See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/316529788

Service quality, patient satisfaction and loyalty in the Bangladesh healthcare

sector

Article  in  International Journal of Health Care Quality Assurance · June 2017

DOI: 10.1108/IJHCQA-01-2017-0004

CITATIONS READS

13 3,124

3 authors:

Selim Ahmed Kazi Md. Tarique

World University of Bangladesh Southeast University (Bangladesh)
31 PUBLICATIONS   149 CITATIONS    9 PUBLICATIONS   95 CITATIONS   

SEE PROFILE SEE PROFILE

Ishtiaque Arif
Universiti Putra Malaysia
10 PUBLICATIONS   25 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Islamic Banking View project

Healthcare quality performance in Bangladeshi's private hospitals View project

All content following this page was uploaded by Selim Ahmed on 13 July 2018.

The user has requested enhancement of the downloaded file.

 International Journal of Health Care Quality Assurance
Service quality, patient satisfaction and loyalty in the Bangladesh healthcare
sector
Selim Ahmed, Kazi Md. Tarique, Ishtiaque Arif,
Article information:
To cite this document:
Selim Ahmed, Kazi Md. Tarique, Ishtiaque Arif, (2017) "Service quality, patient satisfaction and loyalty
in the Bangladesh healthcare sector", International Journal of Health Care Quality Assurance, Vol. 30
Issue: 5, pp.477-488, https://doi.org/10.1108/IJHCQA-01-2017-0004
Permanent link to this document:
https://doi.org/10.1108/IJHCQA-01-2017-0004
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

Downloaded on: 13 June 2017, At: 08:53 (PT)

References: this document contains references to 44 other documents.
To copy this document: permissions@emeraldinsight.com
The fulltext of this document has been downloaded 70 times since 2017*
Users who downloaded this article also downloaded:
(2017),"Measuring quality performance between public and private hospitals in Malaysia",
International Journal of Quality and Service Sciences, Vol. 9 Iss 2 pp. - <a href="https://
doi.org/10.1108/IJQSS-02-2017-0015">https://doi.org/10.1108/IJQSS-02-2017-0015</a>
(2017),"Interrelationships among quality enablers, service quality, patients’ satisfaction and
loyalty in hospitals", The TQM Journal, Vol. 29 Iss 1 pp. 101-117 <a href="https://doi.org/10.1108/
TQM-02-2015-0032">https://doi.org/10.1108/TQM-02-2015-0032</a>

Access to this document was granted through an Emerald subscription provided by

Token:JournalAuthor:EFA41A9C-3FEE-4BCB-8C0E-E21D58E27B09:
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald
for Authors service information about how to choose which publication to write for and submission
guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company
manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as
well as providing an extensive range of online products and additional customer resources and
services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the
Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for
digital archive preservation.

*Related content and download information correct at time of download.

 The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/0952-6862.htm

Bangladesh
Service quality, patient healthcare
satisfaction and loyalty in the sector

Bangladesh healthcare sector

Selim Ahmed 477
Faculty of Management Sciences (ISIAM),
Universiapolis – International University Agadir, Agadir, Morocco, and Received 21 August 2016
Revised 6 January 2017
Kazi Md. Tarique and Ishtiaque Arif Accepted 25 February 2017

School of Business Studies, Southeast University, Dhaka, Bangladesh

Abstract
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

Purpose – The purpose of this paper is to investigate service quality, patient satisfaction and loyalty in
Bangladesh’s healthcare sector. It identifies healthcare quality conformance, patient satisfaction and loyalty
based on demographics such as gender, age and marital status. It examines the differences between public
and private healthcare sectors regarding service quality, patient satisfaction and loyalty.
Design/methodology/approach – The authors distributed 450 self-administered questionnaires to
hospital patients resulting in 204 useful responses (45.3 per cent response rate). Data were analysed based on
reliability analysis, exploratory factor analysis, independent samples t-tests, ANOVA and discriminant
analysis using SPSS version 23.
Findings – Findings indicate that single patients perceive tangibles, reliability, empathy and loyalty higher
compared to married patients. Young patients (⩽ 20 years) have a higher tangibles, empathy and loyalty
scores compared to other age groups. The authors observed that private hospital patients perceive healthcare
service quality performance higher compared to patients in public hospitals.
Research limitations/implications – The authors focussed solely on the Bangladesh health sector, so the
results might not be applicable to other countries.
Originality/value – The findings provide guidelines for enhancing service quality, patient satisfaction and
loyalty in the Bangladesh healthcare sector and other countries.
Keywords Bangladesh, Healthcare, Service quality, Patient satisfaction, Patient loyalty
Paper type Research paper

