MEASURING SERVICE QUALITY IN THE HEALTH CARE INDUSTRY IN A

DEVELOPING COUNTRY CONTEXT

Baharak Mohabbat Talab
DBA Student,
Southern Cross Business School
Southern Cross University
Locked Bag 4
Coolangatta 4225
Australia

Zafar U. Ahmed*
Department of Marketing
School of Business

Lebanese American University

P.O. Box #:13-5053, Chouran
Beirut 1102-2801

Lebanon
Email: zafaruahmed@gmail.com
*(Corresponding Author)

Craig C. Julian
Southern Cross Business School
Southern Cross University
Locked Bag 4
Coolangatta 4225
Australia

ABSTRACT
This study measures service quality in the health care industry in a developing
country of the Middle East, namely Iran, using the full SERVQUAL Gap Model developed by
Parasuraman et al., 1985, via customers perceptions and expectations in an outpatient section in
a private Hospital. The results of the study suggest that all 5 dimensions of the SERVQUAL Gap
Model, namely, tangibles, reliability, responsiveness, assurance and empathy were important to
achieve service quality and thereby maintain some sort of competitive advantage. The study also
provided suggestions/recommendations to senior management at the private hospital to help
enhance functional service quality and increase patients satisfaction.
Key Words: SERVQUAL, tangibles, reliability, responsiveness, assurance, empathy.

INTRODUCTION
In todays global market, the service industry is growing at a rapid pace. Zeithaml and
Bitner (2003) suggested services are deeds, processes and performances whilst Padilla et al.
(2009) suggested services are intangible not including physical products or construction which is
produced and consumed according to the needs and demands of consumers. Kotler et al. (1999)
also claimed services are economic activities or benefits that are offered by one party to another
that does not affect the possession of anything.
In last three decades service quality has been defined differently by many researchers
(e.g., Parasuraman et al., 1985; Bitner et al., 1994; Cronin and Taylor, 1992). Parasuraman et al,
(1985) suggested service quality to be the difference between expectations and perceptions in a
service encounter. Bitner et al. (1994) suggested service quality was the overall impact of the
virtual inadequacy/ascendancy of the service provided by a company whilst Roest and Pieters

(1997) suggested service quality was a known inconsistency among experienced-based norms
and deeds relating to service benefits. Yet Arnauld et al. (2002) suggested service quality was the
customers evaluative verdict about the overall excellence in providing certain desired benefits.
However, many other researchers have defined service quality as an attitude of the customer to
perceived quality.
There have been several attempts to measure service quality in the services marketing
literature, however, Parasuraman et als (1985) work in service quality and the SERVQUAL
Model is probably the most cited and accepted measure of service quality. As such, this study
uses the SERVQUAL measure of service quality developed by Parasuraman et al (1985), namely,
the dimensions of tangibles, reliability, responsiveness, assurance and empathy to assess service
quality in the health care industry in Iran, a developing country of the Middle East.
THEORETICAL FRAMEWORK
Palmer et al (1991) suggested that quality in the healthcare industry was as a result of
enhanced health and the satisfaction of residents surrounded by the construction of equipment,
resources, and patients conditions and situations. Grnroos (1984) and Seth et al (2005)
suggested that there were three aspects of quality in health care that were important, namely,
technical quality, functional quality and corporate image. Technical quality is the technical
exactness of health judgment and procedures. Functional quality is the processes and deeds that
service and treatment is delivered by with corporate image being the service providers image
that is developed through technical and functional quality.
Rivers and Glover (2008) suggested that the technical quality of medical services consists
of two sub-dimensions. Firstly, the suitability of the service performance and the skills with
which that suitable service is performed and that hospitals need to build high-quality services for
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each and every patient. Secondly, the skills with which suitable care is complete and
implemented including overall skill, decisions that are made, and the timeliness of the
implementation. However, the quality of the interface between medical providers and patients
depends on a number of consistent issues, including the quality of communication between
employees and patients, the medical providers ability to sustain the patients trust and a
capability to delight the patient with compassion, integrity and judgment.
Grnroos (1993) noted that, particularly in the healthcare industry, technical quality
might be difficult for patients to assess that do not have sufficient technical experience and
knowledge, however, functional services quality can be assessed as patients have a propensity to
rely on how a service is delivered. Furthermore, Asubonteng et al (1996) suggested that patients
judge functional service quality as the most critical factor in service transactions compared with
technical quality due to a lack of knowledge about technical aspects. Grnroos (1993) also
suggested that quality of service in both technical and functional aspects are the main
constituents to success for a service organization and have a considerable relationship with
profitability, customer satisfaction and customer retention. Singh (1991) further suggested that
when assessing hospitals performance technical aspects must be elaborated on to include
functional quality perceptions as well as technical quality perceptions which lends support to the
use of the Parasuraman et al (1985) SERVQUAL Gap Model when measuring service quality in
such an environment.
Many researchers have a similar viewpoint in relation to a patients perception of quality
in the healthcare sector and believe that the variation in culture influences the assessment of
quality by customers and service providers. For instance, Mattila (1999) contended that cultural
factors have a great influence on a customers assessment of service than on their assessment of

