MINISTRY OF EDUCATION, YOUTH, AND SPORTS NATIONAL UNIVERSITY OF MANAGEMENT

SCHOOL OF GRADUATE STUDIES

An Assessment of Service Quality of Public and Private Hospitals: Evidence for Cambodia
MAO SAVY
A Proposal Submitted to the School of Graduate Studies of the National University of Management in Partial Fulfillment of the Requirements for the Degree of Doctor of Business Administration

SPECIALIZATION MANAGEMENT

Supervised by:

Dr. Veasna Ung Chair of Tourism and Hospitality Faculty National University of Management Phnom Penh, Cambodia

Reth Soeng, PhD. Senior Lecturer National University of Management Phnom Penh, Cambodia

Phnom Penh, Cambodia Submitted 20 March 2013

An Assessment of Service Quality of Public and Private Hospitals: Evidence for Cambodia
MAO SAVY

1. Introduction Services have been viewed as an important sector, making up the majority of the economies of many developed countries (Jensen, 2011). The share of service sector contributing to output and employment is also growing, which is confirmed by Soubbotina (2004) who reported, for the world economies, that the share of services in the total output and employment was 43 percent for low-income countries, 55 percent for middle-income countries, and 64 percent for high-income economies.1 In the case of ASEAN, Petri et al. (2012) also reported that the contribution of service sector to GDP rises, and that the service sector had become the important contributions to income growth in all large ASEAN countries in the late 1990s. The shift towards service sector might be true for the case of Cambodia whose income per capita has gradually increased from around 230 US dollars in 1993 to about 300 US dollars in 2000, and reached 990 US dollars in 2012. It is expected that Cambodias GDP per capita will reach more than 1,000 US dollars in 2013.2 Services delivery is becoming increasingly a vital element of a national economy, and it is crucial to appreciate the distinguishing qualities of services, as well as the resulting management implications, with the specific focus on healthcare services (de Jager and du Plooy, 2011). The recognition and identification of the poor quality of healthcare delivery in developing countries (Devarajan and Reinikka, 2004) has led to the adoption of new efforts to measure and monitor healthcare service quality. In developing countries, such as Cambodia, health care is a necessity or a basic need, involving a
It is the facts showing that agricultural sector is most important for developing countries. However, as per-capita income increases, the agricultural sector loses its primacy to the industrial sector, which in turn loses its importance to the service sector (Soubbotina, 2004). 2 The data are obtained from the Cambodian Ministry of Economy and Finance (various years).
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physiological cure, rather than care as such, while in the developed world, health care is often seen as a luxury. People in the developing world are at times concerned with finding the best ways to meet their health care needs without a compromising quality. Quality patient care is the underlying principle of any nations health system, which needs to be constantly improved through developing an effective, systematic approach for monitoring and evaluating of health services rendered (Sutherasan and Aungsuroch, 2008). As health care sector has become a more highly competitive and rapidly growing service industry around the world, the major challenges faced by healthcare markets is to measure and evaluate the rendered service quality (Irfan and Ijaz, 2011). The quality of service, both technical and functional, is a key ingredient in the success of service-providing organizations (Grnroos, 1984). There is no exception for the quality of health care service. Technical quality in health care is defined primarily on the basis of the technical accuracy of the diagnosis and procedures. Functional quality, in contrast, relates to the manner of delivery of health care services. The delivery of quality healthcare services and the integration thereof in healthcare policies is a concern shared by health sector worldwide (James, 2005). Quality of health services is believed to directly influence health outcomes, health-related behaviors and patient satisfaction. Patient perceptions are considered to be the major indicator for assessing the service quality of a healthcare organization (Cronin and Taylor, 1992; OConnor et al., 1994). It means that patient satisfaction is the major device for critical decision making in selecting a healthcare services (Gilbert et al., 1992) and quality of services delivered to the customers should meet their perceptions (Parasuraman et al., 1985, Reidenbach and Sandifer-Smallwood, 1990; Babakus and Mangold, 1992; Zeithaml et al., 1993). Several techniques for measuring technical quality have been proposed and are currently in use in healthcare sector. However, it has been recognized in the empirical studies that SERVQUAL method, originally developed by Parasuraman et al. (1985), is probably the most comprehensive scale to empirically estimate and measure the level of