Introduction and background

There has been an unprecedented growth and development in the service industries.
In many developed countries, service sectors are the largest contributor (more than
50 per cent) to GDP (Bateson and Hoffman, 1991). Developing countries are following in the
same footsteps by introducing initiatives to boost their service industries. Healthcare is a
key service sector that can attract significant revenue from local and international sources.
East Asian countries, such as Thailand and Singapore, successfully attracted several health
tourists. Many patients from developing countries like Bangladesh, India and Pakistan
frequently visit those countries for quality treatment. It does not mean that the healthcare
sector in those countries (i.e. Bangladesh, India and Pakistan) is poor, rather in most cases it
is a service quality issue.
As a unique service industry, patients demand high-quality services. The service
provided by hospital staff affects patients, family and friends. Any misjudgement or error
can have fatal consequences. A report published by the Institute of Medicine in 1999 entitled
“To err is human: Building a safer health system” revealed that in the USA, 98,000 people
die owing to medical errors annually (McDonald, 2013). In a similar study, the Journal of
International Journal of Health
Patient Safety reports that annually, 210,000-400,000 patients die in US hospitals owing to Care Quality Assurance
preventable adverse events (Allen, 2013). The above examples suggest paying maximum Vol. 30 No. 5, 2017
pp. 477-488
attention to healthcare quality. Service quality or SERVQUAL has become a buzz word in © Emerald Publishing Limited
0952-6862
today’s competitive business world as it is considered a critical factor for survival and DOI 10.1108/IJHCQA-01-2017-0004
 IJHCQA success. SERVQUAL, coined by Parasuraman et al. (1985) to evaluate service performance,
30,5 is based on five dimensions:
(1) Tangibles refer to physical facilities, tools or equipment used to provide services and
staff appearance. The physical facilities such as signs, comfort, accessibility,
spaciousness, functionality and cleanness (D’Cunha and Suresh, 2015). This factor is
a critical service quality dimension to improve quality performance in the service
478 industry (Rad et al., 2010). Additionally, this factor is primarily associated with
service verities to meet customer expectations (Caruana and Berthon, 2002).
(2) Reliability involves service consistency and dependability, which refers to the ability
to deliver the service dependably and accurately that customers desire (Parasuraman
et al., 1985). Providers deliver the service at the right time and honours their promises,
especially billing accurately, keeping records correctly and delivering the service to
the customer at the designated time (Kondasani and Panda, 2015). If service providers
keep their promises, then customer satisfaction increases and their confidence in the
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

service provider increases because the provider’s performance gradually improves

and consistently meet customer expectations (Rad et al., 2010).
(3) Responsiveness concerns service provider’s willingness or readiness to offer a
prompt service (Parasuraman et al., 1985). It deals with timeliness, such as providing
quick services to the customer, setting-up appointments as soon as possible,
immediately sending the transaction slip to the customer so that s/he does not form
the wrong impression and calling the customer quickly (Calisir et al., 2014). If service
providers increase their response to customers, then it is likely to have a positive
effect on customer satisfaction (Parasuraman et al., 1985; Rad et al., 2010).
(4) Assurance refers to employee knowledge, courtesy and the ability to convey trust
and confidence. Employees should have the necessary knowledge and skills to
provide the best service to their customers. Courtesy means politeness, respect,
consideration and friendliness, such as consideration for the customer’s/consumer’s
property. Conveying trust and confidence means trustworthiness, believability and
honesty. It involves having the customer’s best interests at heart such as contact
personnel characteristics (Kitapci et al., 2014).
(5) Empathy refers to caring, knowing customer demands and individualised attention
provided to customers. Capacity to understand customer needs refers to the ability
to respond to them such as recognising regular customers and learning their specific
requirements (Parasuraman et al., 1985). Provider empathy and customer
relationship has a positive influence on customer satisfaction (Fitzpatrick, 1991;
Zarei et al., 2012).
Researchers show increasing interest in examining the link between SERVQUAL and
customer satisfaction, customer loyalty, positive word of mouth, costs and organisational
profitability (Shi et al., 2014; Orel and Kara, 2014). Much service quality performance
research concludes that SERVQUAL significantly influences patient satisfaction and
loyalty in healthcare organisations (Shabbir et al., 2016; Park et al., 2016). Our aim, therefore,
is to: investigate service quality, patient satisfaction and loyalty in Bangladesh; and identify
provider conformance to healthcare service quality standards, patient satisfaction and
loyalty based on demographics (i.e. gender, age, marital status and hospital type).
According to Parasuraman et al. (1988), service quality represents perceived quality, which
influences customer judgement/decision about an entity’s overall excellence. The authors also
mentioned that organisational service quality consistently meet customer/consumers external
and internal needs, wants and expectations to fulfil personal desires. Also, service quality is
 the capability to meet and exceed the results that service provider and customer/consumer Bangladesh
mutually defined at the service encounter (Dedeke, 2003). Service quality dimensions include: healthcare
technical service quality, which refers to performance that the customer/consumer receives in sector
the service encounter; and functional service quality, which relates to subjective perception of
how the service is delivered and defines customers’ interactions during service delivery
(Gronroos, 1990). Good service quality always leads to high customer satisfaction
(Subramanian et al., 2014). To achieve high customer satisfaction, managers must be 479
concerned with four service characteristics (Kotler et al., 2006):
(1) Intangibility: buyers or customers normally cannot see, feel, smell, hear or taste a
service before they make an exchange agreement with a service provider.
(2) Perishability: a service must be consumed or encountered on the spot before it
expires. This service cannot be kept or stored for a long time. Therefore, service
providers must service their customers on the spot.
(3) Inseparability: services are produced and consumed at the same time and that they
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

cannot be separated from their providers, whether the providers are people or machines.
(4) Heterogeneity: services are performed at various levels and quality performance is
different: from one organisation to another; from one service provider to another and
for the same performer at contrasting times.
According to Gummesson (1992), service quality differs between service organisations and
manufacturing organisations. Service managers believe that service quality can be
managed through product quality. Providers find that service quality is more difficult than
product quality to manage and it is difficult to measure because services are intangible;
whereas, product quality is tangible and measurable by inspecting possible defects in the
product. Several defects in a product indicates inferior quality (Buyukozkan et al., 2011).
In the early 1970s, service quality was researched for its capacity to measure service
quality performance.

