SERVQUAL in Health Care Sector: Hospital in Bangladesh

Assignment for the Subject: Service Marketing Subject Code: MKT6406 Prepared by: Md. Monirul Alam ID: MBA110270084 Md. Nafis-UL-Alam ID: MBA 110170078

Prepared for / Course Teacher: Shaikh Rafiqul Islam

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Index:
Acknowledge Abstract Introduction Service & HealthCare: A Synopsis Definition and measurement of service quality (SQ) Dimensions of Service Quality Health Care Sector in Bangladesh: A Brief Variables determining the quality of healthcare services Conclusion Bibliography Page : 2 Page : 2 Page : 3 Page : 4 Page : 6 Page : 7 Page : 8 Page : 18 Page : 20 Page : 21

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Acknowledgement
At outset of this project we would like to thanks the Al-Mighty Allah, who has been gave us patient, skills and mainly sound health to complete this project. Without his help this is totally impossible to finish this project within time frame.

We feel privileged to have had the opportunity to work with our Subject teacher and Lecturer Md. Rafiqul Islam on this project. His guidance and constant encouragement during the course of this eventful journey was critical for developing key insights. The numerous discussions on topics related to this research and other areas have allowed me to grow in many different ways.

We would also like to thank also my course mate and fellows for preparing this project. Collecting information, sorting and finally prepare this output is huge task. I feel very much relief and satisfied to finish this project paper.

Abstract

Health is a basic requirement to improve the quality of life. A national economic and social development depends on the state of health. A large number of Bangladeshs people, particularly in rural areas, remained with no or little access to health care facilities. The lack of participation in health service is a problem that has many dimensions and complexities. Education has a significant effect on participation in health services and administrative factors could play a significant role in increasing the peoples participation in Bangladeshs health sector. But the present health policy is not people oriented. It mainly emphasizes the construction of Thana Health Complexes (THCs) and Union Health and Family Welfare Centers (UHFWCs) without giving much attention to their utilization and delivery services. The study reveals that financial and technical support is very helpful to ensure health service among village people. However, the Government allocates only 5 percent of the budget to the health sector, while it allocates 13 percent for defense. The paper shows that the Governments allocation and technical support (medical equipments) are not sufficient in the rural health complex and that the peoples participation is far from being satisfactory. The paper concludes with a variety of recommendations.

Page 3

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Introduction
Bangladesh is a mostly rural, developing country of South Asia, located on the northern shore of the Bay of Bengal, covering 147,570 square km. People of this country are known as hardworking, with proven capability to preserve mental strength in the event of unexpected extensive loss due to natural calamities, such as floods, cyclones, epidemics, etc. But, their basic needs have remained unfulfilled. Health is a basic requirement to improve the quality of life. National economic and social development depends on the status of a countrys health facilities. A health care system reflects the socio-economic and technological development of a country and is also a measure of the responsibilities a community or government assumes for its peoples health care. The effectiveness of a health system depends on the availability and accessibility of services in a form which the people are able to understand, accept and utilize. The Government of Bangladesh is constitutionally committed to the supply of basic medical requirements to all levels of the people in the society and the improvement of nutrition status of the people and public health status [Bangladesh Constitution, Article- 18]. The health service functions were initially restricted to curative services. With the development of modern science and technology, health services emphasize primitive and preventive rather than curative health care. Yet, a large number of people of Bangladesh, particularly in rural areas, remain with no or little access to health care facilities. It would be critical for making progress in Bangladeshs health services to improve the peoples participation in the health sector. The Government therefore seeks to create conditions whereby the people of Bangladesh have the opportunity to reach and maintain the highest attainable level of health. Bangladesh has a good infrastructure for delivering primary health care, but the full potential of this infrastructure has due to lack of adequate logistics never been utilized. This study aims to explore the sequence of the development and status of peoples participation in Bangladeshs public health services. It uses the methodological triangulation qualitative and quantitative approach as well as a case study design in analyzing data, whereby the exploratory-descriptive design is followed. The study explores peoples participation in health services through personal interview as well as case studies for which Muradnagar Upazila had been chosen as it provides an ideal research setting.

Service and Healthcare: A synopsis

Healthcare is a rare service that people need but do not necessarily want but, remarkably healthcare is the fastest growing service in both developed and developing countries. The traditional services that once dominated the Service sector lodging, foodservice, and housecleaning have been increasingly supplemented by modern banking, insurance, computing, communication, and other business services; and the interest in the measurement of service quality is understandably high in addition to the delivery of higher levels of a service quality strategy being suggested as critical to service providers' efforts in positioning themselves more effectively in the marketplace.