quality services delivered to customers, and it is best suitable in the hospital environment as well (Babkus and Mangold, 1992). Since its inception, the service-measuring technology of SERVQUAL has been used in many settings in both developed and developing world. Voluminous studies also have shown that provision of high-quality services is directly related to increase in profits, market share, and cost savings (Devlin and Dong, 1994). With competitive pressures and the increasing necessity to meet patient satisfaction, the elements of quality control, quality of service, and effectiveness of medical treatment have become vitally important (Friedenberg, 1997). This study intends to investigate the factors that may exert an influence on patient satisfaction, using the augmented SERVQUAL methodology to measure and evaluate the services rendered by Cambodias private and public hospitals.

2. Review of Related Literature Service quality can be defined as the ability to meet the customers needs and expectations (Lim and Tang, 2000). As cited by Lim and Tang (2000), Lewis and Booms (1983) and Webster (1989) define service quality as a measure of how well the service level delivered matches the consumers expectations. It has been revealed as a key factor in search for sustainable competitive advantage, differentiation and excellence in the service sector (Jabnoun and Al Rasasi, 2005; Jun et al., 1998). Service quality has also been recognized as critically important for satisfying and retaining the existing customers (Spreng et al., 1996; Reicheheld and Sasser, 1990). A number of competing models have been developed to measure and evaluate service quality as well as explain its vital importance in the commercial service-providing businesses. Subsequently, in particular following the development of SERVQUAL model by Parasuraman et al. (1985, 1988), a great deal of research has been undertaken to address and assess various aspects of service quality. Basically, the model was that consumer perceptions of quality emerge from the gap between performance and expectations, as performance exceeds expectations, quality increases; and as performance decreases relative to expectations, quality decreases (Parasuraman et al., 1985, 1988;

Asubonteng et al., 1996). Thus, performance-to-expectation gaps on attributes that consumers use to evaluate the quality of a service form the theoretical foundation of the SERVQUAL technology.

To measure non-commercial services such as services delivered by library, the Association of Research Libraries in collaboration with Texas A&M University developed the library-measuring model, now better known as LibQUAL3 (Edgar, 2006), which is conceptually based upon the widely-used SERVQUAL technology used to measure general commercial services rendered by service business organizations. LibQUAL is perceived as a valuable means of assessment for academic libraries service quality (Blixrud, 2002; Nicol and OEnglish, 2012). Similar to SERVQUAL model, LibQUAL underwent four refinements (Yu et al., 2008). The first one was made over 1999-2000 in its 13 member libraries, with 41 pairs of statements related to five service quality dimensions, followed by the second round of refinements, which was tested in 2001, with more member libraries included and 56 statements of service quality dimensions. The third modification was made in 2002 with participation of 164 member libraries, containing 25 pairs of statements relating to four service quality dimensions. The final refinement was undertaken in 2003 in 308 member libraries, containing 22 pairs of statements which were related to three dimensions. LibQUAL has become a standardized model for assessing and measuring service quality of libraries (Blixrud 2002). In general, service quality is viewed as a success factor of a firms endeavors to differentiate itself from its rivals in the increasingly competitive market. Service quality has been approached as a multidimensional construct. At the earliest stage, the SERVQUAL initiated by Parasuraman et al. (1985) introduced ten potentially overlapping components (Soeung, 2012). These dimensions include tangibles, reliability, responsiveness, communications, credibility, security, competence, courtesy, understanding the customer, and access. Later, in their subsequent studies, Parasuraman et al. (1988, 1990) reduced the aforementioned ten potentially overlapping dimensions

LibQUAL+ was developed in late 1999. It is a joint effort of Texas A&M University and twelve additional US educational institutions (Cook and Thompson, 2001).

