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Customer Satisfaction at Public Hospitals in Pakistan: PAKSERV

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Customer Satisfaction at Public Global Business Review

15(4) 677–693
Hospitals in Pakistan: PAKSERV © 2014 IMI
SAGE Publications
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New Delhi, Singapore,
Washington DC
DOI: 10.1177/0972150914543556
http://gbr.sagepub.com

Muhammad Kashif
Umair Altaf
Hafiz M. Ayub
Umer Asif
John C. Walsh

Abstract
Research studies investigating service quality in organizations have popularized various tools. However,
the usefulness of these tools in cross-cultural settings has been challenged and needs further investiga-
tion. The purpose of this study is to examine the efficacy of PAKSERV in deciphering the service quality
of public sector hospitals in the Asian context of Pakistan. The study used a survey method where data
was collected through a questionnaire which employed the PAKSERV dimensions of tangibility, reli-
ability, assurance, sincerity, personalization and formality. Data was collected from 500 respondents
visiting different public sector hospitals in the province of Punjab, Pakistan. The collected responses
were analyzed using means, correlations and confirmatory factor analysis to interrogate the PAKSERV
model’s reliability and confirmation in an entirely new context. Findings suggest some clear gaps in the
quality of public hospitals in Pakistan, specifically in the ‘formality’ and ‘tangibility’ dimensions. However,
all PAKSERV dimensions generated excellent results except for the ‘Formality’ dimension, which
indicates a need for theoretical adjustments while investigating further the service quality of public sec-
tor health care. This research is an original contribution to the body of knowledge as PAKSERV has
been used for the first time to measure service quality of public sector hospitals in Asian settings. The
formality dimension is not valid in case of measuring service quality of public sector hospitals. It indi-
cates a clear need to further investigate PAKSERV service quality with public sector organizations. The
study uncovers certain areas that were not previously discussed through SERVQUAL service quality
measures of public sector hospitals in an Asian setting. The findings of this study will be beneficial for
health care quality assurance officials, aspiring to improve the current stature of public sector health
care in countries like Pakistan. The research is limited to public health care in Pakistan as the sample
consisted of middle-class people, visiting various public sector hospitals.

Muhammad Kashif, Assistant Professor of Marketing, GIFT University, Gujranwala 52250, Punjab, Pakistan.
E-mail: kashif@gift.edu.pk; kshfsaeed@yahoo.com
Umair Altaf, BBA Graduate, GIFT University, Gujranwala 52250, Punjab, Pakistan. E-mail: mr.umair.a@gmail.com
Hafiz M. Ayub, BBA Graduate, GIFT University, Gujranwala 52250, Punjab, Pakistan. E-mail: hafizmayub@live.com
Umer Asif, BBA Graduate, GIFT University, Gujranwala 52250, Punjab, Pakistan. E-mail: umerasif@gmail.com
John C. Walsh, Assistant Professor of Management, Shinawatra University, 197 BBD Building (Viphavadi)
Viphavadi–Rangsit Road, Samsen Nai, Phayathai, Bangkok 10400, Thailand. E-mail: Jcwalsh100@hotmail.com
India Quarterly, 66, 2 (2010): 133–149

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678 Muhammad Kashif, Umair Altaf, Hafiz M. Ayub, Umer Asif and John C. Walsh

Keywords
Public hospitals, SERVQUAL, PAKSERV, service quality, Pakistan

Introduction
The service sector of Pakistan contributes more than 50 per cent of the GDP, generates 34 per cent of
employment and brings US$4 billion in remittances from abroad (Ahmed and Ahsan, 2011). A generally
young workforce, low labour costs, with many workers capable of speaking English and a strategically
important geographical location are the major strengths of Pakistan and these factors are contributing
towards overall growth (Amjad et al., 2005). One of the major sectors of service-based economies is
health care, which provides huge opportunities for employment to low-skilled workers and is recognized
as the ‘pull factor’ for the tourism industry. Developments in the health care sector are underway in
public and private sector hospitals but these organizations also face difficulties in managing the service
quality aspects and challenges of issues such as intangibility, heterogeneity, inseparability and
perishability (Huseyin, 2006). Although little attention has been paid to educating the general public
regarding health care in developing countries, patients can provide valuable feedback to improve the
service quality of health care (Huseyin, 2006). Customer satisfaction in health care is regarded as one of
the most important factors for decision making in the health care industry and has been studied repeatedly
(Butt and de Run, 2010). Consequently, both public and private sector hospitals must take into account
customer satisfaction as an important contributor towards sustaining quality standards (Zeithaml, 2000).
Quality in services is a cultural phenomenon and can only be explained through and for a specific
cultural context. Walbridge and Delene (1992) showed in their study that a physician attitude is actually
an aspect of service quality. Respondents in their sample rated the reliability dimension at the highest,
while the third and fourth most highly rated dimensions were empathy and assurance, respectively.
Peyrot, Cooper, and Schnapf et al. (1992) studied the characteristics of non-medical services among
which were staff behaviour, comfort and perceived worth, examination and hospital atmosphere. The
study concluded that consumer satisfaction depended on such consumer perceptions of service quality.
Service quality has been most commonly assessed through the SERVQUAL scale. However, this
technique has been criticized and experts today believe that it is less appropriate and significant for
measuring service quality in non-western cultures (Malhotra et al., 2005). The researchers (Malhotra
et al., 2005) further believed that marketing is not emphasized in developing countries; hence, more
focus is needed to understand the customers. The PAKSERV model was developed to evaluate service
quality in a non-western context, especially in an Asian society (Raajpoot, 2004). Service quality can
be accessed through many ways but most of the models have limitations in capturing information,
especially in the particular circumstances of a non-western culture. The PAKSERV model is useful in
evaluating service quality in a non-western culture and is, of course, particularly well suited to the
Pakistani context (Raajpoot, 2004).
The poor performance of the health care sector, especially in developing countries, has been noted
and major deficiencies include the absence of staff, non-availability of essential supplies, insufficient
facilities, neglectful behaviour of hospital staff, absence of proper checks and balances, lack of
management skills and fraudulent practices (Andaleeb and Millet, 2010). Increasing population levels,
together with the greater availability of consumer choice in health care has triggered the public’s desire