Page 4

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Service quality has been revealed as a key factor in search for sustainable competitive advantage, differentiation and excellence in the service sector. Besides, it has been recognized as highly important for satisfying and retaining customers. Accordingly the two questions

Have been debated by academics over the last three decades now and is of utmost interest. Moreover, the ongoing debate on the determinants of service quality and issue such as Is there a universal set of determinants that determine the service quality across a section of services? remains unanswered. Additionally, there is concern for the identification of determinants of service quality. In a consumeroriented culture where healthcare delivery is patient-led and commoditized, the patient should be the intermediary of the quality of healthcare. Thus the purpose of the present paper is to develop a conceptual framework for measuring hospital service quality, expending the existing models and literature on healthcare services to benefit academicians, practitioners and researchers to enhance the understanding of patient perceived hospital service quality addressing this gap in literature as there are a few reliable and valid instruments available; and many service providers are implementing measures that are not aligned to the complexities of the health care setting. Consequently understanding of service quality assists practitioners to meet the requirements in their daily operations. SERVQUAL is designed to measure service quality as perceived by the customer. Relying on information from focus group interviews, Parasuraman et al. (1985) identified basic dimensions that reflect service attributes used by consumers in evaluating the quality of service provided by service businesses. As an example, among the dimensions were reliability and responsiveness, and the businesses included banking, credit cards and appliance repair. Consumers in the focus groups discussed service quality in terms of the extent to which service performance on the dimensions matched the level of performance that consumers thought a service should provide. A high quality service would perform at a level that matched the level that the consumer felt should be provided. The level of performance that a high quality service Page 5

SERVQUAL in Health Care Sector: Hospital in Bangladesh

should provide was termed consumer expectations. If performance was below expectations, consumers judged quality to be low. To illustrate, if a firms responsiveness was below consumer expectations of the responsiveness that a high quality firm should have, the firm would be evaluated as low in quality on responsiveness. Parasuraman et al.s (1985; 1988) basic model was that consumer perceptions of quality emerge from the gap between performance and expectations, as performance exceeds expectations, quality increases; and as performance decreases relative to expectations, quality decreases (Parasuraman et al., 1985; 1988). Thus, performance-to-expectations gaps on attributes that consumers use to evaluate the quality of a service form the theoretical foundation of SERVQUAL. The purpose of this paper is to provide a review of the SERVQUAL research on service quality in the following areas:

Definition and measurement of service quality, and Reliability and validity of SERVQUAL measures. The issues we address are of importance to both service managers and researchers. Service quality is important to marketers because a customers evaluation of service quality and the resulting level of satisfaction is thought to determine the likelihood of repurchase and ultimately affect bottom-line measures of business success (Iacobucci et al., 1994). It is important for management to understand what service quality consists of, its definition, and how it can be measured. If management is to take action to improve quality, a clear conception of quality is of great value. A vague exhortation to customer contact employees to improve quality may have each employee acting on his/her notion of what quality is. It is likely to be much more effective to tell a service contact employee what specific attributes service quality includes, such as responsiveness. Management can say, if we can improve our responsiveness, quality will increase. Valid and reliable measurement of service quality is vital to quality management. As an illustration, if employee training or a change in work procedures to enhance quality is undertaken, it would be important to measure customer perceptions of quality before and after the quality action was taken to see if the goal had been achieved. A reliable measure is one that is consistent, that is if quality did not change, the measure of quality would not change. A valid measure is a measure in which the score generated by the measurement process reflects the true value of the property that one is attempting to measure. As an example of the importance of reliability and validity, consider Jones whose weight was measured in a physicians office at 165 pounds and the physician said, You should be no more than 160 pounds. Jones tries to lose weight, but Jones scale at home is unreliable and poor Jones wonders why the diet works one week, but not the next. Next, suppose Jones scale was not valid, low by five pounds; Jones thinks the problem is solved, but it is not. Definition and measurement of service quality (SQ) Definition of SQ Parasuraman et al. (1985) suggested three underlying themes after reviewing the previous writings on services: Service quality is more difficult for the consumer to evaluate than goods quality,

Page 6

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Service quality perceptions result from a comparison of consumer expectations with actual service performance, and Quality evaluations are not made solely on the outcome of service; they also involve evaluations of the process of service delivery. Parasuraman et al. (1988) defined perceived service quality as Global Judgment, or attitude, relating to the superiority of the service. Dimensions of Service Quality Dimensions of service quality (SERVQUAL) were originally introduced by Parasuraman, A, Valerie A Ziethaml and Leonard L Berry in 1955 in the area of service quality. SERVQUAL was developed based on the view of the customers assessment. This assessment has been conceptualized as a gap between the Customers expectations by way of SERVQUAL, from a class of service providers and their evaluation of the performance of particular service providers.