to five testable dimensions. Collapsing from ten to five dimensions was made after rounds of purifications by Parasuraman et al. (1988, 1990), who detected some degrees of overlap among their original ten dimensions. After stages of refinements, Parasuraman et al. (1988) found that assurance and empathy contain items representing the seven original dimensions: communications, credibility, security, competence, courtesy, understanding or knowing customers and access. In other words, assurance dimension contains items representing communications, credibility, security, competence, courtesy while empathy contains items representing understanding or knowing customers and access (Zeithaml et al., 1990; Soeung, 2012). SERVQUAL has been extensively accepted and utilised as a generic instrument that captures the multidimensionality of service quality. Parasuraman et al. (1985)s SERVQUAL has become operationalized in five dimensions that included 22-items (Parasuraman et al., 1988). These five dimensions include tangibles (physical facilities, equipment and appearance of personnel); reliability (ability to perform the service accurately and dependably); responsiveness (willingness to help customers and provide prompt service); empathy (caring and individualised attention paid to customers) and assurance (employees knowledge, courtesy and ability to convey trust and confidence). Soeung (2012) indicated that SERVQUAL suffers from some criticisms on the theoretical and operational grounds, in particular operationalization of expectations, reliability of instruments difference score formulation and scales dimensionality across industrial settings (Sureshchandar et al., 2001; Baumann et al., 2007). Buttle (1996), however, offers some future research directions; of which a direction is to continue to examine the relationships between service quality, customer satisfaction, behavior, customer retention, behavioral intention, word-of-mouth communications and market share. Although SERVQUAL have suffered from criticism, the models core content remains unchanged and has been used for studies of commercial service-providing business organizations in many countries. This model is also found to be superior, with respect to the measurement of service quality in developing economy (Angur et al., 1999).

Parasuraman et al. (1990) claim that, with appropriate adaptation of SERVQUAL model, it can be used in many settings to ascertain the quality of service rendered (Dhurup and Mohamane, 2007). Similarly, Nyeck et al. (2002) indicate that SERVQUAL remains the most complete attempt to conceptualize and measure service quality. In their study on service quality of Iranian private hospital, Zarei et al. (2012) contends that the SERVQUAL model is a valid, reliable and flexible instrument to monitor and measure the service quality in private hospitals in Iran. The reliability and validity of SERVQUAL instrument is also emphasized by Al-Borie and Damanhouri (2013) who compared patient satisfaction with service quality in both Saudi Arabian public and private hospitals. Research has shown that good service quality leads to the retention of existing customers and the attraction of new ones; the improved customer satisfaction; the enhanced corporate image and positive word-of-mouth recommendations; as well as the enhanced profitability of firms (Cronin et al., 2000). Concerning health care industry, a number of empirical studies were undertaken, using the SERVQUAL scale, to evaluate both public and private hospitals. For Bangladesh, Andaleeb (2000) carried out a comparative study on the service quality rendered by public and private hospitals in urban areas, using a modified SERVQUAL technology, with 25 statements representing five aspects of service quality dimensions, namely responsiveness, assurance, communications, discipline, and devotion or dedication. Using a data set from 216 inpatient respondents, Andaleebs study suggested that private hospitals delivered better service than their public counterparts in rural Bangladesh. Lim and Tang (2000) studied, for Singapore, the inpatients expectations and satisfaction by also utilizing a modified SERVQUAL scale, with 25 items representing tangibles, reliability, assurance, responsiveness, empathy, accessibility and affordability dimensions. Their results, using data from 252 inpatient respondents, showed that there was a service quality gap between in-patients expectations and their perceptions. A similar study was conducted by Jabnoun and Chaker (2003) for the United Arab Emirates. They made comparison with respect to the quality of delivered services between the private and public hospitals. Using a modified SERVQUAL, Jabnoun and Chaker incorporated 23 statements representing six dimensions of service quality, namely

