■ Indian Journal of Commerce & Management Studies ■ ISSN – 2229-5674

AN ASSESSMENT OF SERVICE QUALITY OF PRIVATE HOSPITALS IN

PAKISTAN: A PATIENT PERSPECTIVE

Syed Muhammad Irfan

COMSATS Institute of Information Technology,
Lahore, Pakistan.

Aamir Ijaz
Institute of Quality and Technology Management,
University of the Punjab, Lahore, Pakistan.

Saman Shahbaz
Institute of Quality and Technology Management,
University of the Punjab, Lahore, Pakistan.

ABSTRACT
Competitive environment among the industrial and service sector has also influenced the
healthcare especially hospitals in private sector. There is a tremendous growth in private
hospitals during the last couple of years, due to inadequate healthcare facilities available at
public hospitals to meet the 169.6 million people of Pakistan. This factor had provided an
opportunity for the private hospitals to fill this gap by providing better healthcare services
to the patients that leads to patient satisfaction. This paper aimed to evaluate the service
quality delivered by the private hospitals in Pakistan based on patient perception. A
questionnaire is developed based on SERVQUAL model comprised of 22 variables
representing five service quality dimensions; empathy, tangible, assurance, timeliness and
responsiveness. The statistical analysis of this study provides an insight that service
quality of the private hospitals meets patient satisfaction.

Keywords : Service Quality, Private Hospitals, Patient Satisfaction, Pakistan

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INTRODUCTION
Competitive environment among the industrial and service sector has also created a competitive
environment among the healthcare sector especially, the hospitals operated in private sector of Pakistan.
This competitive environment among the healthcare organizations emphasized that improved service
quality is the only mean to acquire the competitive position in the market (Lim and Tang, 2000). Thus
Quality is the only key factor that helps the customer to distinguish between the superiority and inferiority
of services/products. So, healthcare organizations aimed to gain a competitive advantage by maintaining
its service quality and increased patient satisfaction which contributes a critical role in the success (Taylor,
1994). Earlier studies proved that organizations delivering superior quality of services are successful in
gaining customer satisfaction, building organizational image, cost reduction and hence increased their
profit (Rust and Zahorik, 1993; Berry et al., 1989; Cronin et al., 2000; Reichheld and Sasser, 1990; Kang
and James, 2004; Yoon and Suh, 2004).
As service quality is the innermost factor for evaluating customer satisfaction and this issue is at the
horizon of academic research and literature for the last couple of decades (Bei & Shang, 2006; Spreng &
Mackoy, 1996; Wisniewski, 2001) and especially in Pakistan for the last one decade. So the
organizations providing high quality of services to their customers are successful in increasing customer
satisfaction, loyalty, retention, and reduced complaints (Bitner, 1990; Headley & Miller, 1993; Zeithaml
et al., 1996; Magi & Julander, 1996; Levesque & McDougall, 1996; Danaher, 1997). Today the customers
are well informed before utilizing any service and have alternatives due to the rising standards of services
which caused to increased customer expectations and more conscious about services they perceive (Lim
and Tang, 2000). A patient requires detailed information before availing any service by a particular
healthcare organization and in case of dissatisfaction they never hesitate to switch to other service
provider (Ramsaran & Roshee, 2008).
In Pakistan it has been observed that hospitals in private sector like the other service sector has realized
that service quality and customer satisfaction is the strategic advantage for their success. This strategic
significance and importance of service quality has been broadly recognized by the organizaitons (Smith,
2000) and patient satisfaction in health care is evident in more specialized healthcare literature (Cronin
and Taylor, 1994). Customer (patients) perceptions and the key determinants that reflects the service
quality parameters, plays a significant role to patients choice in selecting a hospital or availing services in
terms of medical treatment (Lim and Tang, 2000). To achieve excellence in service delivery, hospitals
have to strive for zero detection and retain each customer to gain profitability (Reichheld and Sasser,
1990) and it requires continuous efforts for service quality improvement (Lim and Tang, 2000). Therefore,
patient’s perceptions about the service provided by a particular healthcare organization also effects the
image and profitability of the hospital (Donabedian, 1996; Williams & Calnan, 1991) and it also
significantly effects the patient behavior in terms of patients loyalty and word-of-mouth (Andaleeb, 2001).
The objective of this research study is to examine the service quality of private hospitals in Pakistan based
on patient perceptions. The healthcare facilities in public sector are inadequate to meet the healthcare
requirement of 169.6 million people of Pakistan. Available healthcare facilities in public sector are not
making much effort to improve the level of service quality due to a number of issues. This factor had
provided an opportunity for the private hospitals to fill this gap by developing facilities that meet customer
expectations and perceptions. Uniqueness of this study is that there were limited studies conducted on this
topic, and this study will help to examine the current status of services delivered to the customers by the
private hospitals in Pakistan.
LITERATURE REVIEW
Service Quality
In some earlier studies on service quality, it is considered as to what extent a service meet the customer’s
needs or wants (Lewis & Mitchell, 1990; Dotchin & Oakland, 1994). Some conceptualized service quality