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Customer Satisfaction at Public Hospitals in Pakistan 679

for better standards of living and now they are demanding and expecting improved health care services
(Padma et al., 2010).
Pakistan is one of the most highly populous countries in the world and almost 70 per cent of the
population resides in rural areas, with just small proportions living in urban and semi-urban areas
(Chaudhry et al., 2006). However, the urban population enjoys health care facilities both in the public
and private sectors, while rural consumers lack basic health care facilities (Irfan et al., 2011). The
Government of Pakistan provides its citizens with a subsidized health care service in the form of public
sector hospitals, known as ‘civil hospitals’, with at least one in all the major cities of Pakistan. Despite
exponential growth in the country’s service sector, there has been less focus on measuring the service
quality of public sector organizations, especially when it comes to health care. The current study
acknowledges recent criticisms on SERVQUAL as well as the knowledge gaps which exist while talking
about service quality of public sector hospitals in the Asian context of Pakistan. Despite significant
research in measuring the service quality through SERVQUAL, Kueh and Voon (2007) and Ladhari
(2008) promote further investigations of through culturally sensitive scales to ensure their validity in
different socio-cultural settings. The current state of health care marketing research calls for answering
the following research questions, especially with respect to countries like Pakistan:

1. What is the current stature of service quality and customer satisfaction in Pakistan?
2. Which dimensions of service quality model(s) have been acknowledged by the lower-income
customers of public health care?

In order to answer these questions, the current study adopts a new model, PAKSERV, to evaluate
customer satisfaction and service quality offered by public sector hospitals. The scale has been designed
specifically for use in Pakistani settings (Raajpoot, 2004). The study will be helpful for health care policy
makers in satisfying the consumers belonging to a lower middle class in a developing country. The
literature review is presented in the next section; the research objectives and methods employed to
complete this research are then discussed under the methodology section; this is followed by the results
and findings section, in which the data analysis is presented through various tools; and the last section
explains the conclusion, while also outlining the contribution to knowledge.

Literature Review

Role of Service Excellence in the Public Sector

The hospital industry is growing very quickly but, like other service sector organizations, public hospitals
are facing the challenges of intangibility, heterogeneity, inseparability and perishability (Huseyin, 2006).
Service quality has become an important element for the satisfaction and sustaining of customers in this
era of global change (Spreng and MacKoy, 1996). Another crucial point to focus upon is that the
marketing of services is relatively different as compared to goods (Grönroos, 1990; Yi, 1990). A customer
who has used both the public and private hospital services over a period of time can provide important
feedback which will be helpful in improving the overall service quality of the health industry (Huseyin,
2006). Service quality is an important factor that helps determine demand for goods and services, as well
as being helpful in sustaining competitive advantage (Fitzsimmons and Fitzsimmons, 1994). Customer

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680 Muhammad Kashif, Umair Altaf, Hafiz M. Ayub, Umer Asif and John C. Walsh

perception is one of the more important factors for indicating service quality in health care but it should
be investigated further to explain the level of service quality properly, especially in the case of developing
countries (Cronin & Taylor, 1994; O’Connor et al., 1994). Customer satisfaction is considered to be an
important factor for decision-making in the health care industry (Gilbert et al., 2004). Consequently,
hospitals take into account customer satisfaction as an important tool for their goals (Zeithaml and
Bitner, 2000). Although the public sector’s service quality has been studied by many researchers from a
Pakistani perspective (Rafi, 2006; Saeed and Ramazan, 2003), service quality work in the health care
sector is absent. This study investigates this missing link and contributes through an assessment of the
perceptions of service quality by users of public health care in Pakistan.