Healthcare service quality

Since 1997, healthcare analysts have been applying the SERVQUAL model to measure patient
satisfaction and loyalty. SERVQUAL helps healthcare service providers to identify the gap
between service delivery and patient expectations (Al-Borie and Sheikh Damanhouri, 2013;
Zarei et al., 2015). Once providers identify their service problems they can immediately
improve their quality performance for the patient’s benefit (Kondasani and Panda, 2015).
According to Buyukozkan et al. (2011), healthcare service quality can be measured in six
ways: tangibles, responsiveness, reliability, assurance, empathy and professionalism. Based
on their research, empathy is the most important healthcare service quality factor in Turkey.
Their research also found that professionalism and reliability are equally important for
hospital service quality performance. Butt and Run (2010) research in Malaysian private
healthcare service quality. They explored service quality gaps between service expectations
(SEREXP) and service perceptions (SERPER) in a Malaysian private healthcare context.
They found that the Malaysian private healthcare SERPER is higher than SEREXP.
Andaleeb (2001) stated that it is not necessary to measure tangibles, responsiveness,
reliability, assurance and empathy in specific service situations. He suggested that quality
dimensions are modified to evaluate specific service situations. In 2001, he studied service
quality perceptions and patient satisfaction in Bangladesh. He measured patient satisfaction
using five dimensions: responsiveness, assurance, communication, discipline and baksheesh
(service tips). His results show that all five dimensions have a considerable influence on
patient satisfaction. Manaf and Nooi (2009) researched Malaysian public hospital service
 IJHCQA quality and its effect on patient satisfaction. Patient satisfaction measurement was based on
30,5 clinical (staff, treatment and information) and physical (cleanliness, environment and visiting)
dimensions. Both dimensions have a positive and major influence on patient satisfaction in
Malaysian public hospitals.

Patient satisfaction
480 Patient satisfaction is widely used in the healthcare sector to determine service quality
(Fenton et al., 2012; Shabbir et al., 2016). Azizan and Mohamed (2013) studied service
quality and patient satisfaction at a public hospital in Pahang, Malaysia. Hospital
service quality was significantly influenced by three factors: administrative service; medical
and nursing care. Hospital infrastructure and interaction have an insignificant relationship
with service quality. Leiter et al. (1998) conducted an empirical study in Canadian hospitals.
They observed that patient satisfaction is significantly influenced by nurses, doctors and
information. These elements led to high patient satisfaction. Manaf et al. (2012) studied the
International Islamic University Malaysia Health Centre. Almost half (46.4 per cent)
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

the patients were satisfied with service quality, whereas 7.3 per cent were dissatisfied.
In Bangladesh, Andaleeb (2001) looked at patient satisfaction in private and public
healthcare sectors using five dimensions: responsiveness; assurance; communication;
discipline; and baksheesh. All, except baksheesh, had a noteworthy influence on
Bangladeshi patient satisfaction.

Patient loyalty
Anbori et al. (2010) defined patient loyalty as a strategic service plan to retain customers in
the long term by providing better service quality. To achieve patient loyalty, providers must
fulfil patient needs and expectations (Aliman and Mohamad, 2016). Anbori et al. (2010)
mentioned that if providers know what service quality aspects are most important to
patients and have mechanisms to prioritise and ensure that these are in place, then this will
lead to patient satisfaction and willingness to reuse medical services. The authors looked at
private hospital patient satisfaction and patient loyalty in Sana’a, Yemen. Reliability,
empathy and assurance significantly influence patient willingness to return. However, their
results show that tangibles and responsiveness do not have a significant impact on patient
loyalty. Mortazavi et al. (2009) conducted research on patient satisfaction and patient loyalty
in four Iranian private hospitals using six dimensions: nursing care; operating room;
admission and administration services; meals; expenses; and patient rooms. They found
that patient satisfaction and loyalty are significantly correlated, and both factors have
significant relationships with nursing care, operating room, admission and administration
services, and patient room. Hu et al. (2011) measured patient satisfaction and patient loyalty
in Taiwan’s hospitals and found that patient satisfaction did not have a considerable
influence on patient loyalty in Taiwan. Fornell (1992) argued that loyal customers are not
necessarily satisfied, but satisfied customers must be loyal customers; i.e., loyalty is not
exclusive, absolute and/or permanent (Roberge et al., 2001). To achieve patient loyalty,
providers need to communicate regularly with patients to understand their needs and
expectations (Roberge et al., 2001).