tangible benefits because of the interface between customers and front line staff when services
are delivered (Julian and Ramaseshan, 1994). Parasuraman et al. (1985) noted the perception of
quality is an outcome of the compression of customer expectations with the actual service they
receive from the service provider.
Numerous studies have shown that high service quality in the healthcare industry is
related to a patients satisfaction and their intention to be loyal and be retained by the service
provider. Tam (2007) suggested that a patients satisfaction is thought to be a significant indicator
of service quality. Bolton and Drew (1988) mentioned that perceived quality by customers is the
most significant variable affecting a customers perception of value and satisfaction and in their
intention to purchase a particular good or service. This was also noted by Ross et al (1987) when
they found that the initial expectation by patients is the first element that determines satisfaction
and if the perceived care and treatment fall short of their expectations, then the consequence will
be a patients dissatisfaction.
Donabedian (1980) illustrated that patient satisfaction is an important contributor to the
meaning of services/products quality from the perspective of patients values and their
expectations and a significant element of care quality because patients who are satisfied are more
willing to act in accordance with the medical providers and to collaborate or continue a
relationship with that particular provider.
Due to differences in expectations, it is also possible that a patients satisfaction may vary
from the same provider (Tam, 2007). One of the barriers for healthcare service providers is to be
able to learn from their patients and this was identified by Wensing et al (2003) as an issue as it
is difficult to meet all of the patients needs and desires. Other factors including increasing
workloads, busy timetables, cost implications and time constraints of the service provider to

spend time with their patients were all cited as issues impacting service quality in the healthcare
industry (Tam, 2007). Jayanti and Burns (1998) also suggested that patients play an important
role in achieving quality treatment and services. As a result, patients must be more proactive in
their own care and treatment (Price et al., 2006).
Numerous studies have also reported issues pertaining to the competitive impact and
perspectives in the healthcare industry. For instance, several studies have investigated the
relationship between competitive intensity and healthcare quality (e.g., Zwanziger and Melnick,
1996; Chassin, 1997), between health care costs and competition (Robinson and Luft, 1985) and
between patient satisfaction and competition (Miller, 1996). In their studies, they stated that
traditional competition in the healthcare sector involves quality, price, expediency, and
excellence in products or services, although it can also be through the adoption of new and
advanced technologies and innovative services/products. Rivers and Glover (2008) suggested
that a main component of competition in the healthcare sector is the ability to produce a method
for reducing medical costs. Competition commonly reduces the inefficiencies of high production
costs that eventually lead to high healthcare service quality and procedures improvements. This
leads to cost reduction, which in turn improves customer satisfaction. Folland et al (1993) noted
that in the healthcare industry market failures also exist due to a lack of competition. Quality
competition is an aspect of an oligopolistic market but price competition generally is not.
As competition increases, in order to survive, service providers need to pay more
attention to increasing customer satisfaction and retaining existing customers. According to
Shahin (2006) the measurement of service quality allows for the comparison of before and after
certain service encounters and the measure of service quality should be the difference between
the expectations of the service encounter by the customer and what was actually delivered.