Service Quality in Health Care

Quality of care represents a focus on the outcomes of the care that is delivered during the hospital stay
and is an important indicator of the quality performance of a hospital (Donabedian, 1966). Previous
research studies measuring the extent of patient satisfaction with hospitals identified five important
elements in this area: communications, cost, facilities, competence and demeanour (Andaleeb, 1998).
Other researchers have suggested additions to the SERVQUAL scale, including items such as economy,
security, performance, convenience, aesthetics and reliability (Raduan, 2004). There has been some criti-
cism of SERVQUAL in that the model is missing elements like ‘caring’ and ‘patient outcomes’, which
should be included alongside other items (technical quality is an important predictor of customer satis-
faction in health care but SERVQUAL is unable to measure whether, for example, a patient is getting
effective pain relief or other post-service aspects (Haywood-Farmer and Stuart, 1988)). It has also been
suggested that the quality of service and customer satisfaction in health care can be measured through
three variables; (a) attitude, behaviour and experience of employees in providing services; (b) service
design, peer-related factors and physical evidence of hospitals; and (c) lead time in service delivery,
tangibles and overall value derived from that service (Brady and Cronin, 2001). Another research study
was carried out in the emergency departments of different hospitals and the researchers recommended
three variables to be included in service quality surveys: image and reputation of physician’s technical
service quality, total waiting time in hospital and the nursing care provided by staff available at the
hospital (Aragon and Gesell, 2003). Given these different arguments in health care service quality, there
still seems a lot of work to be done.

Customer Satisfaction and Service Quality in Health Care

Customers are satisfied when their expectations are met or exceeded. Consumers exhibit different sets of
emotional responses during the service encounters which form the basis for service quality evaluations
(Westbrook, 1995). In other words, the consumer’s ‘emotional pleasure’ must be exceptional during the
service encounters and these are later translated into customer satisfaction (Yi, 1990). Health care organ-
izations, especially in developing countries, tend to spend very little on marketing initiatives but due to
the recent wave of intensive competition from the private sector in countries like Pakistan, enhancing the
focus on customer satisfaction has become imperative. This is also evident from the fact that customer
satisfaction should not be overlooked and is an important contributor towards customer retention in

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Customer Satisfaction at Public Hospitals in Pakistan 681

health care (Mayer et al., 1998). Patients, in various states of health, evaluate hospital quality after
several visits and service quality and delivery are considered important in this regard (Morgan et al.,
1998). These studies have indicated that customers evaluate different aspects of hospital services, instead
of only limited set of variables, contributing towards being ‘satisfied’ or ‘dissatisfied’ customers (for
example, doctors’ attitudes, promptness of service delivery, time spent advising, etc.). Customer satisfac-
tion in health care depends upon the level of comfort, convenience, medical ethics, quality and availabil-
ity of drugs, as well as expenses incurred at the hospital (Lee, Yoon and Lee, 2007).
Measuring the quality of services has been critical to the better performance of businesses and plays
a pivotal role in contributing towards success (Bolton and Drew, 1991). Service quality has increased
customer satisfaction, which benefits the organization through positive word of mouth among the
targeted audience, enhanced customer loyalty and changes to consumer behaviour. There are many tools
to measure the service quality of any firm but SERVQUAL is among the most popular. It was developed
from exploratory work and has five dimensions: tangibility, reliability, responsiveness, empathy and
assurance (Parasuraman et al., 1988). Service quality is considered to be the difference between percep-
tion of performance and expected level of services (Parasuraman et al., 1988). SERVQUAL has the
strongest relationship with overall service quality and is regarded as one of the most widely used service
quality models in western contexts (Quester and Romaniuk, 1997). Babakus and Boller (1992) suggested
that SERVQUAL dimensions can be used to measure the service quality of utility services and the
dimensions have been designed for testing under particular investigations. It has been reported that the
‘tangible’ and ‘responsiveness’ dimensions are significant for collectivist cultures, such as are found in
many Asian countries. Language was considered a possible factor of confusion and inaccuracy in results
(Zhou, 2004), such as when the respondents’ native language is not English and so there may be a lack
of accuracy in scale transformations (Van Herk et al., 2005). SERVQUAL has been criticized, as a
concept, for conceptual deficiencies (Cronin and Taylor, 1994) and operational deficiencies (Babakus
and Boller, 1992; Iacobucci et al., 1995). Its five-dimensional framework has received some experimen-
tal challenges as well, for example, its ability to obtain accurate results in developing countries (Donthu
and Yoo, 1998). In addition, SERVQUAL results are interpreted differently in different cultures, in
accordance with the respective national culture. Consequently, it has generally failed to capture the
essence of the service encounter quality in non-western contexts (Raajpoot, 2004).
Grönroos (1990) studied the service quality construct from a different perspective and proposed that
company image is significant to the perception of service quality. The Grönroos model is widely used in
Europe and has expanded SERVQUAL through functional quality by adding items like corporate image.
It is evident in the literature that service encounter quality has not been fully explained and developed in
non-western cultures. Experts believe that there is a need for more studies measuring the perceived
service quality of health care from an Asian perspective so as to highlight better the areas of improvements
(Butt and de Run, 2010). Cultural differences relate to issues such as frames-of-reference and variable
customer interpretation of quality (Hofstede, 1997).
Despite these classical theories to measure service quality, there are some recent additions to service
quality research. In a study conducted by Niranjan and Metri (2008), researchers challenged the Gap
model popularized by Parasuraman et al. (1988) and argued that an entirely new paradigm is required to
present service quality in IS/ITES outsourcing. These researchers have included some organizational
elements into the scale, such as, vendor management and employees.
Literature in measuring health care service quality from a patient’s perspective is huge but most of
the studies were conducted in a developed country. For instance the study conducted by Arasli et al.