Methodology
We collected data using a three-part self-administered questionnaire. Section A pertained to
respondent demographics (gender, age, marital status and hospital type). Section B measured
five service quality dimensions: tangibles, reliability, responsiveness, assurance and empathy.
Section C connected Bangladeshi patient satisfaction and loyalty. Both B and C had 29 items
and used a five-point Likert scale. Purposive sampling was used and research questionnaires
 were distributed to the respondents in various Bangladeshi places. In total, 450 questionnaires Bangladesh
were distributed to respondents who experienced Bangladesh healthcare service quality. healthcare
In total, 204 responses were received (45.3 per cent response rate). Reliability analysis sector
and exploratory factor analysis (EFA), independent samples t-test, one-way ANOVA and
discriminant analysis were undertaken using SPSS version 23.

Data analysis 481

Demographic profile
Most (52.9 per cent) respondents were female. Patients ⩽ 20 years totalled 7.4 per cent;
21-30 years, 28.9 per cent; 31-40 years, 26 per cent; 41-50 years, 18.6 per cent; 51-60 years,
11.3 per cent; ⩾ 60 years, 7.9 per cent. Most (64.7 per cent) respondents were married. In total,
116 patients (56.9 per cent) were from Bangladesh private hospitals (Table I).

Reliability and validity

Reliability can be analysed in four ways: test-retest; split-half; alternative form and the
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

most popular method, internal consistency (Cronbach’s α). Hair et al. (2010) said that
internal consistency applies to consistency among variables in a summated scale.
The rationale for internal consistency is that scale items or indicators should all be
measuring the same construct and thus be highly intercorrelated. This method was
introduced by Kuder and Richardson in 1937 to measure internal consistency using
Cronbach α, which we used to measure 29 items covering tangibles, reliability,
responsiveness, assurance, empathy, patient satisfaction and patient loyalty. Scores
range from 0 to 1, with values close to 1 indicating high consistency. If Cronbach’s α is
greater than 0.7, then the item scales are regarded as reliable (Hair et al., 2010). Table II
illustrates our Cronbach’s α for seven dimensions, which range from 0.81 to 0.9, exceeding
the 0.70 requirement; i.e., the overall instruments were deemed reliable for this study.
We used 204 responses to perform EFA. The Kaiser-Meyer-Olkin (KMO) value was 0.93,
indicating that research data were suitable for principal component analysis (Table II).
Hair et al. (2010) say that factor analysis can be performed when KMO and Bartlett’s test
are significant. Our results indicated that factor analysis is appropriate. After confirming
research constructs, principal components analysis and the varimax rotation method

Description Frequency Percentage

Gender
Male 96 47.06
Female 108 52.94
Age group
20 years or below 15 7.35
21-30 years 59 28.92
31-40 years 53 25.98
41-50 years 38 18.63
51-60 years 23 11.27
Above 60 years 16 7.85
Marital status
Single 72 35.29
Married 132 64.71
Type of hospital
Public 88 43.14 Table I.
Private 116 56.86 Demographic profile
 IJHCQA Item Factor
30,5 No. Variables loading Cronbach’s α

Tangibles (EV ¼ 14.400, PV ¼ 48.000, CV ¼ 48.000) 0.901

TAN1 Hospital have modern equipment 0.0713
TAN2 Hospital have visually appealing facilities 0.763
TAN3 Hospital staffs have a professional appearance 0.722
482 TAN4 Hospital have visually appealing materials associated with the service 0.792
Reliability (EV ¼ 1.809, PV ¼ 6.032, CV ¼ 54.032) 0.883
REL1 Hospital provide services as promised 0.528
REL2 Hospital staff show sincere interest to solve patients’ problem 0.538
REL3 Hospital perform the service right the first time 0.635
REL4 Hospital perform the services at the time it promises 0.565
REL5 Hospital maintain error-free records 0.694
Responsiveness (EV ¼ 1.683, PV ¼ 5.276, CV ¼ 59.308) 0.811
RES1 Hospital staffs inform me when the services are ready 0.710
RES2 Hospital staffs provide prompt services to their patients 0.608
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

RES3 Hospital staffs are willing to help their patients 0.554

Assurance (EV ¼ 1.415, PV ¼ 3.717, CV ¼ 63.025) 0.807
ASS1 Hospital is capable to handle your medical problems 0.680
ASS2 Doctors can assure you regarding the better treatment 0.855
ASS3 Doctors are well-manner and courteous 0.668
ASS4 Doctors are knowledgeable to answer your questions 0.714
Empathy (EV ¼ 1.357, PV ¼ 1.357, CV ¼ 66.547) 0.886
EMP1 The hospital gives individual attention to the patient 0.702
EMP2 The hospital has convenient consultation hours 0.750
EMP3 Doctors deal with patients in a caring fashion 0.791
EMP4 Hospital staffs have patients’ best interest at heart 0.651
EMP5 Hospital staffs understand patients’ specific needs 0.634
Patient satisfaction (EV ¼ 1.253, PV ¼ 3.176, CV ¼ 69.724) 0.854
PS1 I was satisfied with medical treatment of the hospital 0.865
PS2 I was satisfied with service of the hospital staff 0.860
PS3 I was satisfied with the hospital facilities 0.567
Patient loyalty (EV ¼ 1.133, PV ¼ 2.777, CV ¼ 72.500) 0.884
PL1 Will say positive things about the hospital treatment to my relatives 0.641
PL2 Willing to recommend the hospital treatment to my relatives 0.787
PL3 Will continue to use the hospital service in the future 0.709
PL4 Willing to do further medical treatment at this hospital 0.633
Table II. PL5 Will continue the hospital service even if the cost is higher 0.870
Reliability and Kaiser-Meyer-Olkin (KMO) 0.927
validity Notes: EV, eigenvalue; PV, per cent of variance; CV, cumulative variance