empathy, tangibles, reliability, level of administrative response and support skills, and found that inpatients were more satisfied with service quality of public hospitals than that rendered by the private counterparts. Based on the work of previous authors, Arasli et al. (2008) attempted to develop and compare determining factors of service quality in both public and private hospitals of North Cyprus, using a data set collected from 454 inpatients respondents. Employing a modified SERVQUAL, with 48 statements representing six service quality dimensions, they identified six factors concerning quality of service perceived in both public and private hospitals. The six factors include empathy, giving priority to the inpatients needs, relationships between staff and patients, professionalism of staff, food and physical environment. Arasli et al. (2008) also found that inpatients expectations have not been satisfied in either public or private hospitals. Using SERVQUAL scale and a data set from 983 patients of 8 private general hospitals, Zarei et al. (2012) found that three factors (reliability/responsiveness, empathy, tangibles), explaining 69% of the total variance. The total mean score of patients expectation and perception was 4.91with standard deviation of 0.2 and 4.02 with standard deviation of 0.6, respectively. The highest expectation and perception related to the tangibles dimension and the lowest expectation and perception related to the empathy dimension. There was a significant difference between the expectations scores based on gender and education level. They also concluded that SERVQUAL is a valid, reliable and flexible instrument to monitor and measure the service quality in private hospitals in Iran. In the most recent study, Al-Borie and Damanhouri (2013) compared patient satisfaction with service quality in Saudi Arabian public and private hospitals using SERVQUAL scale with 1000 inpatients respondents, they found that here were significant differences in the service quality between public and private counterparts. Private hospitals service quality was higher than public and these differences were statistically significant. Their result also suggested that the best three dimensions in the public hospitals were tangibles, empathy and security, whereas in private hospitals the best three dimensions were security, empathy and tangibles. The reliability dimension was fourth, followed by responsiveness in all public and private hospitals. The best service quality dimension in public hospitals was tangibles. This dimension included hospital staff appearance, convenient and easily accessible locations, followed by modern equipment and

technology. The best service quality in private hospitals was convenient and easily accessible locations followed by medical staff cordiality and friendliness when dealing with patients. In the globalized world, like other service-providing organizations, Cambodias health care sector has faced with a stiffer competition after the country further liberalized its economy including trade in goods and services to foreign competition. Using our conventional wisdom, we expect that the increased foreign completion in health sector will force the countrys health care providers to search for competitive advantages to remain in todays competitive market. Comparing to foreign health care services, health care rendered by Cambodian public and private hospitals may suffer from the issues of less qualified health professionals, medical technology and medical staff with professional ethics, which are a key to success and profitability of hospital operations. These issues often arise in a relatively less developed nation.

3. Problem Statement Over decades, the Royal Government of Cambodia has made great efforts to fulfill their important tasks and obligations by improving the health care provisions as it is considered to be a central sector in a countrys development process. In this regard, the health care service areas were reformed in order to deliver good health service to the general public, in particular to the Cambodian people. Many of the existing hospitals have been upgraded and modernized. The hospitals aim at providing basic specialized health care services. Further, the training of health personnel has also been intensified, and medical as well as paramedical staff members were appointed to many hospitals across Cambodia. Moreover, the intensive care and laboratory facilities have continuously been expanded with appropriate technology to meet the rising demand for health cares. Despite all aforementioned commitments by the Royal Government, especially by the Cambodian Ministry of Health, notable deficiencies still prevail with respect to the health care services, delivered by the both public and private hospitals in Cambodia.

There have been quite a large number of complaints filed by the public due to delays in taking appropriate actions with regards to delivering services to them by hospitals. The wide spread of world-of-month and headlines of domestic newspapers also highlighted complaints from the public, regarding their deep dissatisfactions with the hospitals services. In other words, hospitals service quality is not as expected by the customers, due to its low quality. This matter is a concern to the public since they are taxpayers and they therefore expect that good services are delivered to them as the return. Many of the hospitals are reported to ignore the non-health expectations of the people such as basic human needs, dignity, kindness and compassion, proper communications with the patients. This combined with less quality of health care service has encouraged more and more people to treat and/or receive medical checkups of their health abroad, especially in neighboring countries such as Vietnam, Thailand and Singapore. There are some reported complaints about the death of a patient, due to inappropriate care and negligence. Although hospitals do provide valuable health services to the public, the services delivered are not well recognized, due to negligence and failure to strict adherence to professional ethics and the like. Yet, some public and private hospitals are reported to have taken the initiative to enhance the quality of their services by improving infrastructure, modernizing medical technology, reviewing monthly performance, preparing manuals and guidelines, initiating productivity improvement programs, and so on. The current study is carried out in order to measure and evaluate the quality of service delivered by both Cambodian public and private hospitals in urban area of Phnom Penh. It also intends to identify the most important service quality dimensions, which contributes significantly to patients satisfaction.

