Service quality in public and private hospitals in urban Bangladesh: a comparative study

Abstract This study compared the quality of services provided by private and public hospitals in urban Bangladesh. Using twenty-four scale items, patient perceptions were sought on aspects of service quality including responsiveness, assurance, communication, discipline and baksheesh. Because private hospitals are not subsidized, it was felt that the incentive structure would induce them to provide better services than public hospitals on the measures of service quality. This contention was largely supported. The results also indicated that both groups have room for improvement.
Keywords: Service quality, Hospitals, Comparative

1. Introduction Appropriate health care strategies are vital to the ability of Third World countries to achieve other development objectives. While not a sufficient condition for development, it is important to recognize that a healthy population is better disposed to achieve the productivity increases that are needed to sustain continued growth in other sectors of the economy. In Bangladesh, unfortunately, the health care delivery system is besieged with a variety of problems that signal an impending crisis. With a burgeoning population and the low level of investment in the health care sector, service quality, especially in the public hospitals seems to have deteriorated markedly as reported with increasing frequency in the popular media. To avert any major crisis or to halt any further deterioration in health care delivery, two major strategic goals increasing access and improving quality must be pursued vigorously and relentlessly to improve the nation's capacity to deliver better health care services. A review of the literature suggests that some attention has been devoted to the question of access. Perhaps gauging the growing problems in public health care delivery, the Government of Bangladesh envisaged a greater role for the private sector as early as 1982 by promulgating the Medical Practice and Private Clinics and Laboratories Ordinance. By June 1996, a total of 346 private hospitals and clinics with more than 5500 beds were registered with the Directorate of Hospitals and Clinics [1]. In addition, according to the Health Economics Unit of the Ministry of Health and Family Welfare [2], the proportion of GDP allocated to the health and population sectors was more than doubled between 1985:86 to 1994:95 from 0.6 to 1.3%. A signicant proportion of this allocation was earmarked for primary health care. While these allocations are encouraging and seem to have had a favorable impact on major demographic indicators such as crude birth rates, crude death rates, infant mortality rates, and total fertility rates, the perceptions that people have regarding the country's health care system remains to be assessed. This assessment is important because perceptions have behavioral implications. In fact, given present conditions, patients' experiences with

the country's health care system might actually reinforce negative perceptions about the system. For example, even with the increased allocation to health care, access to the system continues to be problematic and is evident from a variety of indicators: Critical staff are absent, essential supplies are generally unavailable, facilities are inadequate, and the quality of stafng is poor. Problems of supervision and accountability exacerbate the problems, while corrupt practices seem to be on the increase as media reports indicate. The question of access thus remains an open issue as severe resource constraints continue to plague the health sector. Considering that population growth rate in Bangladesh will place additional demands, the capacity of the existing health care delivery system is clearly inadequate to the task of providing proper health care services to its constituencies. What should be of greater concern, however, is that even if the problems of access were to be substantially alleviated, it would still not guarantee full utilization of the health care system if the quality of services is compromised. In Nepal, for example, the Government made substantial investments in basic health care; yet, utilization remained low because of clients' negative perceptions of public health care [3]. In Vietnam, poor service in the public sector led to increased use of private providers [4]. These instances suggest that the role of quality must be understood better and given greater attention. In fact, problems with quality in health care may be responsible for a rather disquieting and disconcerting trend that has begun to surface in Bangladesh: large numbers of the afflicted, especially those who need secondary and tertiary care, seem to be seeking health care services in other countries. While these people generally represent the wellto-do class, others are also beginning to join the exodus. This loss of condence in the ability of the health care system to meet their needs is largely a reection of the quality problems that are perceived by users of the system. The implications are also grave. Primarily, it places inordinate demands on the country's foreign exchange reserves; their deploy-ment in other sectors is thus severely curtailed. A longer term threat looming in the horizon is that the current exodus could inuence even more people to abandon the health care system in Bangladesh as they gain access to information about the quality of health care services in other countries. Because of these trends, and because the perceived quality of health care in the country can aggravate these trends, this paper sets out to examine the quality of health care services provided by public and private hospitals in Bangladesh. Two propositions are explored in the paper: 1. The quality of services is likely to be better in private hospitals than in public hospitals because of the incentive structure. In other words, because private hospitals must fend for themselves, they will provide better services to retain client loyalty. These pressures do not affect hospitals in the public sector because their operations are guaranteed by the taxpayer and because there are no incentives for them to do any more than what is minimally required. 2. The overall quality of services in both types of hospitals has room for improve-ment as evidenced by the outow of patients to other countries. The assessment of quality, however, can be challenging. For example, Weitzman [5] indicates that health care quality can be dened in relationship to: (1) the technical aspects of care; (2) the interpersonal relationship between practitioner and patient; and (3) the amenities of care. In addition, it is also important to specify who will assess quality and on what criteria. While, historically, quality standards have been established and assessed by those in the medical profession, patients' assessment of quality care has begun to play an important role in recent years. In this regard, Petersen [6] suggests that