were specifically used to extract factors from 29 items. Hair et al. (2010) and Sharma (1996)
recommend that each item’s factor loading must be more than 0.5. Values above 0.6 are
considered highly significant. In total, 29 items fell into seven sub-variables:
tangibles; reliability; responsiveness; assurance; empathy; patient satisfaction; and
patient loyalty, explaining 72.5 per cent of the total variance. The EFA results also
indicated that 0.53 was the minimum factor loading, which makes all factors acceptable
for further analysis.

Service quality, patient satisfaction and loyalty

We analysed seven dimensions: tangibles; reliability; responsiveness; assurance; empathy;
patient satisfaction; and loyalty using independent samples t-test, ANOVA and
discriminant analysis (Tables III-VI). Independent samples t-tests were used to identify
 the differences or conformance between patient perceptions on five service quality Bangladesh
dimensions, Bangladesh patient satisfaction and loyalty based on gender and marital status healthcare
(Tables III and IV). There is no significant difference between male and female respondents sector
on service quality, patient satisfaction and loyalty (Table III). However,
Table IV indicates there are four significant differences between single and married
respondents. Single patients: tangibles ( µ ¼ 3.7791, df ¼ 173, p ¼ 0.001), reliability
( µ ¼ 3.5674, df ¼ 173, p ¼ 0.017), empathy ( µ ¼ 3.3521, df ¼ 173, p ¼ 0.031) and loyalty 483
( µ ¼ 3.6465, df ¼ 173, p ¼ 0.008) to be better compared to married patients. Jubelirer and
Jividen (2011) observed that single patients are more satisfied with nurse interpersonal skills
(empathy) and hospital access (reliability) compared to married respondents.
According to Hair et al. (2010), ANOVA is a statistical technique for testing the
hypothesis that there is no significant difference between two or more population
means. We used one-way ANOVA to investigate significant differences among age groups.
We observed that there are significant differences among our age groups on tangibles
(F ¼ 3.889, df ¼ 5, p ¼ 0.002), empathy (F ¼ 3.278, df ¼ 5, p ¼ 0.007) and patient loyalty
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

(F ¼ 2.337, df ¼ 5, p ¼ 0.043). The results also indicated that respondents aged 20 and below

Variables Gender n Mean t-value p-value

Tangibles Male 96 3.3644 −1.085 0.279

Female 108 3.5071
Reliability Male 96 3.3255 −1.112 0.268
Female 108 3.4509
Responsiveness Male 96 3.2766 −1.384 0.168
Female 108 3.4371
Assurance Male 96 3.6011 −0.076 0.939
Female 108 3.6085
Empathy Male 96 3.3404 −0.940 0.348
Female 108 3.4509
Satisfaction Male 96 3.2660 −0.239 0.812
Female 108 3.2956 Table III.
Loyalty Male 96 3.3894 −0.220 0.826 Independent samples
Female 108 3.4151 t-test on gender

Variables Marital Status n Mean t-value p-value

Tangibles Single 72 3.7791 3.291 0.001

Married 132 3.2500
Reliability Single 72 3.5674 2.405 0.017
Married 132 3.2424
Responsiveness Single 72 3.4574 1.410 0.160
Married 132 3.2525
Assurance Single 72 3.6919 1.285 0.200
Married 132 3.5379
Empathy Single 72 3.5721 2.172 0.031
Married 132 3.2591
Satisfaction Single 72 3.3566 0.955 0.341
Married 132 3.2121 Table IV.
Loyalty Single 72 3.6465 2.662 0.008 Independent samples
Married 132 3.2758 t-test on marital status
 IJHCQA Variables Groups n Mean F-value p-value
30,5
Tangibles 20 years or below 15 4.2857 3.889 0.002
21-30 years 59 3.3771
31-40 years 53 3.2783
41-50 years 38 3.4671
51-60 years 23 3.1591
484 Above 60 years 16 3.8393
Reliability 20 years or below 15 3.8000 1.925 0.092
21-30 years 59 3.3559
31-40 years 53 3.3132
41-50 years 38 3.3737
51-60 years 23 3.1909
Above 60 years 16 3.8000
Responsiveness 20 years or below 15 3.6667 1.741 0.127
21-30 years 59 3.2373
31-40 years 53 3.3019
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

