Bakhtiar Aman  ( Department of Management Sciences, COMSATS Institute of Science & Technology, Islamabad. )
Faisal Abbas  ( Department of Management Sciences, COMSATS Institute of Science & Technology, Islamabad. )

Objective: To determine patients\\\' perception regarding service and quality of healthcare at public-sector institutions.
Methods: The descriptive quantitative study was conducted in Kohat district, Pakistan, between July and December 2014, and focussed on 30 variables to assess the participants\\\' perceptions of the actual healthcare service quality delivered. SERVQUAL instrument was used to measure the reliability and cronbach alpha was calculated to measure the reliability and validity of the instrument.
Results: A total of 200 questionnaires were distributed and 157(78.5%) were received back fully filled. Of them, 105(67%) were men and 52(33%) were women.The mean value of Assurance parameter was 3.05±0.88, indicating trust in public hospitals was high as they had experienced and capable doctors. On the other hand, the lowest mean value of 2.61±0.84 was for Empathy, highlighting the fact that public hospitals lacked the ability to handle patients\\\' problem properly, services were not offered in time and they were short of staff.
Conclusion: Public hospitals were largely seen as failing to deliver quality service.
Keywords: Patient\\\'s perception, Service quality, SERVQUAL, Public health sector, Kohat, Pakistan. (JPMA 66: 72; 2016).


Introduction

Development of a country depends on a healthy human capital and it is a primary responsibility of any government to pay special attention to the health sector.¹ Patients\\\' perceptions are important in the assessment of service quality of the health sector.² Quality can be defined in general terms as the quality of scope in the usage of product or service at certain level which meet the expected requirement.³ Quality is directly linked with customer\\\'s expectations as it is the internal standard of customers to rank the delivered service quality.⁴
Healthcare service provider can gain the patient\\\'s trust if it focuses on patient satisfaction to increase the strength of association between the patient trust and healthcare quality.⁵
Service quality issues are under consideration of the researchers for more than two decades and many efforts in this connection have been made to address the connection and it has been observed that customer satisfaction increases in proportion to the higher level of service quality.⁶
Many researchers recommend the assessment of healthcare quality through observation of family and friends\\\' perceptions, and these classifications of observation groups will denote the probable future customers and influence factor of the healthcare preference of patient.⁷
It is necessary to emphasise on the driving effects of health-seeking behaviour of population in healthcare system, and policy-makers must ensure that acceptable, affordable, cost-effective, efficient and effective services are available to the public.⁸
Perceived quality is the consumer\\\'s comparison with his expectations for the services he received, where he compares the expected service against the perception.⁹ Thus, patient\\\'s satisfaction may be quantified in the context of overall healthcare experience.¹⁰
According to the Statistics Division of Pakistan (2012-13), the country with an estimated population of 184.35 million is the sixth most populous country in the world. Pakistan\\\'s population growth rate in 2012-13 was 02 per cent and if this trend continues, Pakistan will be the fifth most populous country by 2050. According to the Constitution of Pakistan, better healthcare facilities, planning and devising health policies at the national level are subject for the federal and provincial governments to deal with, but the health conditions inside Pakistan are deteriorating day by day. In Pakistan, the healthcare system is largely based on public-sector hospitals, healthcare units and dispensaries, but these are not enough to meet the requirement of a large population.
The current study was planned to investigate patients\\\' perception about the service quality of public-sector health facilities in district Kohat, in the Khyber-Pakhtunkhwa (KP) province of Pakistan.