it is not important if patients are right or wrong, what is important is how they felt even though the caregiver's perception of reality may be quite different. If patients are not convinced that selected hospitals can deliver quality services, they will seek the services elsewhere most likely in other countries if it is within their means. Thus it is important to ask patients directly about the perceived quality of services provided by the country's hospitals. Regarding the criteria for assessing service quality, some guidelines have been established in prior research. For example, the SERVQUAL framework, rst proposed by Parasuraman et al. [79] has guided numerous studies in the service sector. However, empirical support for the proposed framework and the measure-ments has not always been very strong. Not surprisingly, the SERVQUAL model and its measures have been widely debated [1012]. In the context of hospitals, Reidenbach and SandiferSmallwood [13] have shown the existence of measurement problems with SERVQUAL. The Bangladesh context of this study suggested the need to include additional contextual variables to establish service quality criteria and their measures. Qualita-tive interviews provided support to this contention and concepts such as baksheesh (service for extra compensation, i.e. questionable payments) and discipline (a sense

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of order) were included in assessing perceptions of service quality. Consequently, instead of conning the study to the theoretical structure and measures suggested by the SERVQUAL framework, an alternate framework was adopted in this study. The key concepts are described next. Then the research method is explained, followed by the ndings and conclusions.

2. Conceptual framework The proposed core components of hospital service quality in Bangladesh are as follows. 2.1. Responsiveness The literature ideates responsiveness as an important component of service quality and characterizes it as the willingness of the staff to be helpful and to provide prompt services. Six items were used to delineate and measure the construct (see Table 1).

2.2. Assurance Assurance is dened as the knowledge and behaviors of employees that convey a sense of condence that service outcomes will match expectations. Six items were used to measure this construct to reect competence, efciency, and the correctness of services provided to clients (see Table 2). 2.3. Communication Communication is dened as keeping customers informed in language they can understand; it also involves listening to them. Communication with patients is vital to delivering service satisfactions because when hospital staff take the time to answer questions that concern patients, it can alleviate their feelings of uncertainty. Four items were used to assess the level of communication at public and private hospitals (see Table 3). 2.4. Discipline

Discipline is dened as the sense of order that one perceives in a given service environment and is reected in both behaviors of the staff and the appearance of the overall hospital environment. In many organizations and institutions in Bangladesh, lack of discipline is pervasive. Employees are often reluctant to perform their prescribed tasks and demonstrate a proclivity to circumvent existing rules and regulation. Cleanliness is another manifestation of the extent of order and discipline in the organization. In the hospital environment, the extent of discipline