There are many models, which are available to measure service quality, particularly in the
healthcare industry, namely, SERVQUAL (Parasuraman et al., 1985) and SERVPERF (Cronin
and Taylor, 1992) to name just a few. The SERVQUAL Model is the most widely accepted
measure of assessing service quality in the healthcare industry and that is why it has been
selected to assess service quality in a private hospital in Iran.
SERVQUAL was used to evaluate customers expectations before a service was delivered
and their perceptions of the service after it was delivered (Parasuraman et al., 1985).
Parasuraman et al. (1985) identified 22 statements in the SERVQUAL model, across five
dimensions, namely tangibles, reliability, responsiveness, assurance and empathy. A specific
advantage of the SERVQUAL model was that it is a proven reliable and valid measure of service
quality (Brysland and Curry, 2001).

METHODOLOGY
This was an exploratory study conducted in a private hospital in Iran using Parasuraman et
als (1985) SERVQUAL measure to determine service quality and its effect on the healthcare
industry in a developing country context of the Middle East, namely Iran. The questionnaire was
designed in accordance with the 22 original statements from the SERVQUAL model developed
by Parasuraman et al (1985) intending to measure five dimensions of service quality, namely,
tangibles, reliability, responsiveness, assurance and empathy. A 7-Point Likert Scale was used to
measure customers expectations and perceptions against the five dimensions of service quality.
The 7-point Likert Scale ranged from strongly disagree (1) to strongly agree (7). Questionnaires
were hand delivered to the private hospitals patients in the outpatient department. A total of 150

questionnaires were hand delivered to outpatients and 100 were returned indicating a response
rate of 67% and considered to be adequate. All respondents were less than 50 years old.
The amount of information requested in the questionnaire was reasonable because
participants were only requested to specify their level of agreement or disagreement with the 22statements in the SERVQUAL model designed to measure customers expectations and
perceptions against the 5 service quality dimensions of tangibles, reliability, responsiveness,
assurance and empathy. Background information was requested from the participants in order to
the differentiate them. The average time taken by participants to complete the questionnaire was
less than 15 minutes.
DATA ANALYSIS
The data were initially analysed using principal components analysis to assess the
psychometric properties of the instrument. Our primary concern was to ensure all statements
loaded onto their appropriate factors. The 5 service quality dimensions, namely, tangibles,
reliability, responsiveness, assurance and empathy all loaded appropriately and no cross loadings
above .2 were identified with only factor loadings of above .5 being accepted. The final
reliabilities for all scales were greater than .70. The preliminary results indicated that the
psychometric properties of the scales were acceptable and as such it was appropriate to examine
the gap between customer expectations and perceptions within the 5 service quality dimensions
of tangibles, reliability, responsiveness, assurance and empathy.
Patients were asked to show the extent to which they believed the private hospital had the
feature described in the statement. With a number from 1 to 7 that showed their level of
expectation and perception against the 5 service quality dimensions patients responded to 22
statements measuring customer expectations against the 5 service quality dimensions and 22
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statements measuring customer perceptions against the 5 service quality dimensions after being
exposed to the service. The difference between customer expectations and perceptions was used
to measure the gap in service quality that existed in the private hospital on the 5 dimensions of
the SERVQUAL model measuring service quality, namely, tangibles, reliability, responsiveness,
assurance and empathy (Parasuraman et al., 1985).
Data collection involved a summary of typical values with typical being the mean
response when the distribution was sorted from lowest to highest (Cooper and Schindler, 2003).
All data collected from patients was entered into an SPSS spread sheet in order to measure the
service quality gaps as result of G (service quality gap) = P (perceptions) -E (expectations) for
each statement. The total gap was then calculated based on the distribution of statements in each
dimension, namely, tangibles, reliability, responsiveness, assurance and empathy (Parasuraman
et al., 1985). After the final result was calculated for each dimension, as is the requirement of the
SERVQUAL model, all the data was averaged for each dimension for each single patient. The
results are described in Table 1.

