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Healthcare System and Quality in KSA:

In the Kingdom of Saudi Arabia, the health sector, like other sectors, is under full

control of Ministry of health (MOH), although there are also allowed functioning of private

sector hospitals. The Government of Saudi Arabia keeps allocating sufficient funds for the

promotion of the healthcare sector and also encourages the private sector operators to

enhance the healthcare opportunities and flourish service of humanity in this sector in the

Kingdom. Private hospitals will carry on performing an even more vital and key role within

the Kingdom. There are certain diseases which are specifically related to lifestyle of the

residents of the Kingdom which comprise diabetes, hypertension, obesity, heart

(cardiovascular) and kidney (dialyses) and these have generated new prospects for expansion

and the private sector is progressively projected to be a key role player and contributor of

main providers for these sections. (Colliers International, (2012) Kingdom of Saudi Arabia:

Healthcare overview, First Quarter, 2012)

As far as the deliverance of healthcare in the Kingdom of Saudi Arabia and around

the world is concerned, it keeps operating to go forward as the requirements of healthcare

provider become progressively more multifaceted. Inclinations, advancements and day to day

progression requires investors and operators of healthcare services to adapt exigent

resolutions to meet modern challenges in the era of quality, standardisation and excellence.

Owing to well-built development essentials coupled with the growing population and

regulatory transformations and amendments, the sector is projected to practice vigorous

growth in the predictable future (Colliers International, 2012).

In the light of prospective needs and in order to maintain quality in healthcare sector,

the current set-up is covered by various insurance companies and almost 25 companies listed

on the Saudi Stock Exchange and are hence driven by cost versus quality. Unless a fixed

regulation is initiated to supervise pricing, healthcare affording and quality of care in private

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hospitals will persist to suffer lower profit margins and collection holds up which will

outcome in poorer quality of care (Colliers International, 2012).

Pertaining to quality of care in healthcare, later on, contrary to observation of Colliers

International, 2012, Haya Al- Fozan, in her cross-sectional descriptive design study

conducted in 2013, observed that overall mean satisfaction score was 4.45 out of 5. This data

was collected through questionnaire and 302 participants were patients and family caregivers

of National Guards hospitals across the Kingdom. The high level of satisfaction was reported

by the participants in the domain of respecting religion & culture, maintaining privacy and

confidentiality, communication and professionalism (Haya Al- Fozan, 2013).

On the other hand, the least satisfactory areas identified by the participants in her

study were: instructions at the time of discharge from the hospital and keep informing

patients family with various conditions and changes in patients condition during treatment

though it seems contradictory to the point of high satisfaction in communication and

professionalism. In her conclusion of the study, she concludes in these words: This reflected

that the Saudi Nurses are able to deliver culturally appropriate high quality care sharing the

Arabic language of their patients (Haya Al- Fozan, 2013).

Discussing cultural aspect of nursing quality in KSA, Almutairi and McCarthy (2012)

in their study A multicultural nursing workforce and cultural perspectives in Saudi Arabia:

An overview observe that Saudi hospitals are multicultural in their composition as around

67% of nurses are expatriates who need to enhance their cultural competence in order to

improve communication and understanding of cultural implications. They also affirm, In

this scenario, a lack of knowledge of Saudi culture among nurses can lead to cultural conflicts

and misunderstanding of some of the behaviours and practices of the indigenous Saudi

people (Almutairi and McCarthy (2012). Concluding their study, they remarked that better

comprehension of Saudi culture and religious practices during health care delivery by

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expatriate nurses can assist them in building a strong affiliating relationship with their

patients and this will also help in maintain quality care by avoiding impending cultural

clashes (Almutairi and McCarthy (2012).

Definition of Service Quality

Generally, service quality has been elaborated as the net difference between clients

assumptions with reference to standard of service expected and the actual level of it offered

by administration or service provider (Gronroos, 2001; Parasuraman, Zeithamal, and Berry,

1988). In some earlier studies, service quality has been alluded to as the degree to which an

administration lives up to clients' needs or desires (Lewis and Mitchell, 1990; Dotchin and

Oakland, 1994). It is additionally conceptualized as the consumers general impression of the

relative inadequacy or prevalence of the service (Zeithaml, Berry, and Parasuraman, 1990).

Parasuraman et al. (1988), in their study, evaluated five extents of service quality (Viz.

reliability, responsiveness, assurance, empathy, and tangibles) that connection particular

administration attributes to consumers' desires.

(a) Tangibles-physical offices, equipments, appliances and appearance of work force;

(b) Empathy- considering and caring individualized concern;

(c) Assurance-learning and affability of representatives and their capacity to pass on trust and


(d) Reliability-capacity to play out the guaranteed service constantly and precisely; and

(e) Responsiveness-readiness to initiate and accommodate prompt services for clients.

Gaps Scenario in Service Quality:

Gap 1: The distinction between service perspective of what clients expect and what clients

truly do anticipate.

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Gap 2: The contrast between service observations and service quality details - the

standardised gap.

Gap 3: The result of functional vagueness and divergence, poor employee-job fit and poor

technology-job fit, unfortunate managerial power systems, lack of supposed control and

deficiency of teamwork.