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682 Muhammad Kashif, Umair Altaf, Hafiz M. Ayub, Umer Asif and John C. Walsh

(2008) in a Cypriote context, researchers modified the five dimensions of SERVQUAL and developed a
new scale that included: empathy, relationships, priority, professionalism, food and physical environment.
Although their study found certain psychometric properties, but the researchers suggested further
investigations in other regions, in order to develop better understanding of service quality construct in
public and private sector hospitals. Another scholarly work is presented through the study of Vinagre
and Neves (2008) where an element of ‘emotion’ was focused to relate with service quality of hospitals
in a Portuguese context. The study provided excellent results as researchers believed that patients do not
have the ‘skill’ to evaluate technical service quality of health care; hence, interaction quality must be
focused. Further, the researchers promoted the idea to develop a culturally sensitive service quality scale.
Despite the huge amount of work available to measure service quality of health care settings, many
researches are still being conducted with a country-specific focus. For example, in a recent study
conducted by Lei and Jolibert (2012), researchers empirically tested a three-model comparison between
quality, satisfaction, and loyalty in Chinese health care system. Researchers argued that past studies
probing patient satisfaction have been limited only to the US and Western Europe, with limited work is
addressing the Asian, and in our case, no evidence of service quality stature of public sector hospitals in
Pakistan. Lei and Jolibert (2012) further promoted the idea that a culturally sensitive scale must be used
to better understand the current state of service quality and customer satisfaction in health care settings.
It is also evident that many researchers are still employing the traditional SERVQUAL scale in measuring
service quality. However, some researchers have acknowledged the limitations of SERVQUAL and
modified versions have been employed to investigate service quality (Bhat, 2012). Given the criticism
and the importance attached in the literature to culturally sensitive scales to measure service quality,
Raajpoot (2004) developed a new model to evaluate the extent of service quality: PAKSERV. The scale
was developed in the Pakistani context and consisted of six dimensions, with a total of 24 individual
items. Raajpoot (2004) included tangibility, reliability and assurance from SERVQUAL, while replacing
the dimensions of ‘responsiveness’ and ‘empathy’ with three new dimensions:

1. Sincerity: the extent to which staff seem eager to provide customer service through customer
evaluation.
2. Formality: how well the staff served the customers by keeping in view social distances and
rituals.
3. Personalization: customer’s evaluation in terms of the provision of individual level attention.

PAKSERV scale added some dimensions that are directly related to Pakistani and other cultures alike,
particularly in Asia. For instance, Witkowski and Wolfinbarger (2001) through their study popularized
the ‘Formality’ dimension that translates as employees having excellent interpersonal communication
skills, and exhibition of proper etiquette by maintaining social distance. This is exactly in accordance
with the work performed by Hofstede (2001). He argued that people in Pakistan accept maintaining a
social distance through exercising their power and status in the society. Because Pakistani people score
high on being ‘collectivist’, they expect and like to get special attention as well as some unplanned
advices. In addition to that, high power distance score, at times is translated into ‘maintaining the status
quo’. Finally, because Pakistanis score low on being ‘risk takers’ the customers demand a certain level
of ‘personification’ while being served. These factors were well considered through development of a
PAKSERV scale that even SERVQUAL was missing. PAKSERV’s scale development was based on
some assumptions. First, people from different cultural backgrounds interpret ‘service quality’ and its

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Customer Satisfaction at Public Hospitals in Pakistan 683

items differently. Second, the customers’ expectations vary in different cultural settings and there may be
more or less tolerance with respect to service delivery time. Third, customers give importance just to a
subset of the service quality dimensions instead of all the dimensions used in the model (Raajpoot,
2004). It was observed that consumers mostly give more than 50 per cent weight and explained overall
service quality on the basis of just these dimensions. Since the non-US evidence of service quality meas-
urement with PAKSERV is scarce, thereby limiting validity, a number of replications were highly recom-
mended (Raajpoot, 2004). There were two major reasons that we opted for this scale to present the state
of service quality in public sector hospitals. First, the scale was initially developed and recommended to
be used in a Pakistani context and there is no such other scale available to date. Second, Raajpoot (2004)
developed this scale in private sector organizations and recommended further replications where only
one replica study to date has been noted in the South African banking sector (Saunders, 2008). Hence,
the following research objectives are planned:

1. To present the state of customer satisfaction with the service quality offered by public sector
hospitals of Pakistan.
2. To assess the validity and applicability of PAKSERV scale in a public sector health care setting.