TABLE # 1SERVQUAL MEASURE OF SERVICE QUALITY IN

HEALTHCARE.
Dimension

Statement

Average E

Average P

Average G

Statement 1
Statement 2
Statement 3
Statement 4

6.52
6.59
6.6

5.52
5.65
5.59

-1
-0.94
-1.01

6.42
6.58
6.54
6.6
6.66
6.68
6.64
6.61
6.56

5.16
3.23
3.16
5.26
4.24
2.35
5.52
2.38
5.66

-1.26
-3.35
-3.38
-1.34
-2.42
-4.33
-1.12
-4.23
-0.9

6.63
6.6
6.87
6.8

3.17
3.2
5.52
3.36
4.11
4.32
2.37
3.24
4.7
4.77

Dimension Gap

Average Dimension
Gap

Tangibles

Reliability

Responsiveness

Assurance

Empathy

Statement 5
Statement 6
Statement 7
Statement 8
Statement 9
Statement 10
Statement 11
Statement 12
Statement 13
Statement 14
Statement 15
Statement 16
Statement 17

6.84
6.6
6.62
6.63
6.59
6.66
Average Unweighted SERVQUAL Score

Statement 18
Statement 19
Statement 20
Statement 21
Statement 22

-4.21

-1.0475

-14.82

-2.964

-3.46
-3.4
-1.35
-3.44

-9.71

-2.4275

-2.73
-2.28
-4.25
-3.39
-1.89
-1.89

-10.92

-2.73

-13.7

-2.74

-2.3818

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DISCUSSION
After analysing patients perceptions and expectations of the service quality at the
Hospital, it was quite clear that there was a higher expectation of service quality compared to the
actual perception of service quality after patients had been exposed to the service. The average
expectation of service quality was at 6.6/7 while the average perception of service quality after
being exposed to the service was 4.2/7. This suggests that the private hospital was unable to
meet customer expectations as the patients at the private hospital did not perceive the service
quality at the hospital to be at the level they expected. The overall gap between expectations and
perceptions of service quality remained negative for all dimensions of the SERVQUAL model in
the outpatient department at the hospital. The tangible dimension indicated a negative gap of
1.0475/7, which suggests that the hospital was unable to provide physical facilities, equipment
and the appearance of their personnel at a level expected from patients. However, this negative
gap of -1.0475/7 was much less than the gaps in the other SERVQUAL dimensions i.e. reliability
(-2.964/7), responsiveness (-2.4275/7), assurance (-2.73/7) and empathy (-2.74/7) with the
reliability dimension having the highest negative gap. When analyzing the importance of the
different dimensions of the SERVQUAL model, it showed that the responsiveness dimension
was regarded as the most important dimension followed by reliability, assurance, tangibles and
finally empathy.
REFERENCES
Arnauld, E., Price, L. and Zinkhan, G., (2002), Consumers, 2nd edition, Mc-Graw-Hill, New
York.
Asubonteng, P., Mc Cleary, K.J. and Swan, J.E., (1996), SERVQUAL revisited: a critical review
of service quality, Journal of Services Marketing, 10(6): 62-81.
Binter, M.J., Booms, B.H. and Mohr, L.A., (1994), Critical service encounter: the employee
viewpoint, Journal of Marketing, 58(4): 95-106.
Bolton, R.N. and Drew, J.H. (1988), A model of perceived service value, technical note, 88420.1, GTE Laboratories, Waltham, MA.
Brysland, A. and Curry, A., (2001), Service improvements in public services using SERVQUAL,
Journal of Managing Service Quality, 11(6): 389-401.