4. Research Questions The above discussion has provided a brief good overview of how important service

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quality is to the success of the operations of hospitals in Phnom Penh. Of course, general descriptions need to be made in detail. Research questions need to be identified and formulated, and vigorous analysis needs to be made in order to rigorously answer the questions before any sound managerial and policy implications can be offered. While making use of gap analysis to measure service quality of both public and private hospitals, the present study will also focus on the following four main research questions: (1). What does the patients perception meet their expectation on service quality in both public and private health sector in Cambodia? (2). Are there any differences between the quality of services of public and private hospitals? (3). What are dimensions of the augmented SERVQUAL model that affect patients satisfaction? (4). What are the factors that contribute most significantly to the satisfaction of patients?

5. The Purpose of Research: Generally, the main purpose of this study is to determine the relationship between service quality and patients satisfaction in both private and public hospitals in the urban area of Phnom Penh. On the basis of its results, this study will propose a service quality model, with an application to health care service in Cambodia. Second, several factors related to service quality will be discussed and analyzed, based upon the augmented SERVQUALs dimensions, namely tangibles, assurance, reliability, responsiveness, empathy, and accessibility and affordability. Third, the current study also intends to test the statistical differences between the quality of services of public and private hospitals. Fourth, it will also identify the dimensions of the augmented SERVQUAL that contributes most significantly to patients satisfaction. Improving these factors may help convince the Cambodian people as well as foreign nationals staying in Cambodia to use the Cambodian hospitals services. This will

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encourage further development and improvements of the health sector in the small, open economy of Cambodia that had been inflicted by decades of destructive internal conflicts.

6. Significance and Scope of the Study To the best of my knowledge, no research has been conducted with respect to the measure and evaluation of service quality of public and private hospitals in the Kingdom of Cambodia, especially in the urban area of Phnom Penh. This study therefore is considered to be critically important as it intends to measure and evaluate the level of service quality and the level of satisfaction among the patients in both private and public health organizations, in particular public and private hospitals. The result from the study can be used to give valuable information on the elements and the dimensions, which have been given a priority by patients, Cambodian Ministry of Health, health policymakers and all stakeholders concerned in assessing the quality of services rendered by the Cambodian hospitals. In addition, this study will draw conclusions and offer some recommendations, which are believed to be useful for Cambodia. In summary, the findings of the study may be used in many useful ways. First, the hospitals top managements benefit from the results of study as they can use the information and the findings of the study to improve their hospitals services rendered to meet customers needs. Second, hospitals managers and medical staff who are involved in delivering the hospitals services may also use the information for service improvements and for increasing their work performances to bring satisfaction of the rendered hospitals services to the patients. The result of study could also be used as a guideline to improve other services of public and private hospitals, with respect to service quality dimensions of tangibles, reliability, responsiveness, assurance, empathy, and accessibility and affordability. Concerning the scope of the study, it primarily focuses on services rendered by public and private hospitals, located in the urban area of Phnom Penh, rather than all public

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and private hospitals in operations in the Kingdom of Cambodia. The collection of the sample data is obtained from patients who received health care services during last two months in public and private hospitals in the urban area of Phnom Penh.

7. Formulation of Hypotheses A hypothesis is basically unproven statement of a research question in a testable format (Hair et al., 2003). Hypothesis testing is a very effective analytical tool for obtaining valuable information under a wide variety of circumstances (Webster, 1998). Based on both theoretical and empirical literature presented above, the following hypotheses are formulated and to be tested as follows: Hypothesis H1: Tangibility of both public and private hospitals exerts a significant positive effect upon patients satisfaction; Hypothesis H2: Reliability of both public and private hospitals is positively related with patients satisfaction; Hypothesis H3: Responsiveness of both public and private hospitals has positively impacted upon patients satisfaction; Hypothesis H4: Assurance of both public and private hospitals is positively related with patients satisfaction; Hypothesis H5: Empathy of both public and private hospitals has exerted a significant positive influence on patients satisfaction; Hypothesis H6: Both public and private hospitals do not meet patients expectations; Hypothesis H7: Private hospitals in Cambodia are more successful than public hospitals in providing health care services for satisfying patients needs; Hypothesis H8: There is a difference between public and private hospitals concerning their quality of services rendered; and Hypothesis H9: Private hospitals are more successful than public counterparts in delivering heath care services for their patients.