Page 7

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Reliability

Responsiveness

Service Quality

Sutiational Factors

Assurance

Empathy Product Quality Tangibles

Customer Satisfacti on

Customer Loyalty

Price

Personal Factors

Customer Perception of Quality and Customer Satisfaction

Health Care Sector in Bangladesh: A Brief Despite recent developments in the Bangladesh healthcare sector, there is still great concern about the quality of healthcare services in the country. This study compared the quality of healthcare services by different types of institutions, i.e. public and private hospitals, from the perspective of Bangladeshi patients to identify the relevant areas for development. A survey was conducted among Bangladeshi citizens who were in-patients in public or private hospitals in Dhaka city or in hospitals abroad within the last one year. TYPES OF HOSPITALS IN BANGLADESH

Page 8

SERVQUAL in Health Care Sector: Hospital in Bangladesh

About 80% people get their health service from private sector. Only 20% people get health service from Govt. hospital. Although the government has the capacity to provide 60% service, they cannot do it just for the corruption and in active function of those administrations. (Source; Bangladesh health nutrition and population Evaluation) There are mainly two types of hospitals that provide the service to the people of our nation. They are public hospital and private hospital. Public hospital operate and control by the government on the other hand private hospital is operate and control by a set of selected people or by the owners of the organization. Those who fall outside the direct control of Government (Bennett 1992). Private ownership generally includes both for profit and nonprofit provider. For example private ownership would include health care facilities owned by individual who seek to earn profit clinics and hospitals owned by the private employers, and those operate by religious missions and other non government organizations. Beside that
The vital part of private health service can be mentioned:

PRIVATE HOSPITAL IN BANGLADESH Private Hospital and Clinic privately managed organization in which sick and injured persons are given medical or surgical treatment. A clinic however, usually provides treatments to non-resident patients. Traditionally healthcare has been an important activity of the government since the British period and the trend continued after Bangladesh was created in 1971. During the early 1990s Bangladesh firmly

Page 9

SERVQUAL in Health Care Sector: Hospital in Bangladesh

committed itself to free market economy with the result that the healthcare sector slowly began to attract greater attention of the private sector. At present, most of the country's hospitals are in the government sector at different administrative tiers. All of the country's government medical colleges have hospitals attached for teaching purpose, so also does the country's single medical university, the Bangabandhu Sheikh Mujib Medical University. During the 1990s a class of healthcare clinics offering some hospital services began to emerge. These inpatient clinics are described by various names: medical centre, nursing home, hospital etc. These have some properties of a standard hospital, but these are of relatively small size, usually with 10-50 beds and usually do not have the full range of services offered in a standard hospital. Some of these clinics are of general type offering a spectrum of services relating to treatment and general surgery. But a few are specialized such as for eye treatment or for cardiovascular ailments. Such in-patient clinics are mostly located in major cities of the country such as at the six divisional headquarters, 64 district headquarters and 461 Upazila headquarters. The vast majority of such private clinics and certainly the best ones are located in the capital city Dhaka; the number being disproportionately smaller compared to the population size. Two factors may relate to this situation - firstly, the services may be targeted at the upper middle class and secondly, the country being small in size, prospective clients for such hospitals can easily come to the capital in a matter of hours using private or rented motor vehicles. In Dhaka city the number of in-patient clinics at present will be about a couple of hundred, big and small. Standard private hospitals are few mostly attached with private medical colleges of which there are over a dozen operating in the country. There are some fairly old private hospitals established during the British period. The Kumudini Hospital in Mirzapur near Dhaka is the country's most well known private hospital and one of the oldest. In recent years, wealthy people are seen to be in the venture of establishing private hospitals in memory of some loved ones but their number is very small; only a couple are perhaps worth mentioning. In addition community-based hospitals are now being established that are not strictly private, but are operated at non-governmental levels. Some very costly and modern private hospitals are in the process of being established in the private sector largely to stop the outflow of patients from the country to India or Singapore where they hope to receive better treatment. By far the most prolific development in healthcare took place in the diagnostic sector. Up until early 1980s, diagnostic services available mostly were of routine type involving blood, urine and stool examination, some microbiological cultures, routine biochemical tests, X-rays etc. With the transition to free market economy, demand for a wide spectrum of diagnostic services increased considerably. Many clinics were established in the private sector with advanced diagnostic capabilities including imaging, ultra-sound, and tests for hormones, immunological tests and many others. Many of these newer and sophisticated tests became services of great public demand. But when demand is high system abuses sometimes surface. Physicians ask for tests that are not highly relevant for treatment but they do so possibly for client satisfaction and satisfaction of the business motives of the providers of these services so that the latter may reciprocate physician's referral through various incentives. (www.Banglapedia.com)