Research Methodology
The purpose of this study was two-fold: first, to capture the customer impressions of service quality in
the public sector hospitals of Punjab, Pakistan; and, second, to present a model of fitness test of PAKSERV
dimensions in Asian context of Pakistan. To test the applicability of PAKSERV in Pakistani public sector
health care settings, the researchers used confirmatory factor analysis (CFA). This was used by consider-
ing the fact that there is sufficient literature available that explains service quality. More specifically,
CFA helped the researchers to test the hypothesis that public health care service quality in Pakistan is
composed of six dimensions of PAKSERV: Tangibility, Reliability, Assurance, Sincerity, Personalization
and Formality. These six dimensions also formed the basis for questionnaire design to measure service
quality. The instrument was composed of two major parts: 24 items on the PAKSERV dimensions and
then respondent’s demographics (for example, age, income, gender and occupation). This cross-sectional
study employed a survey-method and was conducted during the months of April 2011 to January 2012
from five major cities of Punjab (Gujranwala, Sialkot, Lahore, Faisalabad and Multan). A quota sam-
pling technique was used to collect data from a sample of 500 patients (one hundred from each city)
visiting public hospitals. The researchers handed over questionnaires personally to the respondents and
guided them in completion to ease understanding and encourage accurate completion of all items. The
research team received 400 completed questionnaires with a response rate of 80 per cent. The sample
size and response rate is justified through the work of Mehta (2011), where a similar sample set was
tested to measure patient satisfaction in Indian hospitals. The sample size of that research study was 400
patients, who were visiting different hospitals in Gwalior and New Delhi, India.
Although an attempt was made to select patients randomly, it was not entirely possible as some were
unable or unwilling to complete the questionnaire. In such cases, people accompanying the patients
were given the questionnaire. A five-point Likert scale was used to measure the level of perceived per-
formance of hospitals and respondents were asked to indicate their evaluations on a scale ranging from
1 = strongly satisfied, 2 = satisfied, 3 = neutral, 4 = dissatisfied and 5 = strongly dissatisfied.

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684 Muhammad Kashif, Umair Altaf, Hafiz M. Ayub, Umer Asif and John C. Walsh

Before collecting data from respondents, reliability and validity was ensured to maintain the authen-
ticity of research conducted to measure service quality. The final questionnaire was initially checked for
face validity by some health care professionals (Saunders, 2008). Then a small-scale pilot study was
conducted and data was collected from ten people. These techniques have already been used by market-
ing researchers in order to ensure validity of the instrument used (Wallenburg, 2009). The results of
both the validity measures were highly positive as no further improvement or changes in the instrument
were realized.

Findings
The demographics of the respondents have been shared in Table 1. Amongst the respondents for this
study were 309 males and 91 females. This was due to the fact that males always accompany female
counterparts, even in the health care sector. The dominant age group of respondents was between
21 years and above. Interestingly, most of the respondents were ‘high school’ qualified only; hence, the
majority of the patients and people accompanying public sector hospitals in Pakistan are not highly
educated. A very small proportionate of visitors had undergraduate and graduate degrees, 31 and 14,
respectively. Most of the respondents’ occupation was ‘labour work’ that can be clearly linked to the
educational qualifications of the respondents.
Data collected for this research was analyzed using Statistical Package for Social Sciences (SPSS)
version 16.0 and AMOS to calculate means, standard deviations, reliability measures and CFA. The

Table 1. Demographics of Respondents

Variable Frequency
Gender
Male 309
Female 91
Age
10–15 4
16–20 81
21–25 107
26–30 120
31 and above 88
Education
High school 250
Intermediate 105
Undergraduate 31
Graduate 14
Occupation
Government employees 57
Labour work 192
Businessman 30
Others 121

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Customer Satisfaction at Public Hospitals in Pakistan 685