8. The Proposed Econometric Model

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Based on the literature review presented above, the augmented SERVQUALs dimensions, in particular tangibles, reliability, responsiveness, assurance, empathy, and accessibility and affordability, have been utilized in order to investigate the relationship between these dimensions and patients satisfaction in both public and private hospitals. On the basis of the previous theoretical and empirical literature, the following model is used to examine the service quality dimensions that may affect the overall patient satisfaction in health care services delivered by Cambodias public and private hospitals.

OPS 0 1tangibles 2 reliability 3 responsiveness 4 assurance 5 empathy 5 accessability _ affordability u

where OPS denotes overall patient satisfaction, and u is error term, which is assumed to be normally distributed. The data used for the analysis is from a survey of two thousand patients using health care services delivered by public and private hospitals in operations in Cambodia. Yet, following cleaning process, a sample of more a thousand patient respondents is considered to be usable for the analysis. The data set contains detailed information on the explanatory variables (tangibles, reliability, responsiveness, assurance, empathy, and accessibility and affordability) which are included in the model presented above.

9. Data and Research Methodology

9.1 Data Collection This study used the modified SERVQUAL, initially developed by Parasuraman et al. (1988). Relevant information about patient satisfaction, perceptions, expectations and socio-demographics in both public and private hospitals is obtained by means of a survey conducted to collect a sample containing the needed information for the analysis. A survey questionnaire is designed and distributed randomly to target respondents, who used health care services of public and private hospitals in the urban area of Phnom

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Penh. In order to receive the most accurate responses possible, the questionnaires were translated into Cambodian language, Khmer. The questionnaire is classified into five major parts. The first part of the questionnaire contains respondents expectations of health care services delivered by public and private hospitals. In the second part, questions were asked to obtain the information on perceived performance of hospitals services rendered. The third part asks patients respondents to allocate 100 points to the six factors of service quality. The fourth part captures the information related to overall satisfaction. Respondents were asked to respond to each item on the widely used five-point Likert-type scale. The five part of the questionnaire is used to get the information on the demographic information of the respondents. As cited by Soeung (2012), Roscoe (1975) suggests a series of general rules in determining the acceptable sample size for research, and proposes that for any research that intends to conduct a multiple regression analysis, a sample size should be at least 10 times as large as that of the number of variables. In order to produce the best estimates possible, the collection of a reasonably large data set has to be made from the population. To achieve this, two thousand questionnaires were distributed randomly to patients who once used to receive hospitals services. The rate of the responses was about 63%. Following cleaning process of the data, a sample of more than one thousand respondents is considered usable for the analysis to be carried out. Data collection work took approximately four months, starting from 25 March 2012 to 22 July 2012.

9.2 Measures of the Included Variables The measures of each key variable are as follows. Patients satisfaction is the measure of patient satisfaction, which consists of responses to a single question on the patient satisfaction questionnaires. It is measured, using four items. For instance, Overall how satisfied were you with the treatment you received at the hospital? Responses for all satisfaction questions were made on five-point Likert-type scale, labeled 5 very satisfied and 1 very dissatisfied at each extreme. Tangibles consist of up-to-date and

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well-maintained medical facilities and equipment; clean and comfortable environment with good directional sign; doctors/medical staff being professional and neat in appearance. It is measured, using five items. For instance, Hospital has up-to-date, well-maintained medical facilities and equipment. Respondents were asked to respond to each item on a five-point Likert-type scale. Reliability comprises the ability of the hospital doctors and medical staff to provide service at appointed time and accurately. It is measured using five items. For example, Services are provided at the appointed time. Respondents were asked to respond to each item on a five-point Likert-type scale. Responsiveness includes the willingness of the hospitals doctors and medical staff to provide prompt service and be responsive to patients needs. It is measured using four items. For example, Patients are given prompt services. Respondents were asked to respond to each item on a five-point Likert-type scale. Assurance includes the knowledge and courtesy of the hospitals doctors and medical staff and their ability to convey trust and confidence. It is measured using four items. For instance, Doctors and medical staff are friendly and courteous. Respondents were asked to respond to each item on a five-point Likert-type scale. Empathy contains the caring, individualized attention the hospitals doctors and medical staff provides their patients. It is measured using five items. For instance, Doctors and staff have patients best interests at heart. Respondents were asked to respond to each item on a five-point Likert-type scale. Accessibility and affordability include adequate parking facilities, accessible location of premises, and affordable charges for hospitals services. It is measured using three items. For instance, Affordable charges for service rendered, with accessible location of premises. Respondents were asked to respond to each item on a five-point Likerttype scale.

