nine health centers, five primary level hospitals, and one general level hospital in the Gamo zone. Various pharmacy services are offered by the general hospital, such as inpatient, outpatient, emergency, obstetrics and gynecology, mother and child healthcare, and chronic care pharmacy. Pharmacy services are offered by primary level hospitals as inpatient, outpatient, and emergency and chronic care options. Only patients can receive outpatient pharmacy services from health centers.

Study design

A concurrent mixed method was applied for quantitative survey and qualitative study. The quantitative method was used to compare the level of satisfaction between insured and noninsured clients under CBHI scheme, whereas qualitative method was used to explore the experiences with a pharmacy services offered at outpatient department pharmacy in public health facilities.

PopulationsSource population

All patients who visited the OPD (outpatient department) pharmacy of the study health institutions were included in the source population for this study.

Study population

Adult CBHI members and non-members who received pharmacy services from the OPD pharmacy in the selected public health facilities during the study period were included as the study population.

Eligibility criteriaInclusion criteria

The survey comprised both insured and uninsured patients who visited the public health facilities’ OPD pharmacies during the study period. Patients who were willing to participate in the study and the years ≥ 18 were also enrolled, but for those below 18 years the caregiver or guardians were included.

Exclusion criteria

Patients who were treated in other pharmacy departments (out of OPD), patients with hearing, and mental impairments, and unwillingness to give consent were excluded from the study.

Study variables

There are two variables; dependent (outcome) variable and independent (explanatory) variables.

Dependent variableIndependent variablesIndependent variables for insured clients

Socio-demographic characteristics: Age, gender, marital status, educational level, occupation, religion, place of residence, & monthly income.

CBHI package related factors: CBHI package availability, knowledge on CBHI package, & premium affordability of the scheme.

Service related factors: Pharmacy staff communication, service equality, pharmacist dignity and respect & waiting time.

Products related factors: Availability of supplies & quality of perceived products.

Independent variables for noninsured clients

Socio-demographic characteristics: Age, gender, marital status, educational level, occupation, religion, place of residence, & monthly income.

Service related factors: Pharmacy staff communication, service equality, pharmacist dignity and respect & waiting time.

Products related factors: Availability of supplies, quality of perceived products & cost of pharmaceuticals.

Sample size determination and sampling proceduresSample size determination for health facilities (HFs)

WHO recommended for assessment of health facilities by considering the available funds and human resources, selecting 10-50% facilities to have representative sample [16].

Among the total of 34 health facilities in the selected districts, 30% of health facilities in study districts were selected based on the suggestion. A total of 10 health facilities were selected by simple random sampling using lottery method.

Sampling procedures for HFs

To insure the representativeness of the sample, the health facilities under each districts and town administrations were stratified, then the sample of the facilities were selected randomly, and the redundant selection of health facilities from one district was managed by identifying the pool for selection (Table 1).

Table 1 Districts, town administrations and public health facilities selected to compare the levels of client’s satisfaction with pharmacy services among users and nonusers of community based health insurance scheme at Gamo zone, 2023Sample size determination for quantitative study participants

The sample size for this study was calculated manually by using double population proportion formula, which was assumed to be 80% power of study at 95% of confidence interval (CI). The formula used for the calculation is [17]:

$$n\hspace=\hspace\frac$$

C = Standard value for the corresponding level of α and β selected for the study.

Based on the following values, the sample size (n) is determined as follow:

P1: is proportion of satisfaction in the CBHI member clients and was taken as 63.4% from the study done at West Arsi Zone, Ethiopia on client satisfaction on community based health insurance scheme and associated factors [16];

P2: is proportion of satisfaction in non CBHI member clients and was taken as 50.9% from a study conducted in Debre Tabor Northwest, Ethiopia on Patients’ satisfaction with outpatient pharmacy services and associated factors [18];

α: the level of statistical significant = 0.05; β: type II error = 0.2; and none response rate at 10%.

C = 7.9, when the power of study is 80% and with confidence interval (CI) of 95%.

Therefore, the final calculated sample size is:

$$n\hspace=\frac\hspace$$

$$\begin =\hspace\frac+\hspace0.509*\left(0.491\right) *7.9}-\hspace0.509)2}=\hspace244\hspace+\hspace24\\=\hspace268 \left(Sample\, size\, for\, each\, group\right)\end$$

Sampling procedures for quantitative study participants

Data was gathered from both insured and uninsured patients who visited the OPD pharmacy during the study period by using a simple random sampling technique. A ratio of insured to non-insured was 1:1.

Study participants were proportionally allocated to each selected health facilities to the both study groups based on the previous month patient flow.

By using proportional probability to size (PPS); = Nf × Ni/N, where,

Nf = final sample size,

Ni = one month report of prior to study in each health facilities, &.

N = total of one month report from each health facilities.

Sample size determination for qualitative study participants

Key informant interviews were undertaken to gather qualitative information on patient satisfactions with pharmacy services among community based health insurance scheme users and nonusers. There were different key informants on the defined level of stake. Among this, 16 key informants were included.

This study included carefully chosen key informants, including (insured clients, non-insured clients, pharmacists, the pharmacy head, and CBHI program managers). The sample size for the qualitative study was determined by idea saturation.