11

Chassin, M.R., (1997), Assessing strategies for quality improvement, Journal of Health Affairs,
16(3): 151-161.
Cooper, P.S. and Schindler, D.R., (2003), Business research methods, 8th ed., McGraw-Hill,
New York.
Cronin, J.J. and Taylor, S.A., (1992), Measuring service quality: a re-examination and extension,
Journal of Marketing, 56(7): 55-68.
Donabedian, A., (1988), The quality of care; how can it be assessed? Journal of the American
Medical Association, 260(12): 1743-1748.
Folland, S., Goodman, A.C. and Stano, M. (1993), The Economics of Health and Health Care,
3rd ed., Macmillan Publishing Company, New York.
Grnroos, C. (1993), A service quality model and its marketing implications, European Journal
of Marketing, 18(4): 36 -55.
Jayanti, R. and Burns, A. (1998), The antecedents of preventive health care behavior: an
empirical study, Journal of the Academy of Marketing Science, 26(1): 6-15.
Julian, C.C. and Ramaseshan, B. (1994), The role of customer-contact personnel in the marketing
of a retail banks services, International Journal of Retail and Distribution Management, 22(5):
29-34.
Kotler, P., Armstrong, G., Saunders, J. and Wong, V. (1999), Principles of Marketing, 2nd ed.,
Prentice-Hall, London.
Mattila, A.S., (1999), The role of culture and purchase motivation in service encounter
evaluations, Journal of Services Marketing, 13(4/5): 376-389.
Miller, R.H., (1996), Competition in the health system: good news and bad news, Journal of
Health Affairs, 15(2): 312-320.
Tejeida-Padilla, R., Flores-Cadena, M., Morales-Matamoros, O. and Badillo-Pia, I. (2009), In
search of a viable system model for after-sales spare parts service in Telecom firms. Available
from: <http://journals.isss.org/index.php/proceedings53rd/article/view/1214/421
Palmer, R.H., Donabedian, A. and Povar, G.J., (1991), Striving for Quality in Health Care: An
Inquiry into Policy and Practice, Health Administration Press, Chicago, IL.
Parasuraman, A., Zeithaml, V.A. and Berry, L.L., (1985), A conceptual model of service quality
and its implications for future research, Journal of Marketing, 49: 41-50.

12

Price, S., Stewart, M. and MacPherson, H., (2006), Practitioner empathy, patient enablement and
health outcomes: a prospective study of acupuncture patients, Patient Education and Counseling,
63(1): 239-245.
Rivers, P. and Glover, S.H. (2008), Health care competition, strategic mission, and patient
Satisfaction: research model and propositions, Journal of Health Organization and Management,
22(6): 627 641.
Robinson, J.C. and Luft, H.F. (1985), The impact on hospital market structure on patient volume,
length of stay, and cost of care 1972-1982, Journal of Health Economics, 4(4): 333-356.
Roest, H. and Pieters, R. (1997), The nomological net of perceived service quality, International
Journal of Service Industry Management, 8(4): 336 351.
Ross, C.K., Frommelt,G., Hazelwood, L. and Chang, R.W. (1987), The role of expectation in
patient satisfaction with medical care, Journal of health care marketing, 7(4): 16-26.
Seth, N., Deshmukh, S.G. and Vrat, P. (2005), Service quality models: a review, International
Journal of Quality & Reliability Management, 22(9): 913949.
Singh, J. (1991), Understanding the structure of consumers satisfaction evaluations of service
delivery, Journal of the Academy of Marketing Science, 19(3): 223-44.
Tam, J.L.M., (2007), Linking quality improvement with patient satisfaction: a study of a health
service centre, Marketing Intelligence & Planning, 25(7): 732-745.
Wensing, M., Vingerhoets, E. and Grol, R. (2003), Feedback based on patient evaluations: a tool
for quality improvement? Journal of Patient Education and Counseling, 51(2): 149-153,
Zeithaml, V.A. and Bitner, M.J., (2003), Services Marketing, 3rd ed., McGraw-Hill, New York.
Zwanziger, J. and Melnick, G.A., (1996), Can managed care plans control health care costs?
Journal of Health Affairs, 15(2): 189-99.

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