A PREDICTIVE MODEL OF SATISFACTION OF BANGLADESHI PATIENTS IN TWO SELECTED PRIVATE

HOSPITALS IN THAILAND

By

Adnan NafisGraduate School of Business

Assumption University

Published in AU Journal of Management, vol. 5, No. 2, July-December 2007:

Assumption University, Thailand.

1

Introduction

In the healthcare industry, hospitals provide the same types of service, but they

do not provide the same quality of service (Youssef et al., 1996). Furthermore,

consumers today are more aware of alternatives on offer and rising standards of

service have increased their expectations. They are also becoming increasingly critical

of the quality of service they experience Patient satisfaction is an important indicator

of the quality of medical care and a major determinant in the choice of a care provider

in the future (Croucher,1991). Accurate and reliable survey information provides the

data basis for continuous quality improvement in the delivery of services. By meeting

the needs of the patient, the institution in turn will ultimately ensure its competitive

position (Curbow, 1986). The Bangladesh government allocates $500 million every

year in the health sector. While the efforts are in the right direction, the public health

sector is plagued by uneven demand and perceptions of poor quality. The private

health care sector (including unqualified providers) is the largest provider of health

care as about 70% of the patients seek medical care from this sector (World Bank,

2003). Absenteeism of health care providers has landed Bangladesh 2nd in the world’s

lowest ranking of countries facing doctor absenteeism in healthcare (World Bank,

2003). The Institute of Health Economics, University of Dhaka, estimates that

Bangladeshis spend approximately $300 million a year on foreign healthcare services

which was supported by the Bangladesh Medical Association-BMA President (World

Bank, 2003). At present, unreliable test results and wrong diagnosis and a general

perception of poor and unreliable services may explain why those who can afford it

have been seeking health care services in other countries. A large number of

Bangladeshi patients are forced to go to India, Thailand or Singapore for treatment.

One report suggests that 1200 patients travel abroad every day for treatments.

(Consumers Association of Bangladesh-CAB, 2003).

Thailand has secured a commanding position in the world health care arena.

Though it is a third world country, it has achieved the quality of the developed

countries. Foreigners flock to Thailand's private hospitals for a variety of reasons,

among them accessibility, cost and quality. The kingdom is one of the three countries

in the region cashing in on its ability to use cheap but highly skilled labor, affordable

hospital accommodation and specialist treatments. In 2003, 60% of Bumrungurd

Hospital’s (BH) revenues came from Thai nationals, with the remaining 40% from

international patients. Of the international patients, 60% were resident expatriates and

2

40% were ‘health tourists’ who came from abroad. Surprisingly enough, Bangladeshi

patients make up the largest ‘health tourist’ geographic segment for BH

(www.thaistock.com). Bangladeshi patients in the two major private hospitals in 2005

were 32,417 and in 2006 were 27,813. Up to May 2007, approximately 15,195

Bangladeshi patients visited these two private hospitals.

Research Objectives

In the competitive market of health care, Thai hospitals need to understand the key

factors of Bangladeshi patient satisfaction which will enable them to achieve a

competitive advantage over Singaporean and Indian hospitals. In this study, the

researcher sought to construct a predictive model of satisfaction of Bangladeshi

Patients in two selected private hospitals in Thailand. In order to do that, the

researcher sought to identify the main dimensions of service quality of Thai private

hospitals affecting Bangladeshi patient satisfaction.

The objectives of the research are:

1. To identify the key service quality factors of Thai private hospitals that affect

Bangladeshi patients’ satisfaction.

2. To assess how Bangladeshi patients’ rate the service quality dimensions of

Thai private hospitals.

The research focused on rating all the dimensions of service quality

(Reliability, responsiveness, assurance, tangibles, communication, empathy, process

features, cost, access, billing services, and treatment outcomes) of two selected Thai

private hospitals by Bangladeshi patients to identify the key factors of a predictive

model of their (patient) satisfaction.

Literature Review

The SERVQUAL instrument has been empirically evaluated in the hospital

environment and has been shown to be a reliable and valid instrument in that setting

(Babakus and Manggold, 1992). Other studies of Health care quality measurement

(Canel and Fletcher,2001; Lam, 1997; Donthu, 1991; Sohail, 2003) have also used

SERVQUAL. Despite controversies regarding the validity and reliability of

SERVQUAL (Teas, 1994; Newman, 2001), the application of SERVQUAL, with or

without modification, can be found in healthcare. The extent of modification or

addition to the SERVQUAL dimensions varies from researcher to researcher. In

3

Bangladesh, few studies were done to evaluate quality and patient satisfaction.

SERVQUAL were used in all of them. The SERVQUAL framework was refined for

the Bangladeshi context by Andaleeb (2000a, 2001,2007). Mittal and Baldasare

(1996) agreed that attributes of a service or product affect the position of an

organization in terms of overall satisfaction. They also mentioned that different

attributes of a product / service might influence overall satisfaction differently

depending on their salience. In the health care context, the consumer – the patient –

participates in the production of the service, and therefore performance and quality

can be affected by patient actions, moods and cooperativeness (Zeithaml, 1981). The

idea that perceived service quality results from a comparison of expectations with

perceptions of performance would seem to imply that perceived quality equates with

satisfaction. That is, if a customer is satisfied then there is quality of service.