41-50 years 38 3.4561

51-60 years 23 3.2121
Above 60 years 16 3.7857
Assurance 20 years or below 15 3.9286 1.450 0.208
21-30 years 59 3.4831
31-40 years 53 3.5896
41-50 years 38 3.6842
51-60 years 23 3.5000
Above 60 years 16 3.8036
Empathy 20 years or below 15 3.9714 3.278 0.007
21-30 years 59 3.3186
31-40 years 53 3.3434
41-50 years 38 3.4789
51-60 years 23 3.0091
Above 60 years 16 3.7714
Patient satisfaction 20 years or below 15 3.5000 1.150 0.336
21-30 years 59 3.1412
31-40 years 53 3.2956
41-50 years 38 3.4035
51-60 years 23 3.0909
Above 60 years 16 3.5714
Patient loyalty 20 years or below 15 3.9143 2.337 0.043
21-30 years 59 3.3288
31-40 years 53 3.3585
Table V. 41-50 years 38 3.5158
One-way ANOVA 51-60 years 23 3.0636
tests on age groups Above 60 years 16 3.6000

have better perception towards hospital tangibles ( µ ¼ 4.2857) and also better patient
loyalty ( µ ¼ 3.9143) compared to other age groups (i.e. 21-30 years, 31-40 years, 41-50 years,
51-60 years and above 60 years). They also perceive doctor and nurse empathy to be better
( µ ¼ 3.9714) compared to other age groups (Table V).
Hair et al. (2010) explains that discriminant analysis is an appropriate statistical
technique where the dependent variable is categorical (e.g. male vs female, married vs single
and high vs low) and the independent variables are metric (e.g. five-point Likert scales or
6 and 7 points rating scales). Discriminant analysis can handle either two or more groups.
Our two-group ( public hospital (0) and private hospital (1) discriminant analysis explored
seven dimensions. We found significant difference between public and private hospitals
regarding staff appearance hospital equipment (Wilks’ λ ¼ 0.646, F ¼ 108.699, p ¼ 0.000),
 Dependent variable group means l Group means equality testa
Bangladesh
Group ¼ 0 Group ¼ 1 healthcare
Independent variables Public hospitals (n ¼ 88) Private hospitals (n ¼ 116) Wilks’ λ F-value p-value sector
Tangibles 2.8052 3.9189 0.646 108.699 0.000
Reliability 2.8721 3.7842 0.677 94.417 0.000
Responsiveness 2.8798 3.7251 0.739 70.107 0.000
Assurance 3.2820 3.8487 0.833 39.809 0.000 485
Empathy 2.8302 3.8281 0.643 109.779 0.000 Table VI.
Patient satisfaction 2.7907 3.6520 0.761 62.145 0.000 Discriminant analysis
Patient loyalty 2.9186 3.7684 0.737 70.606 0.000 between public and
Note: aWilks’ λ (U-statistics) and univariate F-ratio with 1 and 198 degrees of freedom private hospitals

reliability (Wilks’ λ ¼ 0.677, F ¼ 94.417, p ¼ 0.000), responsiveness (Wilks’ λ ¼ 0.739,

F ¼ 70.107, p ¼ 0.000), assurance (Wilks’ λ ¼ 0.833, F ¼ 39.809, p ¼ 0.000), empathy (Wilks’
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

λ ¼ 0.643, F ¼ 109.779, p ¼ 0.000), patient satisfaction (Wilks’ λ ¼ 0.761, F ¼ 62.145,

p ¼ 0.000) and patient loyalty (Wilks’ λ ¼ 0.737, F ¼ 70.606, p ¼ 0.000). Discriminant
analysis also indicates that private hospital patients perceive staff appearance and hospital
equipment ( µ ¼ 3.9189), reliability ( µ ¼ 3.7842), responsiveness ( µ ¼ 3.7251), assurance
( µ ¼ 3.8487), empathy ( µ ¼ 3.8281), patient satisfaction ( µ ¼ 3.6520) and patient loyalty
( µ ¼ 3.7684) to be better compared to public hospital patients (Table VI).

Conclusions
Service quality, patient satisfaction and loyalty data can be used in quality management,
thereby enabling service managers to monitor and maintain service quality.
Service providers can better understand how various dimensions and items affect
overall service quality, and to design service delivery processes efficiently. By identifying
service quality strengths and weaknesses, providers can allocate resources to services and
ultimately enhance their service quality. Our findings show significant differences
between single and married patients regarding their perception of tangibles, reliability,
empathy and loyalty. Single patients perceive tangibles, reliability, empathy and loyalty
more favourably compared to married patients. Young patients (20 years or below)
generally have more favourable perceptions than other age groups. We examined the
differences between public and private healthcare sectors regarding service quality
dimensions, patient satisfaction and loyalty. Private hospital patients perceive healthcare
service quality performance more positively compared to public hospital patients. Private
hospital patients are more satisfied and are more loyal compared to the public hospital
patients. Though Bangladesh’s private hospitals managers charge more than their
public hospital counterparts, staff ensure that quality health services are provided. Public
hospital staff fail to provide the best medical services to their patients owing to a poor
healthcare system, corruption and duplication (Chaudhury et al., 2006; Andaleeb, 2000).
To improve healthcare service quality, patient satisfaction and loyalty, public healthcare
providers should design service standards that promote reliable consist services and not
promise more than what they can deliver. Both public and private healthcare
organisations need to focus on the married patient loyalty and their service quality
perceptions. They need to fulfil married patient needs, patient satisfaction and loyalty.
Public healthcare providers need well-planned strategies to strengthen service
quality that improves their patients’ perceptions. Our findings provide insights for
Bangladeshi healthcare organisation and managers in other countries, which will help to
improve service quality towards patient satisfaction and loyalty.
 IJHCQA References
30,5 Al-Borie, H.M. and Sheikh Damanhouri, A.M. (2013), “Patients’ satisfaction of service quality in
Saudi hospitals: a SERVQUAL analysis”, International Journal of Health Care Quality
Assurance, Vol. 26 No. 1, pp. 20-30.
Aliman, N.K. and Mohamad, W.N. (2016), “Linking service quality, patients’ satisfaction and behavioral
intentions: an investigation on private healthcare in Malaysia”, Procedia-Social and Behavioral
486 Sciences, Vol. 224, pp. 141-148.
Allen, M. (2013), “How many die from medical mistakes in US hospitals?”, ProPublica, National Public
Radio (NPR), available at: www.npr.org/blogs/health/2013/09/20/224507654/how-many-die-
from-medical-mistakes-in-u-s-hospitals (accessed 7 July 2016).
Anbori, A., Ghani, S.N., Yadav, H., Daher, A.M. and Su, T.T. (2010), “Patient satisfaction and loyalty to
the private hospitals in Sana’a, Yemen”, International Journal for Quality in Health Care, Vol. 22
No. 4, pp. 310-315.
Andaleeb, S.S. (2000), “Public and private hospitals in Bangladesh: service quality and predictors of
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