Page 10

SERVQUAL in Health Care Sector: Hospital in Bangladesh

PRESENT STATUS IN BANGLADESH Bangladesh, with a population of 180 millions, cramped within an area of about 147570 square km, is one of the densest populated areas of the world. It has a scanty infrastructure and is frequented by natural calamities like floods and cyclones too often. Bangladesh has only one Doctor per 5000 persons and one hospital bed for 3200 persons. The per capita annual income is equivalent of US$ 240 and the population density is about 820 per sq. km. The Government can hardly manage per capita annual expenditure of about US$ 2.5 on health and family planning. Primary health care is identified as the key to attain Health for all by the year 2000. Health Services Delivery System follows the overall strategies and directives for providing optimum Medicare to its population in the form of curative, preventive and rehabilitative care. The health sector development is emphasized through adopting various programs in the national development plan with the purpose of building a network of primary health care services. The goal is to improve health status of the common masses through reducing morbidity, mortality and poverty related diseases. In terms of infrastructure, Bangladesh has developed relatively well scattered facilities. At the grassroots union-level one service delivery within a static facility is available for a unit of 20,000 populations; one Thana (Police Station) level facility services for 200,000 people; one district level facility (District Hospitals and Maternal and Child Welfare Centers) services for 1.5 million population. One medical-college hospital serves 9.3 million populations. There is a yawning gap between the actual and officially recommended services in those facilities. The efficacy with which the existing health care and manpower are utilized or not utilized becomes clear from the following dismal numbers. A recent study reports that 39 percent of the district hospitals function as comprehensive, emergency obstetric care (EOC) facilities. 64 percent of the Maternal and Child Welfare Centers and 56 per cent of Thana Rural Health Centers render the minimum basic EOC services. The crisis of maternity related deaths is concentrated in the countryside. Roughly 7 out 10 of the below five age group are underweight, compared with 4 out of 10 in Sri Lanka. Over 90% of all children suffer some degree of under-nutrition. More than one quarter of them are measurably undersized. 70% of mothers suffer from nutritional anemia. Some 30000 children go blind due to Vitamin A deficiency and about 2 million suffer from iodine deficiency. Medical facilities in Bangladesh are very inadequate to provide minimum basic treatment to its population. The total capacity of the beds in Government hospitals and Health complexes is 34,000. Private hospitals and clinics can accommodate 7500 patients. Dhaka is the capital of Bangladesh with a population of nine million. Although the capital city of Dhaka possesses a good number of relatively well-equipped tertiary care institutions and sophisticated hospitals, the general low income population of the city still does not have adequate provisions for general treatment. The Medical College Hospitals and tertiary care institutions are over-burdened with patients and hardly an acceptable standard of treatment can be provided due to rush of patients from different parts of the country to these hospitals. There is lack of collaboration between different authorities and agencies responsible for health care delivery and hence there is inefficiency of management.

Page 11

SERVQUAL in Health Care Sector: Hospital in Bangladesh

There are hardly any qualified Doctors available in rural areas of Bangladesh where 80% of the population live. Doctors posted in rural areas do not normally want to stay there, as basic amenities like educational and recreational facilities are not available. The rural health complexes constructed with relatively high cost can hardly attract Doctors from cities, resulting in meager health service in rural areas and rush of rural patient in the overcrowded hospitals in cities. For treatment in Bangladesh, the rural poor flock in city hospitals and well to do city dwellers flies to neighboring countries. Although a number of private Medical Hospitals and Clinics are being set up in the country, the number of patient going for treatment in neighboring countries like India, Thailand and Singapore are increasing at an alarming rate. The lesser availability of specialist Doctors in Bangladesh is compelling the patients to make arduous and costly travel to foreign countries for treatment. PRESENT STATUS OF PRIVATE HOSPITAL IN DIFFERENT LOCATIONS According to the Directorate of health there is 1378 government approved private hospital in Bangladesh up to 31-12-2010. Among those there are 349 private hospitals for Dhaka city and 811 private hospitals rest part of the country. Source :( Statistic; Directorate of health)