Gap 4: The contrast between service oriented observations and service related quality details

the standardised gap.

Gap 5: The contrast between what clients expect from administration and what they really

get, desires are comprised of past understanding, informal exchange and needs of clients

estimation is on the premise of two arrangements of articulations in gatherings as per the five

key service linking measurements.

Measurement of Service Quality

In the light of these gaps, patients get different services of therapeutic care and judge

the nature of services afforded to them (Choi et al., 2004). The service quality has two

measurements: (a) a specialized measurement i.e., what service has been provided and (b) a

procedure/practical measurement i.e., how the service has been provided (Grnroos 2000).

The first one related quantitatively and the other one is related qualitatively. Parasuraman, et

al (1988) recommended a broadly utilized model known as SERVQUAL for assessing the

prevalence of the service quality. In the SERVQUAL model, Parasuraman et. al.

distinguished the gap between the recognition and desire of purchasers on the premise of five

characteristics viz. unwavering quality, responsiveness, confirmation, compassion and

physical assets to quantify buyer fulfillment in the light of service quality (Parasuraman A.,

Berry L,1988).

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As regards to service quality, patient satisfaction studies are utilised to look at the

nature of the service quality offered by the healthcare providers (Lin and Kelly 1995). Much

confirmation has been recorded for the service quality to fulfillment interface in various

customer fulfillment research studies incorporating those in the domain of healthcare

marketing (Brady and Robertson 2001; Gotlieb, Grewal, and Brown 1994; Rust and Oliver

1994; Andaleeb 2001). The Consumer Assessment of Healthcare Providers and Systems

(CAHPS) is one of the instruments connected for measuring service quality in the field of

healthcare. As indicated by Agency for Healthcare Research and Quality (2009), CAHPS is a

universally approved instrument or tool to be implemented on a particular prospect of contact

between the patient and healthcare service professionals. CAHPS concentrates on surveying

the genuine experience of patients during healthcare process instead of measuring patients'

observation. According to the CAHPS philosophy, patients are inquired as to whether they

get a particular nature of care with quality.


Measuring service quality is troublesome because of its remarkable attributes:

Impalpability, heterogeneity, indivisibility and perishability (Bateson, 1995). Service quality

is connected to the ideas of observations and desires (Parasuraman et al., 1985, 1988; Lewis

and Mitchell, 1990). Clients' impression of service quality emerges from a correlation of their

before-service expectations and what level of service they actually receive. The service will

be viewed as astounding, if observations surpass desires; it will be viewed as great or

sufficient, if it parallels the desires; the service will be classed as terrible, poor or lacking, if it

doesn't meet expectations at all or quite opposite to expectations (Vzquez et al., 2001).

In light of this viewpoint, Parasuraman et al. (1988) built up a scale for measuring

service quality, which is generally known as SERVQUAL. This scale operationalizes service

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quality by ascertaining the distinction amongst desires and discernments, assessing both in

connection to the 22 things that speak to five service quality measurements known as

'physical assets', 'unwavering quality', 'responsiveness', "affirmation" and 'sympathy'. The

SERVQUAL scale has been tried or potentially adjusted in an extraordinary number of

studies directed in different service settings, social settings and geographic areas like the

nature of service offered by a hospital or a clinic (Babakus and Mangold, 1989), a CPA firm

(Bojanic, 1991), a dental school/clinic, business college or placement institute, and intense

care clinic (Carman, 1990), pesticide control business, cleaning, and fast food (Cronin and

Taylor, 1992), banks and financial institutions (Cronin and Taylor, 1992; Spreng and Singh,

1993; Sharma and Mehta, 2004) and mega malls and departmental stores (Finn and Lamb,


All these studies do not conform to the element structure proposed by Parasuraman et

al. (1988). The universality or inclusiveness of the scale and its measurements has always

been debatable and likely to face criticism (Lapierre et al., 1996) and it is proposed that this

scale requires customization to the particular service segment in which they are implemented.

In the time of globalization, rivalry has turned into a key issue in a wide range of industry and

also in public service sector. Literature review of past studies concluded in the field proposes

that there are two significant points that must be considered while evaluating service quality

which are: a) patient satisfaction and b) perceived service quality. Both these should be

measured together for the solidity of a health care organization in a competitive atmosphere.

Researchers in this field have recommended distinctive models and strategies for measuring

persistent satisfaction considering service quality as one of the precursors. Distinctive literary

works sum up and declare that SERVQUAL is a famous model for measuring service quality.

SERVQUAL is an institutionalized and solid instrument that recognizes five distinct

measurements of service quality and approves those measurements in various service

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circumstances (Rohini and Mahadevappa, 2006). Parasuraman (1988), in their

SERVQUAL demonstrate, recognized five measurements viz. responsiveness, dependability,

affirmation, physical assets and compassion on the premise of which clients' desires and

observations are measured. They clarified all the previously mentioned measurements with

the assistance of twenty two proclamations that have been distinguished as qualities making

those five measurements (Parasuraman et. al., 1988, Bhattacherjee, 2010). Babakus and

Mangold (1992) distinguished SERVQUAL as a solid and legitimate model in the clinical


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