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can inuence perceptions of service quality. Six items representing aspects of discipline were used to measure the construct (see Table 4). 2.5. Baksheesh Baksheesh represents the extra compensation that is expected in many service settings in Bangladesh for `due' services. This concept seems to have taken root in the country's social fabric. Although there is a ne line, it may be distinguished from bribes in that bribes represent payments or demands for money to obtain or render `undue' services. Two items were used to measure Baksheesh (see Table 5). These ve constructs represent the initial set of factors that emerged as latent variables from our exploratory analysis. Services at private and public hospitals were compared along the measures of these factors. 3. Methodology 3.1. Secondary research Existing research was rst examined to determine whether any studies were conducted in Bangladesh to compare the quality of services between private and public hospitals. An extensive search turned up relatively little information. Conse-quently, this study was based on in survey data. The conceptual framework and its key parameters were based on qualitative interviews with experts and a cross-sec-tion of recipients of health care service in Bangladesh. Based on their inputs, and a review of the literature from other countries, a number of issues were identied. Five important dimensions of hospital service quality were derived as latent variables from the data structure. 3.2. Questionnaire design A preliminary version of the questionnaire was rst developed in English. The items were translated next into the local language (Bangla) and retranslated until a panel, uent both in English and Bangla, agreed that the two versions were comparable. These items were rated on seven-point Likert scales in a structured format with the verbal statements `strongly disagree' and `strongly agree' anchored to the numerals 1 and 7. This format has been recommended for health care surveys [14]. Multiple items were used to represent each construct and were assessed for their reliability and validity. The questionnaire was pre-tested several times. 3.3. Sampling and data collection Because of the preliminary nature of this investigation, 300 interviews were planned from Dhaka City only. In the absence of reliable lists, considerable effort was devoted to selecting the sample. The population was dened as residents of Dhaka City who had utilized hospital services in the past 12 months.

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To obtain a random sample, stage-wise area sampling was combined with systematic sampling. First, 17 residential areas were randomly selected from a generated list of all major residential areas. In each selected area, a list of major streets was developed based on trafc ow. At least two streets were randomly selected from this list. Some judgment had to be used at this stage because a `major' street is not a standardized concept. Residential homes were considered as the sampling units; if they were situated on the selected streets, and they generally were, households were chosen using systematic sampling. If enough interviews were not generated from a major street, bylanes were selected, assuming that the population characteristics would be similar in a residential area along a major street. Interviewers were sent in pairs. They were also given a letter of introduction from a recognized university for residents to see that the study was authentic. A telephone number was also provided if respondents had questions or concerns. Field interviewers met with some difculty since not all the selected households had a member who was hospitalized in the past 12 months. Other households did not grant interviews because, being unfamiliar with studies of this nature, they seemed suspicious about the purpose of the study. Due to time and resource constraints, interviewers who were not able to complete the required number of surveys were given a second option. Assuming that the population characteristics were similar in a given area, they were asked to go to ofces and shopping centers in their selected areas. Again, using systematic sampling and after a quick screening question on respondents' use of a hospital in the past 12 months, interviewers proceeded with the survey questions. A total of 216 surveys were nally completed of which nine were discarded because of missing data and response biases. Approximately 11% of the total sample were drawn from the population centers. In proling the respondents, it was found that they had been to 57 hospitals and clinics in the city. Of them, 48% went to a public hospital while 52% went to a private hospital. The demographic distribution of the respondents indicated the following: gender 60% were males and 40% females; education 14% had primary education, 33% had secondary school certicate or a higher secondary certicate, and 53% had a higher degree (perhaps reecting who has access to health care); and income 23% had income less than Tk. 5000 (US $1Tk. 50 approx.), 42% had income of Tk. 500120 000 and 34% had income of Tk. 20 000 or higher (again a reection of who has access to hospital). While we have no basis for comparison, the sample seemed consistent with the type of person living in a residential area who would be able and willing to use hospital facilities in Dhaka City.

4. Analyses Several data analysis techniques were used. Frequency distributions were ob-tained to check for data entry errors (e.g. unrecognized or missing codes) and to obtain descriptive statistics. The constructs depicting service quality were derived

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from factor analysis with varimax rotation; these factors were assessed for reliabil-ity (using coefcient alpha). The results indicated that the reliability coefcient exceeded the value of 0.7 for each construct. These values conform to the recommendations of Nunnally [15]. Validity of the measures was supported by the loadings of the multipleitems in the factor structure; all items loaded on clearly discernible factors.