Hypotheses 1:

Ho: Reliability of Thai private health care providers has no impact on Bangladeshi

patients’ satisfaction

Ha: Reliability of Thai private health care providers has an impact on Bangladeshi

patients’ satisfaction.

Reliability refers to a providers’ ability to perform the promised service

dependably and accurately. For instance, in Bangladesh, reliability of the provider is

often perceived as low for various reasons, such as the accusation that doctors

recommend unnecessary medical tests, there is an irregular supply of drugs at the

hospital premises, supervision of patients by care providers is irregular, and

specialists are unavailable. Perceptions of reliability are also attenuated when doctors

do not provide correct treatment the first time.

Hypotheses 2

Ho: Responsiveness of Thai private health care providers has no impact on

Bangladeshi patients’ satisfaction.

Ha: Responsiveness of Thai private health care providers has an impact on

Bangladeshi patients’ satisfaction.

Patients expect hospital staff to respond promptly when needed. They also

expect the required equipment to be available, functional and able to provide quick

diagnoses of diseases.

Hypotheses 3:

4

Ho: Assurance from Thai private health care providers has no impact on Bangladeshi

patients’ satisfaction.

Ha: Assurance from Thai private health care providers has an impact Bangladeshi

patients’ satisfaction.

Knowledge, skill and courtesy of the doctors and nurses can provide a sense of

assurance that they have the patient’s best interest in mind and that they will deliver

services with integrity, fairness and beneficence. For a service that is largely credence

based (Zeithaml and Bitner 2000), where customers are unable to evaluate the quality

of the services after purchase and consumption, the sense of assurance that is

engendered can greatly influence patient satisfaction. In the health care system,

assurance is embodied in service providers who correctly interpret laboratory reports,

diagnose the disease competently, provide appropriate explanations to queries, and

generate a sense of safety.

Hypotheses 4:

Ho: Physical appearance (tangibility) of the Thai private hospitals has no impact on

Bangladeshi patients’ satisfaction.

Ha: Physical appearance (tangibility) of the Thai private hospitals has an impact on

Bangladeshi patients’ satisfaction.

Physical evidence that the hospital will provide satisfactory services is very

important to patient satisfaction judgments. Generally, good appearance (tangibility)

of the physical facilities, equipment, personnel and written materials create positive

impressions. A clean and organized appearance of a hospital, its staff, its premises,

restrooms, equipment, wards and beds can influence patients’ impressions about the

hospital.

Hypotheses 5:

Ho: The quality of communication perceived by the Bangladeshi patient has no

impact on Bangladeshi patients’ satisfaction.

Ha: The quality of communication perceived by the Bangladeshi patient has

an impact on Bangladeshi patients’ satisfaction.

Communication is also vital for patient satisfaction. If a patient feels alienated,

uninformed or uncertain about her health status and outcomes, it may affect the

healing process. When questions of concern can be readily discussed and when

patients are consulted regarding the type of care they will be receiving, it can alleviate

their feelings of uncertainty. Also, when the nature of the treatment is clearly

5

explained, patients’ awareness is heightened and they are better sensitized to expected

outcomes. Appropriate communication and good rapport can, thus, help convey

important information to influence patient satisfaction. In particular, patients expect

doctors and nurses to communicate clearly and in a friendly manner regarding

laboratory and other test results, diagnoses, prescriptions, health regimens, etc.

Similarly, nurses are expected to understand patient problems and to communicate

them to the doctor properly.

Hypotheses 6:

Ho: Empathy received from Thai private health care providers has no impact on

Bangladeshi patients’ satisfaction.

Ha: Empathy received from Thai Hospitals has an impact on Bangladeshi patients’

satisfaction.

Health care providers’ empathy and understanding of patients’ problems and

needs can greatly influence patient satisfaction. Patients desire doctors to be attentive

and understanding towards them. Similarly patients expect nurses to provide personal

care and mental support to them. This reflects service providers’ empathy.

Hypotheses 7:

Ho: The process features of Thai hospitals have no impact on Bangladeshi patients’

satisfaction.

Ha: The process features of Thai hospitals have impact on Bangladeshi patients’

satisfaction

Process features refer to an orderly management of the overall health care

service process. This constitutes patients’ expectation that doctors will maintain

proper visiting schedules and that there will be structured visiting hours for relatives,

friends, etc. Updated patient records and standard patient release procedures also

facilitate patient care. Process features in Thai healthcare includes the interpreters,

who guide the Bangladeshi patients through the whole process of getting treatment.

Hypotheses 8:

Ho: The perceived overall cost of Thai Hospitals has no impact on Bangladeshi

patients’ satisfaction.