Table 2. Sample Adequacy

Kaiser–Meyer–Olkin Measure of Sampling Adequacy 0.931

Bartlett’s Test of Sphericity Approx. Chi-Square 3392.981
Df 171
sig. 0.000

SPSS assisted in performing means, correlations and reliability tests, but to assess the ‘goodness of
model fit’, the research team employed AMOS version 7.0. The PAKSERV model was tested using
multiple measures: Goodness of Fit Index (GFI), Normal Fit Index (NFI) and Root Mean Square Error
of Approximation (RMSEA).
An item analysis was conducted to test the reliability of the questionnaire and an overall Cronbach’s
alpha of 0.931 was recorded for the six dimensions, which indicates excellent reliability results. The
research methodology that was followed for the investigation is consequently justified. It is pivotal to
understand how data fit particular models and this is demonstrated through GFI. However, for large-
scale sample size measurements, some other GFI are used and recommended. The GFI employs absolute
fit indices where a value greater or equal to 0.9 demonstrates an excellent level of model fit. (There are
other measures commonly used in confirmation analysis for different models which are CFI and NFI.)
The GFI value of 0.99, CFI value of 1.00, and RMSEA value of 0.075 indicate an excellent model fit,
free from errors. These benchmarks have been used by previous researchers in their PAKSERV-led
studies, although in the banking sector of South Africa (Saunders, 2008).
The Kaiser–Meyer–Olkin Measure of Sampling Adequacy (KMO) should be > 0.5 and allows the
researcher to proceed towards factor analysis. A KMO value of 0.9 to 1.00 is considered marvellous, 0.80
to 0.89 meritorious, 0.70 to 0.79 middling, 0.60 to 0.69 mediocre, 0.50 to 0.59 miserable and less than
0.5 inaccurate. The KMO value for this study is 0.931, which places it in the marvellous category and
indicates that the sample is suitable for factor analysis and other data reduction tools. The sample
adequacy test results are presented in Table 2.
The consistency of all the items included in the questionnaire was measured through item-to-total
correlation for the purpose of this study. All the items’ computed values were measured against the stand-
ard value of 0.4. Any item having a computed value less than 0.4 was declared as ‘inconsistent’ and
dropped from the questionnaire. Table 3 exhibits all the items included in the questionnaire, the com-
puted correlation value and consistency. There was only one item, ‘Staff do not use foul language during
service encounters’, which earned a score of less than the standard (0.4): 0.22 and so was dropped.
Keeping in view the mean results, the respondents seem to be satisfied with overall quality delivered by
civil hospitals. The extent of satisfaction for each dimension of PAKSERV has been elaborated further.
Table 4 exhibits the results of service quality as perceived by consumers of public health care in
Pakistan. The Likert scale ranged from 1 = Strongly Agree to 5 = Strongly Disagree. The service quality
of ‘Reliability’, ‘Assurance’ and ‘Sincerity’ and ‘Formality’ items was good with an overall mean score
of 1.25, 1.30, 2.38 and 3.00, respectively. However, under the dimensions ‘Personalization’ and
‘Tangibility’, it was observed that customers are not satisfied with ‘Latest equipment is used’ (M = 4.09),
and ‘Employees treat customers on equal basis’ (M = 3.89). Under the ‘Sincerity’ dimension, all the
items’ mean scores were below 2.20, which signal excellent performance. It can be inferred through
results that staff providing services to customers keep customers’ best interest at heart, provide unsolicited

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Table 3. Item-to-Correlation Analysis

Item-total
Cronbach’s a Correlation Value Consistency Item Status
Tangibles a = 0.491
Q1 Latest equipment is used 0.6409 Consistent Accepted
Q2 Attractive facilities are offered by 0.6810 Consistent Accepted
hospital
Q3 The employees wear neat and clean 0.5912 Consistent Accepted
dress
Q4 The written material is easy to read and 0.6144 Consistent Accepted
understand
Q5 The building is appropriate and signifies 0.5976 Consistent Accepted
quality
Reliability a = 0.766
Q6 Promises are kept by the employees 0.6034 Consistent Accepted
Q7 Specifications provided to customers 0.7336 Consistent Accepted
are followed
Q8 Employees are able to maintain 0.5566 Consistent Accepted
error-free records
Q9 Services are available to patients 0.6341 Consistent Accepted
Assurance a = 0.661
Q 10 Employees treat customers on equal 0.6184 Consistent Accepted
basis
Q 11 Employees ensure physical safety during 0.5357 Consistent Accepted
service encounters
Q 12 Employees are courteous 0.6558 Consistent Accepted
Q 13 Employees are knowledgeable 0.6944 Consistent Accepted
Sincerity a = 0.750
Q 14 Employees keep customer’s best 0.5847 Consistent Accepted
interests at heart
Q 15 Employees provide unsolicited advice 0.6087 Consistent Accepted
Q 16 All the queries are dealt in an 0.5498 Consistent Accepted
appropriate manner
Q 17 Employees are not over-friendly 0.5336 Consistent Accepted
Personalization a = 0.713
Q 18 Individual attention is paid to 0.7124 Consistent Accepted
everyone
Q 19 First name is used to deliver service 0.6754 Consistent Accepted
Q 20 Immediate attention is paid 0.5587 Consistent Accepted
Q 21 Employees provide customized solutions 0.5880 Consistent Accepted
Formality a = 0.348
Q 22 Family names are remembered 0.7323 Consistent Accepted
and used
Q 23 Staff do not use foul language 0.2278 Inconsistent Dropped
Q 24 Total attention is paid to patients 0.7455 Consistent Accepted