hospital choice”, Health Policy and Planning, Vol. 15 No. 1, pp. 95-102.
Andaleeb, S.S. (2001), “Service quality perceptions and patient satisfaction: a study of hospitals in a
developing country”, Social Science & Medicine, Vol. 52 No. 9, pp. 1359-1370.
Azizan, N.A. and Mohamed, B. (2013), “The effects of perceived service quality on patient satisfaction
at a public hospital in state of Pahang, Malaysia”, Asian Journal of Social Sciences & Humanities,
Vol. 2 No. 3, pp. 307-323.
Bateson, J.E.G. and Hoffman, K.D. (1991), Managing Services Marketing: Text and Readings,
Dryden Press, London.
Butt, M.M. and Run, E.C. (2010), “Private healthcare quality: applying a SERVQUAL model”,
International Journal of Health Care Quality Assurance, Vol. 23 No. 7, pp. 658-673.
Buyukozkan, G., Cifci, G. and Guleryuz, S. (2011), “Strategic analysis of healthcare service quality using
fuzzy AHP methodology”, Expert Systems with Applications, Vol. 38 No. 8, pp. 9407-9424.
Calisir, F., Bayraktaroglu, A.E., Gumussoy, C.A. and Kaya, B. (2014), “Effects of service quality
dimensions including usability on perceived overall quality, customer satisfaction, and return
intention in different hospital types”, International Journal of Advanced Operations
Management, Vol. 6 No. 4, pp. 309-323.
Caruana, A.M. and Berthon, P.R. (2002), “Service quality and satisfaction and the mediating role of
value”, European Journal of Marketing, Vol. 34 Nos 11/12, pp. 1338-1352.
Chaudhury, H., Mahmood, A. and Valente, M. (2006), “Nurses’ perception of single-occupancy versus
multioccupancy rooms in acute care environments: an exploratory comparative assessment”,
Applied Nursing Research, Vol. 19 No. 3, pp. 118-125.
D’Cunha, S. and Suresh, S. (2015), “The measurement of service quality in healthcare: a study in a
selected hospital”, International Journal of Health Sciences and Research, Vol. 5 No. 7,
pp. 333-345.
Dedeke, A. (2003), “Service quality: a fulfillment-oriented and interactions-centred approach”,
Managing Service Quality, Vol. 13 No. 4, pp. 276-289.
Fenton, J.J., Jerant, A.F., Bertakis, K.D. and Franks, P. (2012), “The cost of satisfaction: a national study
of patient satisfaction, health care utilization, expenditures, and mortality”, Archives of Internal
Medicine, Vol. 172 No. 5, pp. 405-411.
Fitzpatrick, R. (1991), “Surveys of patient satisfaction: i – important general considerations”, British
Medical Journal, Vol. 302 No. 6781, pp. 887-889.
Fornell, C. (1992), “A national satisfaction barometer: the Swedish experience”, Journal of Marketing,
Vol. 56 No. 1, pp. 6-21.
Gronroos, C. (1990), Service Management and Marketing: Managing the Moments of Truth in Service
Competition, Lexington Books, Lexington, MA.
 Gummesson, E. (1992), “Quality dimensions: what to measure in service organization”, in Swartz, T.A., Bangladesh
Brown, D.E. and Brown, S.W. (Eds), Advances in Services Marketing and Management, healthcare
JAI Press, Greenwich, CT, pp. 177-205.
sector
Hair, J.F., Black, W.C., Babin, B.J. and Anderson, R.E. (2010), Multivariate Data Analysis: A Global
Perspective, 7th ed., Pearson, NJ.
Hu, H.-Y., Cheng, C.-C., Chiu, S.-I. and Hong, F.-Y. (2011), “A study of customer satisfaction, customer
loyalty and quality attributes in Taiwan’s medical service industry”, African Journal of Business 487
Management, Vol. 5 No. 1, pp. 187-195.
Jubelirer, S. and Jividen, V. (2011), “A study of in-patient oncology satisfaction”, ASCO Annual Meeting
Proceedings, Vol. 29 No. 15, p. e16629.
Kitapci, O., Akdogan, C. and Dortyol, İ.T. (2014), “The impact of service quality dimensions on patient
satisfaction, repurchase intentions and word-of-mouth communication in the public healthcare
industry”, Procedia-Social and Behavioral Sciences, Vol. 148, pp. 161-169.
Kondasani, R.K.R. and Panda, R.K. (2015), “Customer perceived service quality, satisfaction and loyalty
in Indian private healthcare”, International Journal of Health Care Quality Assurance, Vol. 28 No.
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