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■ Indian Journal of Commerce & Management Studies ■ ISSN – 2229-5674

as the consumer’s overall impression about the superiority or inferiority of the services they received
(Zeithaml, Berry, & Parasuraman, 1990). Generally, service quality is assumed as the difference between
customer expectations and the perceptions about the services being received by customer from the service
provider (Grönroos, 2001; Parasuraman, Zeithaml, & Berry, 1988).
Services are intangible in nature and thus the quality of the services delivered by the service provider is
difficult to measure and thus it is an elusive and distinct construct. Similarly, service quality of hospitals is
also difficult to define like other services however, it can be defined from numerous perspective like, “The
ability to satisfy the needs and expectations of the customer”, (Bergman and Klefsjo, 1994, p. 16) or “The
totality of features and characteristics of a product or service that bear on its ability to satisfy given needs”,
(Evans and Lindsay, 1996, p. 15). Lewis and Booms (1983) considered it to be a comparison between
service quality and customer expectations. Parasuraman et al. (1985, p-42) stated that service quality is
“perceived by customers and stems from a comparison of their expectations of the services they will
receive with their perceptions of the performance of the service provider”.
Service Quality Model
The development of the instrument to measure the service quality was an important issue. First
Parasuraman et al. (1985) suggested that service quality measurement is a multi-dimensional process. He
suggested 10 dimensions of service quality on the basis of information collected from 12 focus group
interview with the consumers; he concluded that consumers or customer can evaluate service quality by
comparing expectations with perceptions on the basis of the following ten dimensions:
1. Tangibles
2. Responsiveness
3. Access
4. Reliability
5. Communication
6. Credibility
7. Security
8. Competence
9. Courtesy
10. Understanding/knowing customers
There were some other viewpoints about to measure the service quality like Grönroos (1982) and
characterized service quality in two dimensions; first is functional aspect mean ‘how’ services are provided
to customers and the second is technical aspect mean ‘what’ services is provided. Whereas, Sachdev and
Verma (2004) suggested that service quality may be measured in terms of customer expectations and
perceptions, customer attitude and their satisfaction about the services they received.
Parasuraman et al. (1985) first came with a comprehensive model and suggested that service quality is
based on customer perception and it is influenced by five gaps. Difference between customer expectations
and management perceptions of customer perceptions is represented in GAP 1 and the management
perceptions of customer expectations and the translation of these perceptions in to service quality
specifications is expressed as GAP 2, the difference between the actual deliverance of services by the
frontline service personnel on daily basis and the specifications set by the management is said to be GAP
3, GAP 4 is the difference between the delivery and what is promised in external communication to the
consumers and finally GAP 5 is the difference between customer expectations and perceptions and is also
known as perceived service quality (Parasuraman et al., 1985). This model is known as SERVQUAL and
it was based on gap 5, which includes ten dimensions and these dimensions were merged into five generic
service quality dimensions comprise of 22 items. These five dimensions are: empathy, reliability,
responsiveness, tangibles and assurance.
SERVQUAL instrument has been widely used around the globe in almost all the service industries, like
healthcare (Carman, 1990; Headley and Miller, 1993; Lam, 1997; Kilbourne et al., 2004), banking (Mels