Subjects and Methods

The descriptive quantitative study was conducted in KP province\\\'s Kohat district between July and December 2014, and assessed the participants\\\' perceptions of the actual healthcare service quality delivered.
After getting approval from the Departmental Supervisory Committee, Advisory Committee, Campus Graduate Programme Committee and Board of Advance Studies and Research, data was collected using a questionnaire which was designed on the basis of modified SERVQUAL model. In the domain of service quality measurement, SERVQUAL is the most commonly used model, providing the opportunity to assess the performance of service quality on the basis of each dimension independently as well as the overall standard.⁹ Five service quality dimensions were included: Tangibility (actual physical existence), Reliability (trustworthy), Responsiveness (expectation Vs response), Assurance (confidence certain expectations), and Empathy (feelings about the staff). The five categories covered a total of 30 items: Tangibility 8 items, Reliability 7 items, Responsiveness 6 items, Assurance 4 items, and Empathy 5 items.
The questionnaire also explored socio-demographic characteristics of the respondents such as gender, age, income and area of residence. All the respondents, who were selected using simple random sampling technique, voluntarily participated in the study.
Two main public-sector hospitals in district Kohat were visited. The daily outpatient department (OPD) record showed 180 to 220 patients were visiting every day
Initially 50 questionnaires were distributed to check reliability and validity. Thereafter cronbach alpha was calculated which helps to measure the reliability of the data and it should be greater than 0.70.11 Cronbach alpha for the study was 0.92 and the value for each of the five dimensions were >0.70.
SPSS 20 was used for data analysis.


Results

A total of 200 questionnaires were distributed and 157(78.5%) were received back fully filled. Of them, 105(67%) were men and 52(33%) were women. Of the total, 91(58%) were between 20-30 years of age, followed by 32(20.4%) between 31-40 years, 17(10.8 %) between 41-50 years, 9(5.7%) between 51-60 years, and 4(2.6 %) were >60 years.
Income of the respondents was divided into four groups; 42(26.8%) were <10,000; 48(30.6%) in 10,000-30,000 group; 23(14.6%) 30,000-50,000 group; and 9(5.7%) >50,000.
Out of the total study population, 109(69.4%) were from urban areas the district, while 48(30.6%) were from rural areas.
The five constructs and 30 variables used to assess service quality and perception were analysed (Table-1).


Comparison of mean values of the five constructs was also done which showed that respondents generally believed that assurance level in public hospitals was high as they had experienced and capable doctors. On the other hand, respondents said public hospitals lacked the ability to handle patients\\\' problem properly, services were not offered in time, and they were short of staff (Table-2).

Correlation amongst the variables suggested that the highest correlation was between Reliability and Responsiveness , while the lowest was between Assurance and Empathy (Table-3).




Discussions

The study focussed on service quality measurement of public hospitals based on patients\\\' perceptions. Service quality analysis would provide the healthcare managements a better understanding about how to implement their plans in those areas that have the most impact on customer perceptions.¹² Profitability of the hospital depends on the patients\\\' perception.^13,14 Loyalty and word of mouth have also significant effects on patient behaviour.¹⁵ Service-related approach is called perceived quality; it involves the responses which form attitude related to satisfaction, resulting expectations\\\' comparison with the performance perception.^9,16,17 Need to improve quality of services have been realised globally because of the quality-consciousness of the customers.¹⁸
A patient judgment in respect of clinical experience is believed to be an attitudinal response in the shape of satisfaction.¹⁹ Prediction of patient satisfaction is linked with factors of Empathy, Reliability, Responsiveness and Caring.²⁰ Other dimensions are customisation competence, communications, care services and professional credibility.²¹ Influencing factors of patients\\\' overall quality perceptions are the five dimensions which are prominent in SERVQUAL analysis.²² The most important aspect of SERVQUAL model is a tried and tested instrument which can be used comparatively for benchmarking purposes.²³
Our study results are comparable with earlier studies done in Pakistan and Bangladesh.^1,15
As per results, the highest correlation existed between Reliability and Responsiveness. This ultimately increases patient\\\'s trust in the hospital and leads to satisfaction about the services delivered. On the other hand, the weakest correlation was between Assurance and Empathy. Nevertheless, the correlation amongst all the five service quality constructs was positive and p=0.001 indicates a significant correlation amongst them at 1% of significance.


Conclusion

Results showed that among all the constructs, only Assurance had significant impact on patient satisfaction. Major reasons include the negligent behaviour of the government towards the health sector Healthy environment, which is essential for hospitals, was lacking and overcrowded OPDs made it difficult for doctors and nursing staff to concentrate on patients\\\' problems.


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