9.3 Estimation Techniques The collected data are imported into statistical packages, namely the Statistical Package for the Social Sciences (SPSS 16) and/or STATA 12.1 for statistical analysis, which includes descriptive statistics, gap analysis and multiple regression analysis and other necessary testing to obtain the best possible results. To report the most accurate results from the estimation of the regression model, several diagnostic tests need to be carried

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out. Reliability check is to be performed in order to assess the degree to which data collection method will yield consistent findings, with similar conclusions drawn by other researchers. In order to test the reliability of the instrument, the reliability coefficient Cronbachs alpha is used. It is generally agreed that Cronbachs Alpha should exceed 0.70 to be reliable (Hair et al., 2010). Other statistical diagnostic tests will also be conducted. These tests include multicollinearity checks, heteroskedasticity test and model specification test, known as Ramsey (1969)s specification test. Since the data collected is cross-sectional, heteroskedasticity is often present in such as data set. This is why the usual OLS estimator is not the best linear unbiased estimator (BLUE) and the t-statistics are no longer t-distributed. These problems cannot be resolved by using a large sample size (Wooldridge, 2009). Similarly, F-statistics are no longer F-distributed. There are a number of competing tests for heteroskedasticity (Wooldridge, 2009). Only the modern tests are briefly discussed here. The first one is the Breusch and Pagan (1979) test for heteroskedasticity (Verbeek, 2004), which is based on an LM statistic, shown to be equal to LM n.Ru22 , where Ru22 is obtained by regressing the OLS squared

residuals on all k dependent variables, and n being the sample size. Under the null hypothesis of homoskedasticity, the LM statistic is asymptotically distributed with

k degrees of freedom. The second test is known as the general White test for
heteroskedasticity and is based on an estimation of the OLS squared residuals on all independent variables, squares of independent variables, and all their cross products. The general White test consists of the LM statistic for testing all the coefficients in the squared residual estimation on all independent variables, their squares and cross products, being zero, except for the intercept. However, the general White test clearly suffers from a weakness in the pure form of the test because it employs many degrees of freedom. To conserve degrees of freedom, especially when a model consists of a moderate or large number of independent variables, Wooldridge (2009) proposes the special White test for heteroskedasticity, which incorporates the Breusch-Pagan and the general White
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tests. The special White test, also based on the LM statistic, suggests testing for heteroskedasticity by estimating the OLS squared residuals on the fitted values and squared fitted values. Under the null hypothesis, the LM statistic for the special White test is chi-square distributed with two degrees of freedom, regardless of the number of independent variables included in the model. This is why the special White test for heteroskedasticity is to be preferred and will be used to test for heteroskedasticity in the study. A multiple regression model may suffer from functional form misspecification when it does not or insufficiently account for the relationships between the dependent and explanatory variables. Important or relevant variables may be excluded from the regression equation or the model, when a non-linear model is estimated as a linear model. Such misspecification will be detected by using the RESET test (F statistic), which is based on Ramsey (1969). Under the null hypothesis that the model is correctly specified, the F statistic distribution is approximately F3, n k 4 in a large sample. Rejection of the null hypothesis implies that the model under consideration is misspecified.

10. Research Structure

The current study consists of five chapters. Chapter 1 covers the problem being studied, research objectives, research questions, significance and scope of the study, formulation of hypotheses, and research structure. Chapter 2 carries out both theoretical and empirical literature review related to service quality and satisfaction in order to provide background and form the foundation for defining the studys parameters to be estimated. Chapter 3 deals with overview research design, model development, variable measurements, sampling method, sample size, questionnaire design, reliability testing, and data screening. Chapter 4 describes about hospitals profile in Cambodia. Chapter 5 describes result findings, multiple regression analyses and discussion. Chapter 6 draws conclusion, offer recommendations for health policymakers and all stakeholders concerned as well as suggestions for future research.

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