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et al., 1997; Lam, 2002), and library services (Cook and Thompson, 2000). It is evident from the literature
that ‘SERVQUAL’ is widely used in healthcare to measure the service quality and in health care literature
it is the most reliable and valid measurement of perceived service quality (Reidenbach & -Smallwood,
1990; Babakus & Mangold, 1992; Vandamme & Leunis, 1993; Scardina, 1994; Taylor & Cronin, 1994;
Lam, 1997; Wong, 2002; Kilbourne et al., 2004). However, “SERVQUAL” model which was originally
developed by Parasuraman et al. (1985, 1988) and later refined this model in 1991 and 1994 is perhaps the
most commonly used to measure service quality (Riadh Lidhari, 2009).

HEALTH SECTOR OF PAKISTAN

Pakistan is the world sixth largest populated country in the world with an estimated 169.9 million at the
end of June 2009, with high growth rate of 2.05%. According to constitution of people republic of
Pakistan, providing best health care facilities to the people is the responsibility of Federal Government and
the provincial Government and they are also responsible for planning and devising the national health
policies. In Pakistan a larger proportion of people are living in rural areas, where health care facilities are
inadequate for the people. Majority of the health care facilities are located in the urban areas especially in
major cities of Pakistan and it advantaged by a few number of city dwellers (Arzoo & Hajra, 2005).
According to economic survey of Pakistan (2009), total number of registered doctors in the country is
139,555; total number of dentists 9,822 and registered nurses are 69,313 shows in the graph below.

Figure 1: Registered human resource for healthcare

REGISTERD DOCTORS
REGISTERED DENTIST
REGISTERED NURSES

125,000

100,000
Value

75,000
139,555
133,984
128,093

50,000

69,313
65,387
62,651

25,000

8,215 9,013 9,822

0
2007-2008 2008-2009 2009-2010
year

Source: Economic Survey of Pakistan 2009-2010

Similarly, from the 169.9 million of the total population of Pakistan, currently population to doctor ratio is
1183:1 mean one doctor is available to serve 1,183 persons, population to dentist ratio is 16,914:1, and
patient per bed ratio is 1592:1 and is shown in graph below.

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■ Indian Journal of Commerce & Management Studies ■ ISSN – 2229-5674

Figure 2: Population vs. healthcare facilities

PATIENT PER DOCTOR

PATIENT PER DENTIST
20,000
PATIENT PER BED

15,000
Value

10,000
19,417
18,010
16,914

5,000

1,245 1,544 1,575 1,592

1,212 1,183
0
2007-2008 2008-2009 2009-2010
year

Source: Economic Survey of Pakistan 2009-2010

Currently, the health care units to serve the patients in the public sector comprised of hospitals,
dispensaries, basic health units, rural health centers are 968, 4,813; 5,345; 572 respectively and it is shown
in the graph below.
Figure 3: Healthcare units in Pakistan

Therefore, the above statistics provides insufficient healthcare services to meet the 169.6 million people of
Pakistan provided by the government. The above population and doctor proportion also effect the smooth
functioning of the available health facilities in Pakistan and it create problems for both the patients and
hospitals management. It is evident that the numbers of public hospitals are inadequate to meet the
healthcare requirements of the people and due to this factor public hospitals are not able to provide quality
of healthcare services to the patients. The private hospitals came with the objective to fill the gap by
providing superior services to the people. The following five hypotheses were developed:
H1: There exists a positive relationship between empathy and service quality
H2: There exists a positive relationship between tangible and service quality
H3: There exist a positive relationship between assurance and service quality
H4: There exist a positive relationship between timeliness and service quality
H5: There exist a positive relationship between responsiveness and service quality