5, pp. 452-467.
Kotler, P., Bowen, J. and Makens, J.C. (2006), Marketing for Hospitality and Tourism, Pearson Prentice
Hall, NJ.
Kuder, G.F. and Richardson, M.W. (1937), “The theory of the estimation of test reliability”,
Psychometrika, Vol. 2 No. 3, pp. 151-160.
Leiter, M.P., Harvie, P. and Frizzell, C. (1998), “The correspondence of patient satisfaction and nurse
burnout”, Social Science & Medicine, Vol. 47 No. 10, pp. 1611-1617.
McDonald, I. (2013), “Hospital medical errors now the third leading cause of death in the US”, Fierce
Healthcare, available at: www.fiercehealthcare.com/ story/hospital-medical-errors-third-leading-
cause-death-dispute-to-err-is-human-report/2013-09-20 (accessed 12 July 2016).
Manaf, N.H.A. and Nooi, P.S. (2009), “Patient satisfaction as an indicator of service quality in Malaysian
public hospitals”, Asian Journal on Quality, Vol. 10 No. 1, pp. 77-87.
Manaf, N.H.A., Mohd, D. and Abdullah, K. (2012), “Development and validation of patient satisfaction
instrument”, Leadership in Health Services, Vol. 25 No. 1, pp. 27-38.
Mortazavi, S., Kazemi, M., Shirazi, A. and Aziz-Abadi, A. (2009), “The relationships between patient
satisfaction and loyalty in the private hospital industry”, Iranian Journal of Public Health, Vol. 38
No. 3, pp. 60-69.
Orel, F.D. and Kara, A. (2014), “Supermarket self-checkout service quality, customer satisfaction, and
loyalty: empirical evidence from an emerging market”, Journal of Retailing and Consumer
Services, Vol. 21 No. 2, pp. 118-129.
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, Vol. 49 No. 4, pp. 41-50.
Parasuraman, A., Zeithaml, V.A. and Berry, L.L. (1988), “SERVQUAL: a multiple-item scale for
measuring customer perceptions of service quality”, Journal of Retailing, Vol. 64 No. 1, pp. 12-40.
Park, G.W., Kim, Y., Park, K. and Agarwal, A. (2016), “Patient-centric quality assessment framework
for healthcare services”, Technological Forecasting and Social Change, Vol. 113, pp. 468-474.
Rad, N.F., Som, A.P.M. and Zainuddin, Y. (2010), “Service quality and patients’ satisfaction in medical
tourism”, World Applied Sciences Journal, Vol. 10 No. 1, pp. 24-30.
Roberge, D., Beaulieu, M.-D., Haddad, S., Lebeau, R. and Pineault, R. (2001), “Loyalty to the regular care
provider: patients’ and physicians’ views”, Family Practice, Vol. 18 No. 1, pp. 53-59.
Shabbir, A., Malik, S.A. and Malik, S.A. (2016), “Measuring patients’ healthcare service quality
perceptions, satisfaction, and loyalty in public and private sector hospitals in Pakistan”,
International Journal of Quality & Reliability Management, Vol. 33 No. 5, pp. 538-557.
Sharma, S. (1996), Applied Multivariate Techniques, John Wiley & Sons, New York, NY.
 IJHCQA Shi, Y., Prentice, C. and He, W. (2014), “Linking service quality, customer satisfaction and loyalty in
30,5 casinos, does membership matter?”, International Journal of Hospitality Management, Vol. 40,
pp. 81-91.
Subramanian, N., Gunasekaran, A., Yu, J., Cheng, J. and Ning, K. (2014), “Customer satisfaction and
competitiveness in the Chinese E-retailing: structural equation modeling (SEM) approach to
identify the role of quality factors”, Expert Systems with Applications, Vol. 41 No. 1, pp. 69-80.
Zarei, A., Arab, M., Froushani, A.R., Rashidian, A. and Tabatabaei, S.M.G. (2012), “Service quality of
488 private hospitals: the Iranian patients’ perspective”, BMC Health Services Research, Vol. 12 No. 1,
pp. 1-7.
Zarei, E., Daneshkohan, A., Pouragha, B., Marzban, S. and Arab, M. (2015), “An empirical study of the
impact of service quality on patient satisfaction in private hospitals, Iran”, Global Journal of
Health Science, Vol. 7 No. 1, pp. 1-9.

Corresponding author
Downloaded by Doctor Selim Ahmed At 08:53 13 June 2017 (PT)

Selim Ahmed can be contacted at: selim.research@gmail.com

For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com

View publication stats