Number of private hospital for Dhaka city Number of private hospital outside Dhaka city Total Govt. approved private hospital

=411 =967 =1378

Table1: Number of private hospital in Bangladesh *Name of the hospitals with number of beds are attached at appendix SERVICE QUALITY OF PRIVATE HOSPITALS Since private hospitals are not subsidized and depend on income from clients (i.e. market incentives), they would be more motivated than public hospitals to provide quality services to patients to meet their needs more effectively and efficiently. This premise was supported. Patient perceptions of service quality and key demographic characteristics were also used to predict choice of public or private hospitals. With the growth of private health care facilities, especially in Dhaka city, it is important to assess the quality of services delivered by these establishments. In particular, it is important to determine how the quality of services provided by private clinics and hospitals. If quality issues are being compromised by these establishments, it calls for the reevaluation of policy measures to re define their role, growth and coverage, and to seek appropriate interventions to ensure that these institutions are more quality focused and better able to meet the need of the patients. A search of the literature suggests that such a comparative study Page 12

SERVQUAL in Health Care Sector: Hospital in Bangladesh

has not been undertaken. While anecdotal evidence suggests the existence of serious service related problems in both sectors. (Andaleeb SS. School of Business, Pennsylvania State University, Erie, USA.) Service quality of private hospital is hampered because of not having the proper equipment to provide the service. Adequate secondary or tertiary care is beyond the reach of all but a very few people. Government hospitals are often little more than clinics, and suffer from severe shortages of trained staff. There is a growing private hospital sector, largely based in Dhaka, which caters for the well-off. It is in the private sector where the most advanced services are located, and where almost all the demand for advanced equipment will be found. Given the country's lack of spending power, the medical equipment market, at around US$44 million, remains tiny in comparison with the size of the population. Steadily improving economic performance, combined with a general determination to boost the quality of healthcare, should lead to steady, if unspectacular, market growth. There is very little local production of medical equipment, so the market is heavily reliant on imports, often supplied in conjunction with aid projects. The appointment of a local agent will be necessary to achieve any lasting presence in the Bangladeshi market. There are a number of these, usually based in Dhaka. It has also been suggested that suppliers could use Calcutta, just across the border in India, as a base, although this appears not to be a popular option at present. Foreign direct investment is encouraged by the government, although it is difficult in practice; climate, poor communications, power supplies and transport links make the establishment of local operations nearly impossible. A few multinationals, such as Braun or Siemens, have established a direct presence in Bangladesh. Few Private hospitals and clinics will make individual purchasing agreements. The private sector represents the best opportunity for selling advanced or expensive equipment, although even here resources remain severely limited. Private hospitals are located throughout the country, although the bulk of private resources are concentrated in Dhaka. Beside that the rest part of the country serves the patient with their backdated equipment. Government spending will concentrate on more basic items, with larger tenders almost always funded through international aid projects, which may well be tied to the donor country. Tenders for equipment will usually be handled by the government, while those for basic medical supplies will often be co-ordinate by aid agencies themselves.

Materials and Methods

Study Context: This study has been conducted at a renowned private multi-specialty hospital in Dhaka, Bangladesh. The hospital is functional since over few years and an established corporate group manages the business after its takeover for years. The hospital has a bed strength of 150 beds, employee strength of about 400 and average bed occupancy of over 70 per cent.