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METHODOLOGY
This research was conducted at local level, the second biggest and 2nd largest populated city, Lahore, of
Pakistan. A questionnaire was developed using ‘SERVQUAL’ instrument consisting of 22 items
representing five service quality dimensions empathy, assurance, tangible, timeliness and responsiveness.
These service quality dimensions are considered as construct: empathy contains 4 items, assurance
constrains 6 items, tangible contains 6 items, timeliness contains 3 items and responsiveness contains 3
items.
The target population of this study was the employees working at officer level in the service organizations
and availing healthcare services including consultation and inpatient from the best private hospitals in the
city, Lahore of Pakistan. A total 375 questionnaire was send to the different service organizations and total
320 questionnaires were returned back, which represents an effective response rate of 85.3%. Five-point
Likert Scale from strongly disagrees to the strongly agrees was used for empirical analysis. The coding of
the Likert scale was made as [1 = strongly disagree], [2 = disagree], [3 = neither agree nor disagree], [4 =
agree], [5 = strongly agree]. The descriptive statistics of the respondents of this study is given below.
Table 1: Freque ncy Distribution of Gender

Cumulative
Frequency Percent Valid Percent Percent

Valid Ma le 218 68.1 68.1 68.1

Female 102 31.9 31.9 100.0

Total 320 100.0 100.0

Table.1 shows the frequency distribution of the gender comprised of male and female. There were total
320 participants in this study and 218 participants were male representing 68.1 % of the total population
and 102 participants were female representing 31.9% of the total population. Table 2 shows the frequency
distribution of qualification of the respondent. Out of 320 respondents, 22.5% of the respondents were
graduates, 49.4% of the respondents were having masters’ degree and 28.1% were MS.
Table 2: Frequency Distribution of Qua lification

Cumulative
Frequency Percent Valid Percent Percent

Valid Graduate 72 2 2.5 22.5 22.5

Master 158 4 9.4 49.4 71.9

MS 90 2 8.1 28.1 100.0

Total 320 10 0.0 100.0

STATISTICAL ANALYSIS
To measure the service quality of the private hospitals, data was analyzed using SPSS 16.0 and AMOS
16.0 was used. Structural equation modeling (SEM) is most frequently and commonly used method to test
the validity of the models that are path analytic with mediating variables and it includes latent variables
(Agresti, 2002; Hair et al., 2008; Luna-Arocas & Camps, 2008) and it is also a powerful tool in
investigating causal relationships between categorical variables (Bollen, 1989; Bollen & Long, 1993;
Mels, 2004). Due to this reason SEM is used in this study to analyze the results and hypothesis.

RESULTS
The theoretical service quality model is presented in Figure 1, using AMOS 16.0 for windows. A
significant Chi-square having p-value less than 0.05 and the value of normed-chi-square between 1 and 3
indicates that proposed model is providing a sufficient presentation of the relationship among the studied

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■ Indian Journal of Commerce & Management Studies ■ ISSN – 2229-5674

variables (Seo, Han, & Lee, 2005). The goodness of fit indices (GFI) (Bentrler, 1990) having values
greater than 0.70 in case of complex models (Judge & Hulin, 1993), the comparative fit index (CFI) traces
the relative improvement of the assessed model over a null where observed variables are assumed
uncorrelated and it value from 0 .00 to 1.00 and the value close to zero indicates a well fit model and its
value close to 1.00 indicate a very good fit (Bentler, 1990; Hu & Bentler, 1999). Root mean squared error
of approximation (RMSEA) (Bowne and Cudeck, 1993) and for RMSEA a value of less than 0.05
indicates a close fit and value less than 0.08 represents a good model (Browne & Cudeck, 1993; Byrne,
2001).
Table 3, shows the variable used in the study and their brief description, factor loading and measurement
coefficient Cronbach alpha of each construct. To check the validity of the instrument is another important
factor during statistical analysis. According to Gatewood and Field (1990), reliability of the instrument
helps to provides consistency in the results and the Cronbach alpha is used to measure the reliability of the
data (Green et al., 2000). Twenty two items of this study has provided acceptable values of Cronbach
alpha (0.911), as a value of alpha greater than 0.70 is acceptable (Nunnally, 1978).
Secondly, the reliability of the individual constructs is also calculated and it provides us acceptable values
as mentioned by Nunnally (1978). The first construct of the study was empathy comprises of 4 items and
the measurement coefficient Cronbach alpha for this construct is has (0.80) providing an acceptable value.
The second construct is tangible, contains 6 items and the measurement coefficient Cronbach alpha for
this construct is (0.76) providing an acceptable value of alpha. The third construct was assurance contains
6 items and the measurement coefficient Cronbach alpha for this construct is (0.80), fourth construct
contains 3 items and the value of Cronbach alpha is (0.72) and fifth construct contains 3 items having
Cronbach alpha (0.74). Therefore all the constructs used in this study have an acceptable value of alpha.