5. Results For each construct, its component measures were compared using multivariate and univariate ANOVA to look for signicant differences in service quality between public and private hospitals. 5.1. Responsi6eness Table 1 indicates that the multivariate test of signicance for responsiveness was signicant. The null hypothesis of no group difference was rejected. For each of the six items measuring responsiveness, private hospitals were perceived as more responsive than public hospitals. This nding supports the rst proposition. The mean scores also indicate that private hospitals were rated slightly above the mid-point of the seven-point scale while public hospitals were rated near or below the mid-point. 5.2. Assurance Table 2 summarizes the results for assurance. Interestingly, while the multivariate tests of signicance led to rejection of the null hypothesis, univariate analysis showed only one signicant difference. No signicant difference was perceived in the skills of the staff at public and private hospitals. This may be explained by the fact that many hospital staff (especially doctors) working for the public hospitals are also afliated with private hospitals. Thus, it is not surprising that there was no signicant difference on this item. The results also indicate that services were not provided more efciently at the private hospitals. This result is at variance with the rst proposition that the incentive structure in the private sector would lead to more efcient services in this sector.

The third item suggests that staff professionalism at both public and private hospitals are perceived as comparable as there was no statistical difference. The fourth item indicated that medical procedures were more apt to be performed correctly the rst time in private hospitals. This nding supports the rst proposi-tion since the quality of service delivery was expected to be tied directly to potential rewards that the private hospitals can tap into. For example, when medical procedures are performed correctly the rst time, the potential rewards are high (loyal clients, positive word-of-mouth advertising, etc.); when performed poorly, patients' refusal to pay or to demand additional time to correct the

problem (when

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Table 1 Manova: tests of group differences on responsivenessa Variable Means Univariate F-tests

x
pub

x
pvt

F-value 17.026 15.49 23.40 8.65 16.75 21.57

Signicance PB 0.001 0.001 0.001 0.01 0.001 0.001

The staff were responsive to patient's needs The staff was caring The staff responded immediately when called The staff were courteous Hospital staff were helpful Services provided were prompt Responsiveness Multivariate tests of significance Pillais Hotelling's Wilks
a

4.29 (1.74) 4.13 (1.77) 3.76 (1.84) 4.29 (1.86) 4.14 (1.72) 3.79 (1.72) a 0.91

5.26 (1.46) 5.08 (1.53) 4.99 (1.62) 4.99 (1.36) 5.06 (1.34) 4.88 (1.49)

0.1353 0.1564 0.8646

Exact F4.70 with 6

df PB0.001

Figures in parentheses represent the standard deviations.

Table 2 Manova tests of group differences on assurancea Variable Means Univariate F-tests

x
pub

x
pvt

F-value (1.53) (1.41) (1.46) (1.69) 0.54 2.57 0.94 5.00 0.32 0.06

Signicance PB 0.46 ns 0.11 ns 0.33 ns 0.027* 0.57 ns 0.13 ns

The facility had skilled staff Services were provided efciently The staff were professional Medical procedures were correct the rst time The doctors were competent The nurses were well trained Assurance Multivariate tests of significance

5.00 4.64 4.85 5.01

(1.38) (1.51) (1.49) (1.74)

4.83 5.00 5.07 5.60

5.61 (1.33) 4.97 (1.57) a 0.89

5.50 (1.26) 4.92 (1.39)

Pillais Hotelling's Wilks

a

0.10349 0.11544 0.89651

Exact F3.161 with 6 df

PB0.001

Figures in parentheses represent the standard deviations.