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Customer Satisfaction at Public Hospitals in Pakistan 687

Table 4. PAKSERV Dimension Scores

Dimension Mean Rank

Reliability 1.25 1
Assurance 1.30 2
Sincerity 2.38 3
Formality 3.00 4
Personalization 4.25 5
Tangibility 4.50 6

advice, deal with queries in appropriate manner and are reasonably friendly. For the ‘Formality’
dimension, with an overall mean score of 3.00, customers were satisfied with the way service staff
recalled their names and also agree to the fact that staff uses proper language during service encounters.
However, it was noted that staff do not pay ‘total attention’ to the customers with a mean score of
3.59. On the other side, there are major areas for improvement for public sector hospitals as custo-
mers are dissatisfied with the ‘Personalization’ (M = 4.25) and ‘Tangibility’ (M = 4.50) aspects of
service encounters. Customers strongly disagreed that staff in hospitals ‘pays individual attention’ with
M = 4.32. Customers also felt that ‘immediate attention’ is also not paid (M = 4.01). For items, under
the ‘Tangibility’ dimension, the highest de-motivation was with the items: ‘Latest equipment is
used’ with an M = 4.09. Customers also strongly disagreed that the hospital offers modern facilities
(M = 4.31). However, patients were strongly satisfied with the dress requirements as well as the easy
understanding of written materials used to guide patients and their accompanying persons.
Figure 1 shows the CFA diagram, which uncovers the health care users’ satisfaction and PAKSERV
model fitness in the application to the Pakistani public health care sector. Basic analysis of CFA, through
AMOS, was performed and the model examined how well customers’ perceptions based on the PAKSERV
scale fit the data. The model was assessed in the perspective of previously conducted health care studies
(Butt and de Run, 2010) and GFI, CFI and REMSA were used to evaluate the quality.

Service Quality Tier Structure: The Application Perspective

The study is useful in many ways; outlining current state of service quality of public sector hospitals in
Pakistan, delineating model fir for PAKSERV in country context of Pakistan, and on the application side,
to explain the relative importance of attributes through a tier structure (Lai et al., 2007; Saunders, 2008).
This tier structure has been well-documented and effectively used by Saunders (2008), to present the
relative importance of PAKSERV scale dimensions to South African Banking consumers. The three tiers
present the consumer judgement of service quality dimensions, in order of importance. Saunders (2008)
found that ‘Assurance and Sincerity’ are the first tier dimensions, while in our study, ‘Reliability’ and
‘Tangibility’ are found to be the most important dimensions. More specifically, ‘Assurance’, ‘Sincerity’
and ‘Personalization’ are second tier dimensions in this study with only ‘Sincerity’ matching with the
study findings of Saunders (2008). Pakistani health care consumers perceived ‘Formality’ as least
important while Saunders (2008) study found ‘Tangibility’ as the least important dimension for African
banking customers.

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688 Muhammad Kashif, Umair Altaf, Hafiz M. Ayub, Umer Asif and John C. Walsh

Figure 1. PAKSERV Service Quality Model

Source: Author data analysis.

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Customer Satisfaction at Public Hospitals in Pakistan 689

Figure 2. Service Quality Tier Structure

Source: Author data analysis.

Discussion
The study was initiated to serve several purposes; to evaluate service performance of public sector hos-
pitals in Pakistan and to assess the validity of the PAKSERV model in measuring service quality of
public health care. The results of model significance are encouraging and, except for the ‘Formality’
dimension, all other facets of the PAKSERV model are applicable to measure the health care service
quality offered by public hospitals. Tables presented in this study signal various interpretations. For
instance, while looking at the descriptive statistics, concerning PAKSERV dimensions, it has been
noticed that respondents mostly seem to be satisfied with the service quality offered by public sector
hospitals in Pakistan. This may be due to the fact that health care services in the public sector are offered
at very low prices that are affordable to people of every class, particularly lower income segments.
During the course of this study, it was observed that people, who visit public sector hospitals, mostly
belong to the lower income segment, their education levels, occupation and researchers’ observation and
experience in understanding the health care system in Pakistan are the evidence for this interpretation.
However, there are many areas of improvement, concerning service quality, especially under the
‘Personalization and Tangibility’ dimensions, in public hospitals of Pakistan. The tier structure idea has
been highly influenced by the work of Saunders (2008) but presents some valuable interpretations:
Pakistani people value ‘Reliability’ and Tangibility’ that is contradictory to the previous study conducted
by Saunders (2008). This is attributed to the fact that there are major investments made by the private
sector hospitals in Pakistan by improving their quality with a special focus on providing spacious build-
ings, modern tools and reliable services. These initiatives of private hospitals have increased the expecta-
tions of all the consumers, and making them more demanding and knowledgeable (Irfan et al., 2011).
The ‘Formality’ dimension in tier 3, has not been much valued by Pakistani consumers, and it is also
evident through Figure 2, where this dimension scored a negative result: −0.52. This has several reasons
and implications. As stated earlier, the patients visiting public hospitals mostly belong to the lower
income segment and they do not seem to expect the staff to remember their name and pay full attention
to each and every consumer. They cannot afford private health care and pay very little to avail public
sector health care services, their expectations are much different than those consumers who are paying a
high price for health care services. Another compelling reason for the ‘Formality’ dimension not consid-
ered as valid is that the sample chosen for this study are composed of people having lower income levels,
are from the labour class and are less educated. These people do not demand staff to be highly ‘formal’