TABLE 3: DIMENSIONS OF THE SERVQUAL INSTRUMENT

Factor
Variables and Constructs
Loading
Empathy (α =0.80)
PREMP1 Doctors have genuine concern about patients 0.56
PREMP2 Doctor care their patients 0.61
PREMP3 Staff and nurses care the patient 0.59
PREMP4 Hospital put their best efforts to provide comfort 0.65
to patients
Tangible (α=0.76)
PRTNG1 Hygienic conditions at hospital 0.58
PRTNG2 Waiting facilities for attendants and patients 0.51
PRTNG3 Healthy environment at hospital 0.50
PRTNG4 Cleanliness of toilets/bathrooms 0.64
PRTNG5 Cleanliness in wards/rooms (sheets, floor) 0.68
PRTNG6 Lab and pharmacy facilities within the hospital 0.53
Assurance (α=0.80)
PRASS1 Doctor’s expertise and skills 0.49
PRASS2 Thorough investigations of the patient 0.66
PRASS3 Doctors almost make right diagnoses 0.66
PRASS4 Doctors go for expert opinion in critical cases 0.58
PRASS5 Accuracy in lab reports 0.52
PRASS6 Special attention to emergency patients 0.56

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Timeliness (α=0.72)
PRTIM1 Patients are observed according to appointment 0.47
PRTIM2 In time delivery of reports/services 0.64
PRTIM3 Doctors/Staff observe the promised time 0.52
Responsiveness (α =0.74)
PRRES1 Doctors/staff efficiently respond to the patients 0.61
PRRES2 Doctors/Staff are willing to help/facilitate the 0.50
patients
PRRES3 Feedback mechanism 0.58
Model fit summary of the variable studied provides that chi-square value is 514.315, degree of freedom is
209 and the p-value is 0.000 and normed-chi square is 2.461. As the values of normed-chi square between
1 and 3 indicate that proposed model is providing a sufficient presentation of the relationship among the
studied variables (Seo, Han, & Lee, 2005).
The value of goodness of fit index for this model (GFI) is 0.77 and therefore, the values greater than 0.70
provides a good fit (Judge & Hulin, 1993). Value of the comparative fit (CFI) for this model is 0.76,
therefore, this value lies between 0 and 1, so value from 0 .00 to 1.00 and the value close to zero indicates
a well fit model and its value close to 1.00 indicate a very good fit (Bentler, 1990; Hu & Bentler, 1999).
Root mean squared error of approximation (RMSEA) for this model is 0.07 indicates a good model, as
value of RMSEA 0.05 indicates a close fit and value less than 0.08 represents a good model (Browne &
Cudeck, 1993; Byrne, 2001).
According to the above discussion we can say that overall proposed structural model is a fair
representation of patient perception about service quality.
Figure 1: Proposed Model

EMP1 0.56
0.61
EMP2
0.59 Empathy
EMP3 0.65

EMP4

TNG1
0.58
TNG2 0.50
0.65 0.81
TNG3
0.64 Tangible
TNG4 0.68
0.53
TNG5
0.78
TNG6

ASS1
0.49
Service Quality
ASS2 0.66
0.82
0.66
ASS3
0.58 Assurance
ASS4 0.52
0.56
0.89
ASS5
ASS6
0.73
TIM1 0.47
0.64
TIM2
0.52 Timeliness
TIM3

RES1 0.61
0.50
RES2
0.58 Responsiveness
RES3

Chi-Square=514.315, df=209, p-value=0.000, GFI=0.77, CFI=0.76, RMSEA=0.07

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■ Indian Journal of Commerce & Management Studies ■ ISSN – 2229-5674