S.S. Andaleeb : Health Policy 53 (2000) 2537 Table 3 Manova: tests of group differences on communicationa Variable Means Univariate F-tests

33

x
pub

x
pvt

F-value 5.76 4.74 17.11 13.69

Signicance PB 0.01 0.05 0.001 0.001

The doctors were willing to answer any questions I received adequate explanations of any tests I had to undergo I was given adequate information about my health condition I was given adequate information about my treatment Communication Multivariate tests of significance Pillais Hotelling's Wilks
a

4.62 (1.76) 4.28 (1.94) 4.10 (1.93) 4.33 (1.89) a 0.85

5.24 (1.54) 4.91 (1.70) 5.21 (1.47) 5.27 (1.31)

0.10076 0.11205 0.89924

Exact F4.40 with 4 df

PB0.001

Figures in parentheses represent the standard deviations.

Table 4 Manova: tests of group differences on disciplinea Variable Means Univariate F-tests

x
pub

x
pvt

F-value 8.92 23.41 34.64 11.35 25.90 1.92

Signicance PB 0.01 0.001 0.001 0.001 0.001 0.167 ns

Rules and regulations were strictly maintained questions Cabins:wards were regularly cleaned Toilet facilities were clean The staff was disciplined Cleanliness was maintained throughout the facility The hospital staff had a clean Appearance Discipline Multivariate tests of significance Pillais Hotelling's Wilks
a

3.88 (1.86) 4.28 3.12 4.11 3.61 (1.98) (2.12) (1.76) (1.76)

4.65 (1.57) 5.57 (1.57) 4.84 (1.78) 4.92 4.93 (1.69) 5.14 (1.57)

4.81 (1.69) a 0.92

0.19099 0.23608 0.80901

Exact F6.77 with 6 df

PB0.001

Figures in parentheses represent the standard deviations.

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Table 5 Manova: tests of group differences on baksheesha Variable Means Univariate F-tests

x
pub

x
pvt

F-value 1.70 0.08

Signicance PB 0.1 0.90 ns

Services were not provided properly without tips Hospital staff expected tips Baksheesh Multivariate tests of significance Pillais Hotelling's Wilks
a

4.07 (2.19) 4.66 (2.14) a 0.90

3.45 (2.22) 4.67 (2.17)

0.03751 0.03360 0.96769

Exact F2.96 with 2 df

PB0.1

Figures in parentheses represent the standard deviations.

possible) can represent an opportunity cost of additional earning. Negative word-ofmouth is also likely to further erode potential future earnings. In the public sector, the xed compensation and inadequate incentives imply that the opportunity cost of making mistakes is much lower. This is what patients seem to be corroborat-ing. On the remaining items, there was no difference. 5.3. Communication Table 3 indicates that the multivariate test for this construct was signicant; on all four items measuring communication, private hospitals obtained a signicantly higher rating than public hospitals. It is interesting to note that although the hospital staff are perceived as comparable in skill and professionalism (see Table 2), their behavior patterns are signicantly different: those at private hospitals are rated better by the patients. This apparent contradiction may be explained by the incentive structure. 5.4. Discipline Table 4 indicates that the multivariate test was signicant. As expected, private hospitals are perceived as signicantly better on discipline than public hospitals except on one attribute: the cleanliness of the staff. We feel strongly that it is the incentive structure that drives a lower level of discipline in the public hospitals where service standards, responsibility, and accountability are compro-mised often. 5.5. Baksheesh Table 5 indicates that the multivariate test for Baksheesh was not signicant. In other words, the propensity to seek Baksheesh in public hospitals is no greater than

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in private hospitals. Somewhat surprising was the nding that while the respondents indicated that hospital staff expected baksheesh (scores were higher than the mid-point of the scale), they did not feel as strongly that services would not be provided without baksheesh. The mean scores also suggest that the propensity to expect baksheesh is not extreme. While this is a welcome sign, additional studies are needed to corroborate the ndings. The following additional observations, derived form the results, are also perti-nent. On responsiveness, the highest score attained by private hospitals was 5.26 on one of the measures; the lowest attained score was 4.88 on another. Public hospitals did not even earn a score of 5.00 on any item but were rated as low as 3.76 suggesting the negative perceptions held about their responsiveness. The ratings were somewhat better for assurance, marginally lower for communication and discipline, and around average for baksheesh. These results do not indicate that public hospitals deliver abysmal service, especially when their circumstances are considered. However, both groups have room for improvement; and unless they do so, patients may be inclined to seek health care services in other countries that may be perceived as providing better quality of services.