Page 13

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Questionnaire, Development and Structure
The developers of SERVQUAL have suggested that it can be adapted or supplemented to fit the characteristics or specific research needs of a particular organization. Hence, we subjected the scale to a preliminary evaluation. Inputs were received from senior management personnel and an academician. The decisions to modify the scale were based on relevancy of the questions to hospital services and ability of the patients to respond to those without undue frustration or confusion. The Gap model based on the SERVQUAL depicted in figure one defines service quality as the difference between perceptions and expectations. It advocates that as service providers perceptions are important in design and delivery of services while those of patients are important in the evaluation of services, the views of both parties are important if a thorough understanding of service quality is to be gained. The questionnaire included a section on expectations and another on perceptions. Each section consisted 20 items. These were derived from the Yousseef et al modified version of the SERVQUAL. The instrument is added with a section three on demographics (gender, age, education and income) and a final question on overall service quality of the hospital to be rated on a five point scale. All questions were close ended. The scale used is a five point Likert scale with ends anchored strongly disagree to strongly agree. Though the original SERVQUAL scale uses a seven point Likert scale, and 22 items this study has used a five point scale with 20 items as literature shows no association between the number of items, method of administration and sample size and the reliability of the instrument. The present ability of the questionnaire was given due attention. Considering that the scale has 20 statements related to expectations from excellent hospitals and another 20 about perceptions about the study hospital, common terms were used for statements. These terms were used instead of repeating the term for each of those statements as has been done in previous research. In the expectation scale the term excellent hospitals will have and personnel at excellent hospitals will was printed as a common term for the 11 statements and nine statements following these respectively. Similarly, in the perception scale the common terms were this hospital has and personnel at this hospital. Another questionnaire was developed for staffs. It included the same statements as those in the questionnaire for patients, except that the respondents were asked to mark patients expectations and perceptions, as understood by them. The common terms, as described above, hence in the staffs questionnaire were patients expect excellent hospitals to and patients expect personnel at excellent hospitals to The questionnaires were made available in Bengali and English languages after pilot testing. A constant sum scale to determine relative importance of quality dimensions was put as a separate section as in the originally designed questionnaire. However, during the pilot testing it was realized that almost all respondents, in spite of explanation, marked the importance in percentages instead of from a total of 100 units as was desired. It was then decided to omit this section to avoid difficulty in response and also to reduce the length of the questionnaire and rather use regression analysis to reach the objective.

Page 14

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Sample and data collection: A total of 100 patients who had a stay of at least two days were voluntarily enrolled in the study on the day of/evening prior to discharge from the hospital. Patients were requested to fill the responses on the bedside after ensuring that they were comfortable. Each patient took about 20 minutes to complete. Of the 100 forms filled, five were found to be incomplete, and were excluded from analysis. All participants were approached with respect and researcher followed ethical principles in research. Informed consent was obtained from each participant. The questionnaire for staff members was administered during their duty hours. Staff members included in the study were nurses, doctors- generalists as well as specialists, front office staff, patient assistants and those from accounts, marketing, human resource and billing departments. Staffs who have worked for a minimum of three months at the study hospital were invited to participate in the study. Each staff member took about 12 minutes to complete the form. The data collection for staff and patients was carried out simultaneously during the first quarter of 2009.

Results and Discussion

Patients: Male respondents represented about 57 per cent of the patients surveyed. The study had 52 per cent patients aged below 40 years. The largest group (25 per cent) being in the 21-30 years age group, the smallest group (five per cent) was aged below 20 years while the elderly formed about 12 per cent of respondents. Majority of the patients were educated up to secondary school. Of all the survey questionnaires completed, 39 patients (41 per cent) did not state their income and were labelled 'Not Stated'. Excluding these, majority earned below Rs. 20,000 per month. The average length of stay of the patients as on the day of the study was four days Staffs: The staff members interviewed included 26 nurses, nine generalist and 14 specialist doctors, and 11others who were staff from other departments as mentioned above. The staff members surveyed included 65 per cent females and 35 per cent males. The higher number of female participants is representative of the hospital industry. Of the staffs interviewed most (81 per cent) were less than 40 years of age. Their average work experience in the hospital industry was 10.6 years while that at the study hospital was 7.8 years.

Validity and Reliability of SERVQUAL Instrument

Considering the objectives of the present study and the recognized instability of the dimensionality of SERVQUAL, it was considered necessary to address the construct validity of the scale. It is noteworthy that in the literature about SERVQUAL, there is no agreement as to which scores (expectation, perception or quality gap scores) should be factor analyzed and indeed, all three types of scores have been used in previous research. In the present study the researcher has adopted Vogels et al(1989) view which suggests that the expectation scores should be factor analyzed to determine the items that should be included in the service quality dimensions because these scores are not influenced by possible flaws in the service rendered by various firms in the industry. Thus, in the present study, SERVQUAL scale was factor-analyzed by principal component analysis in the patients expectation scores. The Statistical package for Social Sciences (SPSS) was used for data analysis. A rotation procedure was applied to maximize the correlations of item on a factor. Assuming factors were uncorrelated, Varimax rotation was utilized and four factors with