• With respect to the first construct, empathy has a direct positive effect on service quality and the
factors like doctor’s genuine concern for their patients (0.56*0.81 =0.45). The factors like doctor
care their patients (0.61*0.81=0.531), nurses and supporting staff care their patients
(0.49*0.81=0.50), hospital put their best effort to provide comfort to their patients
(0.65*0.81=0.22) has direct positive effect on service quality. The standardized regression weight
of the construct empathy is 0.81. Therefore, these results support the hypothesis H1 that patient
perception about empathy has a positive impact on service quality.
• With respect to the 2nd construct, tangible has a direct positive effect on service quality, as all the
variables representing this construct also has a direct positive impact on service quality. The
regression weight for this construct is 0.78 which support our hypothesis H2 that the level of
tangible has a positive impact on service quality.
• With respect to the third construct, assurance all the items has a positive direct impact on the
service quality. The regression weight for this construct is 0.82 which support our hypothesis H3
that assurance has a positive impact on service quality.
• With respect to the fourth construct, timeliness all the items representing this construct are
depicting positive values, therefore timeliness has a positive direct impact on the service quality.
The regression weight for this construct is 0.89 which support our hypothesis H4 that assurance
has a positive impact on service quality.
• Last construct responsiveness, all the items representing this construct are depicting positive
values, therefore, responsiveness has a direct positive impact on service quality. The regression
weight for this construct is 0.73 which support our hypothesis H5 that responsiveness has a
positive impact on service quality.

TABLE 4: Correlation among the service quality Dimensions

Table 4 provides information regarding correlation between the five service quality dimensions namely;
empathy, tangibles, assurance, timeliness and responsiveness. The highest correlation between the
variables among all the variables (constructs) is between empathy and tangible and is 67.7%, which
indicates that there is a positive and strong correlation among the two variables. It means that
infrastructure and sufficient facilities available to human resource (like doctors, nurses and supporting
staff) at hospitals helps to increase the empathy level among them which creates a positive impact on
increased quality of services to the patients. It is also observed that p-value between these two variables is
0.000 indicates that there is a strong correlation among these variables. Since p-value between two
variables is 0.000 so it can be conclude that at 1% level of significant the correlation between tangible and
empathy is significant and it is the strongest correlation among all the variables. The weakest correlation is
54.1% among timeliness and empathy, however, the correlation is positive among them and the p-value
among the variables is 0.000 indicating a significant correlation among them at 1% level of significant.

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RESULTS AND DISCUSSION

From the above results generated from Amos 16.0 and path diagram, shows that patient perceive that
private hospital are delivering quality healthcare services to the patients. All the service quality constructs
empathy, tangible, assurance, timeliness and responsiveness has a positive impact on service quality of
private hospitals. It is also concluded that service quality is a latent exogenous variable, which is
represented by five observed endogenous variables namely, ‘empathy’, ‘tangible’, ‘assurance’,
‘timeliness’ and ‘responsiveness’. Results of the five factors showed that the measurement model for
service quality constructs had a good fit and the model is valid and reliable.
Results show that in private hospitals doctors are genuinely concerned for their patients, doctors and
nurses has attentions to care their patients and private hospitals are putting their maximum efforts in order
to provide comforts to their patients. These variables are representing the first construct empathy and all of
these variables have a positive impact on service quality.
Hygienic conditions, cleanliness, hospital environment and availability of the lab and pharmacy facilities
have a positive impact on the service quality and these variables were representing the second construct
tangible. Doctors and supporting staff are highly qualified and expert in their field and labs are highly
equipped and generating accurate results also have a positive impact on service quality. Similarly,
observation of patients according to appointment, in time delivery of reports and doctors also observe
promised time also have a positive impact on service quality and finally, efficiently response to patients
calls, willingness to help and facilitate the patients and feedback mechanism also have a positive impact
on service quality.
The above results indicate that service quality in private hospitals is meeting patients’ satisfactions. It is
evident from the literature that private hospitals in Egypt are delivering better quality of services as
compare to public hospitals (Mostafa, 2005). Similarly, the hospitals in Bangladesh are providing better
healthcare services as compare to public hospitals and foreign hospitals are far better than public and
private hospitals (Andaleeb, 2000). These results also validate our study, that private hospitals are
delivering better healthcare services.

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