6. Conclusions It was proposed that the incentive structure in the private and public hospitals would explain differences in the quality of services provided by these organizations. This contention was largely supported since private hospitals obtained better ratings than public hospitals on most of the measures of responsiveness, communi-cation, and discipline. These differences suggest that private hospitals are playing a meaningful role in society, justifying their existence, continuation, and growth. If private hospitals are encouraged because of the increasing demand for services, it is important that they are not allowed unbridled expansion. This is because private hospitals have been known to reduce quality by reducing inputs, disregard social pricing considerations, or, worse, try to increase their prots by providing services that are unnecessary or even harmful ([16]). These practices can be of concern, especially in an environment where little has been done in the area of malpractice law. Moreover, there are no known instances where hospitals or doctors have been held accountable or penalized for negligence, a not so uncom-mon occurrence. Thus, any effort at expanding private hospital care must also be preceded and strengthened by the introduction of laws that protect the patient better than what they do today. At the same time, the government must not intrude into planning the size, type, and location of the private hospitals. In fact, to strengthen health care practices in the country, the government should consider encouraging and inviting foreign capital and expertise so that new technology and modern managerial practices with their attendant efciencies are gradually intro-duced in the country for local hospitals to emulate. These views on privatization are not intended to imply that public hospitals ought to be phased out or de-emphasized because they have an important role to

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play in the area of equity by making health care available to a wider community who cannot afford private care. What they need, however, is to establish a set of criteria against which their performance is benchmarked and compared at regular intervals (at least once a year). Several important criteria and their measures are suggested by this study. In addition, the incentive structure in public hospitals must also be designed to ensure that the appropriate standards of service are delivered. One solution is to tie a part of the compensation of health care personnel in public hospitals to services rendered and the feedback received from patients. This, of course, is a complex issue and has implications for pay scale administration where health care staff, as government servants, are bound by certain pay struc-tures. The practice of baksheesh must also be curbed in both public and private hospitals because things could go out of hand; worse still, practices such as bribery could become commonplace. Where government agencies have failed to effectively control this aspect of service delivery, they may have to be replaced by community groups or in-patient committees to counteract the growing menace. Without continuous monitoring and rapid enforcement of the law, the problem could escalate rapidly. The results also indicate that while the private sector has an edge over the public sector, the differences in service evaluations were not great. Moreover, with the exception of a single item (see Table 2), the scores do not exceed the 5.5 mark for any item on the 7-point scales. Clearly, both public and private hospitals have room to improve and must strive to achieve higher scores on all the variables except baksheesh. To determine whether this is being achieved, evaluations must be conducted on the selected constructs at regular intervals and compared against a benchmark such as this study. These ndings must also be widely disseminated. By doing so, they will continue to raise the awareness of the public and send a strong message to those hospitals that are slow to respond to `customer' needs. A continuous stream of such studies, that would be open to public scrutiny, could inuence complacent health care providers to respond to the standards of service that the public expects. Otherwise, the exodus to foreign countries, in search of better health care, will intensify, hurting the economy by draining its meager resources. In addition, if the pride and professionalism of the people who work in the hospitals in Bangladesh can be provoked through continuous evaluations and appropriate incentives, the long-neglected patient is likely to be better off physically, emotionally, and nan-cially.

Acknowledgements The author acknowledges the assistance provided by Nuzhat Zaman, Sohel Shams, and Imtiaz Karim during data entry and preliminary analysis. The contri-butions of individuals associated with Independent University, Bangladesh and a grant from the Ofce of International Programs at Pennsylvania State University were also instrumental in completing this study.
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