Page 15

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Eigen values above one were extracted. To measure the adequacy of the sample for extraction of the four factors the Kaiser-Mayer-Olkin (KMO) measure was computed. The KMO value (.890) indicates that the examined data set is highly adequate for factor analysis. Moreover, the data set was found to be multivariate normal and acceptable for factor analysis according to Bartletts test of sphericity (p = 0.000) The Bartletts test of Sphericity compared the correlation matrix to the identity matrix and showed clearly a significant relationship between the variables, approximately Chi-Square 990.33, df = 190, p < 0.0001. Total variance explained (63.039) by these four components exceeds the 60 per cent threshold usually accepted in social sciences to support the solution. The first factor, which explained 24.37 per cent of the total variance, was labeled - The human aspect of the service quality. Factor one contains nine items similar in nature to assurance and empathy and hence could be regarded as the soft dimension of quality. The second factor includes four items and explained 13.82 per cent of the total variation. It was labeled Responsiveness dimension of service quality. Factor three that includes five items, explained 12.73 per cent of the total variance and was named 'Reliability dimension of service quality'. The fourth factor comprises three items and explained 12.1 per cent of the variance, it was named 'Tangible dimension of service quality'. The extracted factors with factor loadings are presented in table one. The current research results highlighted that the structure proposed by Parasuraman et al., (1988) for the SERVQUAL scale was not confirmed. This finding is in line with previous relevant studies. Many of the items loaded heavily into different factors from the prior dimensions proposed by Parasuraman et.al. (1988). It was decided to keep these dimensions and analyse the data accordingly. The validity of the dimensionality of these groups supports the suggestions made by Babakus, Cronin and others that the dimensions of SERVQUAL may depend on the type of industry being studied. An internal consistency analysis was performed to assess the reliability aspect of the derived four dimensions. The value of the alpha coefficient ranged from .74 to .89 ( alpha > .70 (Table two) indicating that the four dimensions are reliable measures of service quality. Reliability analysis was similarly conducted for the expectation scale and for the perception scale. Both scales were found to be reliable with Cronbachs alpha value of .92 and .93 respectively. Descriptive Statistics Patients expectations (PE): In terms of patients expectation, the mean ranged between 3.73 and 4.60. The lowest 'expectation score' was for the statement stating Excellent hospitals will have pamphlets and other communication material visually appealing, while the highest score was for that stating Excellent hospitals will have the patients best interest at heart. This suggests that patients are highly concerned about trust in the hospital. This could be explained by the mystified nature of medical services or simply that these are high in credence attributes and hence it is highly difficult for customers to evaluate them. Another reason for the high expectation could possibly also be news reports of growing incidences of unethical conduct and irrational practices in hospitals. The fact that all the top five expectations are in the human aspect factor indicate that the management must ensure that the patients realize that the hospital has patients best interest at heart. It is important that this is emphasized in communications to patients and also through staff behavior.

Page 16

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Amongst the five items that received the lowest expectation scores, three are from the tangibles dimension while two are from the responsiveness dimension. Tangible dimension includes items stating about modern looking equipment, visually appealing physical facilities and visually appealing communication material. All the tangible dimensions receiving lowest scores indicate that patients do not go very much by the look of the hospital as is usually assumed. It is surprising that patients have one of the lowest expectations to staff never being too busy to respond to patients needs. Possibly patients perceive a hospital to have a large client base and hence likely to be offering good quality by noticing staff to be busy. Patients Perceptions Patients mean scores for 'perception of actual service' ranged between 3.65 and 4.32. The lowest perception score' was for This hospital has pamphlets and other communication material visually appealing. The highest 'perception score' was for the two statements stating The personnel in this hospital give prompt service to patients and The personnel in this hospital are always willing to help patients. The findings of high perceptions in the human factor dimension imply that the personnel are perceived to be serving well. The lowest perception is for the hospital has visually appealing communication material, and about meals being served hot and of good flavor indicating patients unhappiness about catering services. Indian hospital managers need to particularly consider this in view of the varied food habits in the country probably indicating need to give choice of food items to patients. One item from the human factor that has scored low perceptions is about personnel telling patients exactly when services will be performed. Patients perceptions are low about two items from the tangible dimensions. As these items are also among the low expectation items, the implication is to include these items in areas of improvement but not in the highest priority category. A comparison of patients expectations and perceptions for the four factors is presented in figure one. Statistical analysis shows that the mean patient expectations for two of the factors- Factors one and three are significantly different (p<0.05) from the respective mean patient perceptions. Staffs Understanding of Patients Expectations and Perceptions The mean value for staffs understanding of patients expectations ranged from 3.87 to 4.70. The lowest score is for statement stating patients expect excellent hospitals to have visually appealing pamphlets and other communication material, while highest score was for the statement patients expect excellent hospitals to always be willing to help patients. Mean scores for staff understanding of patient perceptions ranged between 3.52 and 4.28, the lowest being for statement five which stated that patients perceive this hospital has pamphlets and other