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690 Muhammad Kashif, Umair Altaf, Hafiz M. Ayub, Umer Asif and John C. Walsh

during service encounters. Hence, the ‘formality’ dimension being not valid must be acknowledged
under the limits of the sample of this study and may prove to be different if data is collected from people
with diverse demographics. The respondents seem dissatisfied with the ‘Tangibility’ and ‘Personalization’
dimension of public hospitals and interestingly, these two dimensions are figured in Tier 1 and Tier 2,
respectively. This calls for many improvements in the service provision of the Pakistani public sector
health care system. The respondents tend to believe that hospital staff do not pay immediate attention to
everyone, do not provide customized solutions, latest equipment is not used and hospitals do not have
attractive facilities on offer for the patients. These results are in line with the study conducted by Andaleeb
and Millet (2010), where poor service processes and systems of health care in developing countries were
highlighted. The dissatisfaction of customers and low scores on the ‘Personalization’ dimension confirm
the findings of Malhotra et al. (2005) where researchers commented that ‘marketing’ is not actually
focused and applied in developing countries. Low scores on this dimension mean that the service pro-
vider does not know the customer and his/her needs. This may lead to a gap between customer needs and
service provider’s understandings of customer needs, resulting in a total failure (Parasuraman et al.,
1994). This all entails that in order to improve the service quality of public sector hospitals in Pakistan,
the officials need to focus on the ‘Reliability’ and ‘Tangibility’ dimensions. On the other side, dissatis-
faction in the ‘Personalization’ and ‘Tangibility’ dimensions must be encountered.

Conclusion
The PAKSERV model appears, from this research study and elsewhere, to be somewhat more useful in
these circumstances than alternative models such as SERVQUAL and others. However, this does not
mean that it is either the best possible fit or that it will remain the best available fit in the years to come
and when circumstances change. Additional customer satisfaction measurement research is particularly
relevant in this case. The major contribution of this study is on two grounds; first the PAKSERV scale
that has proven valid except for the ‘Formality’ dimension in public health care of Pakistan. Second, the
state of customer satisfaction and service quality is presented through the lens of PAKSERV dimensions
and suggests major areas of importance and improvements. It is concluded that PAKSERV dimensions
are not merely useful for the private sector but also for the public sector in Pakistan. Given the changing
nature of Asian and other cultures, the generalizability of PAKSERV may be extended to some other
regions. This study presented some applications of PAKSERV in the public health care context of
Pakistan; these are rather limited to a particular sector. For a wider generalization of this scale, some
more replications are needed. Since the scale was developed and presented eight years ago, this calls
for another comprehensive assessment of culture-based expectations of service quality dimensions
in Pakistan and elsewhere. The logical frame behind this assumption is the changes occurred in socio-
cultural environments that are shaping customer mindset. Health care research poses a separate issue,
which relates to the relationship between patients and companions and the service to be received. In
general, most episodes of interaction are not voluntary but mandatory and usually undesirable. This
tends to make the relationship between service provider and receiver different from normal and emotions
such as apprehension, gratitude and concern about costs of service which cannot be accurately estimated
beforehand. Again, this adds complexity to the customer service measurement and makes the need for
an accurate research tool more acute, especially since there are strong incentives for respondents to

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Customer Satisfaction at Public Hospitals in Pakistan 691

withhold all or part of their real opinions about current and future health care. This evolves another
area for future research that is inclusion of other health care stakeholders like role of doctors, nurses,
janitorial staff and people accompanying patients in creating an overall service experience.

Managerial Implications
As the previous sections have signalled, there are some clear implications for managers of health care
providers in Pakistan and elsewhere arising from this research study: constant attention should be paid
to the issue of how customer satisfaction may best be measured and how existing research tools should
be improved; as possibilities for health care delivery develop, then managers will need to consider
both how they are incorporated into their hospitals and how such developments should be monitored.
For example, western countries are among those who are adding more functionality to nurse practition-
ers, who are much less expensive than doctors and more likely to be women, whose role in delivering
primary health care can be increased. This will need careful management with respect to the interactions
involved.

Acknowledgement
The authors are grateful to the anonymous referees of the journal for their extremely useful suggestions to improve
the quality of the article. The usual disclaimers apply.

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