Sampling procedures for qualitative study participants

Purposive sampling technique was used to select clients from both insured and noninsured group and to select key informants (pharmacists, CBHI program manager, and pharmacy head) in order to explore the experience with a pharmacy services offered at OPD pharmacy for insured & noninsured groups of clients in public health facilities.

Data collection instrumentFor quantitative data

The data collection tools for this study were a structured and semi structured interview questionnaire. The questionnaire was prepared after an intensive review of related literature on the topic [7, 13, 14].

The CBHI scheme related part was adopted and developed from the Federal Democratic Republic of Ethiopia, Ethiopian Health Insurance Agency Evaluation of CBHI pilot scheme in Ethiopia and WHO CBHI scheme guideline [15, 16].

There three items of questions were used in five point Likert scale to measure the level of satisfaction for the both groups of clients, such as; study participants’ opinions towards the pharmacy setting, medication availability, and cost, study participants’ satisfaction towards the dispensers approach or communication & study participants’ satisfaction with the pharmaceutical services instructions. The level of client satisfaction was rated out of five. The patients were asked to rate their level of satisfaction on a five-point Likert scale in each of the satisfaction questions (1: very dissatisfied, 2: dissatisfied, 3: neutral, 4: satisfied, and 5: very satisfied).

For qualitative data

Semi-structured & interview administered questionnaires was adopted and developed from different literatures [15,16,17].To gather qualitative data for the study, an open-ended data tool with probes was used.

Data collection procedure

Patient exit interview (survey) was used for quantitative study, while in-depth interview was applied for the qualitative study.

For quantitative study

The data collectors were pharmacy technicians working in the neighboring health facilities and they were trained on the data collection process. A two-day long training was given for the collectors on principles of data collection, components of instruments and ethical principles.

Based on the results of a pretest, tools used in the study was modified by in lining the data tools with specific objectives of the study, and the total time adjustment for the data tool was done, then a patient exit interview survey was used to collect data. The total time to collect the data was 30 min.

Interviewees whose age is 18 years old and above were interviewed, while caretakers or guardians of those who are below 18 years were interviewed.

For supervisory tasks, senior pharmacists were hired. Every day, the supervisors observed the data collection process.

For qualitative study

The clients were interviewed through in-depth interview after getting pharmacy services at outpatient department pharmacy. Field note for each questions and responses was taken in local language (Gaamotho) and an audio recorder was used. Interviewee guide with probes was used to clarify and expand on the key informant’s response. The place of interview was at the office of respective key informants, and it was conducted by the principal investigator.

Data processing, analysis and presentationFor quantitative study

After being checked for accuracy and consistency, the data was coded, imported into Epi Data 3.1, and exported to the statistical program SPSS version 23 for analysis. Descriptive statistics (including mean scores, frequencies and percentages) were employed to summarize the socio-demographic characteristics of the patients and facility-related factors.

The collected data’s were scored using a five-level Likert scale of categories, then patient satisfaction was assessed by using 22 items of satisfaction measurement. For each group of clients, a mean score was calculated by summing individual perceived scores for each item of the questions under the Likert scale and dividing the result by five.

The five scales were combined into a two-scale structure for descriptive interpretation by calculating the cut point from the mean value by using demarcation threshold formula: + Total lowest score [16]. Overall customer satisfaction was categorized as “satisfied” for both groups of members if the score was above a predetermined cut point and “dissatisfied” if it was below it. The cut point value of satisfaction level with the pharmacy service was found to be 3.7 for insured & 3.2 for noninsured clients.

The adjusted odds ratio (AOR) was used to measure the association between independent variables and patient satisfaction toward outpatient pharmacy services at the P values < 0.05 and 95% confidence interval (CI).

Binary logistic regression analysis was used to determine associations between the different independent variables and the key outcome variables. Finally the findings were presented using tables, charts, figures, graphs and texts.

For qualitative study

The field notes and audio records were transcribed and translated to English for.

further analysis. The data was coded by categorizing the collected non numerical data in to groups and assigning the numerical codes to those groups.

Following the translation and transcribing of the data into multiple codes, the qualitative data was analyzed manually by using a thematic analysis technique. Every code was divided into four categories, and each category was then divided into themes by collating together the results of the coding process, generating themes that tie together the identified codes in to groups according to their meaning or subject matter.

Data quality managementFor quantitative study

After being created in English, the questionnaire was translated into the local language by those proficient in the language, and its consistency was verified. Before the real data collection period, the 5% of sample was pre-tested for the both groups of clients in the similar setting of the randomly selected health facilities to assess clarity, consistency, understandability of the data tool. Each scale’s reliability was assessed separately. To evaluate the reliability of components, Cronbach alpha coefficients were computed. The Cronbach alpha coefficient values indicate that it was within the acceptable alpha value range (> 0.7). Then, the necessary comments and feedbacks were incorporated into the final tool to improve its quality.

For qualitative study

The trustworthiness parameters (credibility, transferability, conformability, and dependability) were ensured through participant validation, peer debriefing, informant feedback, and prolonged time spent with the key informants.

Appointment times were made up to ensure continued communication between the investigator and the study’s key informants. The specifics of the situation were noted (note-taking with probes & audio recording were employed). Through the employment of various key informant categories at various sites, triangulation was made.