Page 17

SERVQUAL in Health Care Sector: Hospital in Bangladesh

communication material visually appealing while highest was for statement which stated that patients perceive the personnel in this hospital understand the specific needs of their patients. The mean patient expectation and perception scores as perceived by staff for each factor are presented in figure two. Gaps in Service Quality Gap five: The Customer Gap: This study finds differences between patients expectations from an excellent hospital and their perceptions of the service quality delivered at the study hospital. The SERVQUAL model labels this as gap five- the customer gap. This study finds that there exists gap five in the hospital analysis reveals that these gaps are significant (p<0.05) in the human factor and the reliability dimension. Gap one: The Knowledge Gap: The SERVQUAL model defines gap one labeled Knowledge gap as the gap between the management/ staff understanding of patients expectations and perceptions and the actual expectations and perceptions of patients about service quality at the hospital. It is the first step by which hospitals can proceed to reaching patients expectations. This entails identifying areas where patients expectations and perceptions of service quality mismatch with the staff and management understanding of these. The figure three shows that staff members have largely overestimated patient expectations. As regards understanding of patient perceptions of service quality, the reverse is found- staff has underestimated the hospitals performance. Variables determining the quality of healthcare services Physicians: availability:

Doctors and specialists were available when required Doctors followed up treatments regularly Doctors were present during visiting hours

Physicians: assurance/competence

Doctors interpreted laboratory reports correctly Doctor gave correct treatment at the first time Doctors were competent in diagnosing the problem Doctors gave knowledgeable answers to questions You felt safe in the hands of the doctors

Nurses: empathy

Nurse communicated your problem to doctors

Page 18

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Nurse understood your problem Nurse explained prescription to patient/ relatives Nurse was consistently caring Nurse paid individual attention to patient Nurse provided moral courage

Nurses: responsiveness

Drugs

Nurse administered treatment in time Nurse was willing to respond to patients' call Nurse cared patient cordially whenever called Nurse replied correctly to patients query You felt comfort with nurse service

Drug was available 24 hours at premises Prescribed drug was timely supplied to patient Nurses administered drugs to patients with own hand

Perceived cost

Doctor's consultation fee was higher Laboratory test fee was higher Operation cost was higher Travel cost was higher Accommodation cost was higher

Tangibility

Hospital was visually appealing

Page 19

SERVQUAL in Health Care Sector: Hospital in Bangladesh

Hospital premises were neat and clean There was enough waiting room/space Healthcare centers had modern equipment Cabin/Ward's bedding and floors were clean Cabin/Ward's waste bins were regularly cleaned Hospital had regular water supply Hospital had regular electricity Hospital had adequate security Toilets and bathrooms were clean

Conclusion This study leads to the following conclusions which are particularly important for further use of the SERVQUAL model in Bangladeshi Hospitals. The SERVQUAL questionnaire can be modified to specific needs as recommended by Parasuraman et al. However, this raises concern about loss of the power of standardization. Although the scale is tested for reliability and validity, the process of evolution of the scale being subjective, the possibility of negligence of important items cannot be ruled out. The length of the questionnaire is another important consideration in using the SERVQUAL model. In view of the middle socio-economic class patients and their cultural contexts, this study has attempted to improve the present ability and the readability of the questionnaire which was found useful in keeping participants interest in it. Involvement of staffs directly interacting with patients instead of management alone as recommended by the original SERVQUAL model is a unique feature of this study. This has been found helpful in not only better identifying understanding of patients expectations and perceptions, but also in creating acceptance for subsequent service quality improvement strategies. This study concludes that the dimensional structure of SERVQUAL is unstable within the hospital industry and this finding is similar to that reported by Carman (1990) and Babakus and Boller (1992). While the original study by Parsuraman et al 1988 proposed five (universal) dimensions which were supposed to measure the service quality in any sector, this study reports four dimensions for the hospital industry rather than five. This result supports the work of quality gurus who found that quality is a relative notion with respect to a given client segment. The regression analysis found the service quality gap in the responsiveness dimension to be the most strong predictor of overall service quality followed by reliability. However the model points that there are predictors of service quality other than the gaps in the four dimensions that this study finds.

Page 20

SERVQUAL in Health Care Sector: Hospital in Bangladesh

[ Bibliography: Service Marketing: Valarie A Zeithaml SERVQUAL: Parasuraman Internet Source: www.mohfw.gov.bd / www.dghs.gov.bd/ www.dgfp.gov.bd/ www.icddrb.org/ ]

Page 21