Ha: The perceived overall cost of Thai Hospitals has an impact on Bangladeshi

Patients’ satisfaction.

In addition to service factors, perceived treatment cost is another factor that

patients may perceive as excessive. In the more affluent western world, Schlossberg

6

(1990) and Wong (1990) suggest that health care consumers have become much more

sensitive to costs, despite health insurance coverage. Andaleeb (2001,2001) and Hasin

et al.,(2001), used cost in the SERVQUAL dimensions. Wong (1990) also predicts

that consumers will shop for the best value. In the developing world, especially

Bangladesh, cost is a perennial concern among those seeking health care service,

given their low earnings. Such costs include consultation fees, laboratory test charges,

travel, drugs and accommodation.

Hypotheses 9:

Ho: The Bangladeshi patients’ access to Thai private hospitals has no impact on

Bangladeshi patients’ satisfaction.

Ha: The Bangladeshi patients’ access to the Thai private Hospitals has an impact on

Bangladeshi patients’ satisfaction.

Availability of doctors, nurses and hospital beds round the clock is of concern

to patients in defining the level of access they have to health care. In Bangladesh

hospital beds and cabins are hard to avail. Most of the hospitals have to deal with over

capacity. To access a foreign hospital, visa processing matters and arranging for

accommodation and food are major concerns; patients usually prefer countries with

minimum hassle in this regard. Therefore, it is hypothesized that when a hospital has

easy physical access, where doctors, nurses, beds/cabins, etc. are available and when

visa processing is simple, patients will be more satisfied.

Hypotheses 10:

Ho: The billing services of Thai Private Hospitals have no impact on Bangladeshi

Patient satisfaction.

Ha: The billing services of Thai Private Hospitals have an impact on Bangladeshi

Patient satisfaction

Making or sending out of bills or invoices. Hughes (1991) used billing

services in his attribute based model to measure patient satisfaction. For Bangladeshi

patients it is an important factor. In most hospitals, billing services are crude and

some times insensitive. In most hospitals, the billing services cause a lot of tension.

So, billing services have a big impact on Bangladeshi patient satisfaction.

Hypotheses 11:

Ho: Treatment outcome of Thai Private Hospitals has no impact on Bangladeshi

patient satisfaction.

7

Ha: Treatment outcome of Thai Private Hospitals has an impact on Bangladeshi

patient satisfaction.

Results or impact of medical care. Treatment outcome is an important factor

for patient satisfaction. In hospital’s view outcome is defined by “hard” data such as

length of stay or mortality. From the patients point of view, if they do not feel cured

in their mind, indeed they have not been cured. Hughes (1991) used it to measure

patient satisfaction. For Bangladeshi patients it is an important factor.

Methodology

Questionnaire design

The questionnaire is patterned on previous studies, i.e, “Patient satisfaction

with Bangladeshi Health services” (Andaleeb, 2007); “Quality of services research in

hospitals in Malaysia” (Sadiq, 2003). The questionnaire was modified to

accommodate the suggestions of the Marketing Director of Bumrungrad Hospital and

Marketing Director of Bangkok Hospital. Malhotra (2004) indicated a value of at least

0.6 is considered satisfactory. The reliability measured in this research is as follows:

Reliability 0.726, Responsiveness 0.704, Assurance 0.795, Tangibles 0.858,

Communication 0.803, Empathy 0.794, Process features 0.675, Cost 0.758, Access

0.653, Billing services 0.838, Treatment outcome 0.812.

Data collection

The researcher obtained authorization letters from the two hospitals to

distribute self-administered questionnaire to collect data for the research. The

researcher distributed the questionnaires at the cashier’s section in both the hospitals

and was there to collect them back. Help was given to those patients who had

problems in the interpretation of the questionnaire. Moreover, the respondents were

informed that this participation was entirely voluntary, and had anonymity and

confidentiality

Sampling method

Bangladeshi patients in the two major private hospitals in 2005 were 32,417

and in 2006 were 27,813. Up to May 2007, approximately 15,195 Bangladeshi

patients visited these two private hospitals. Thus, the target population is

approximately 30,000. Therefore, according to Anderson (1996), the researcher

choose 5% points of error (or 95% level of confidence), the sample size is 381.

However, in order to be sure of collecting at least 381 valid questionnaires with

8

correct and complete answers, the researcher distributed 400 questionnaires among

patients in the two private hospitals. Equal numbers of questionnaires were distributed

in both the hospitals.

Analysis

To measure the levels of Bangladeshi patient satisfaction with the dimensions of

service quality, the researcher had to calculate the means of all service quality

dimensions. From the statistical data in Table 1, the researcher found that the

Bangladeshi patients were satisfied most with assurance (strongly satisfied) followed

by tangibles (strongly satisfied), communication (strongly satisfied),

reliability(satisfied), billing services (satisfied), process features(satisfied), treatment

outcome ( satisfied), access ( satisfied), responsiveness(satisfied), empathy (satisfied).

They were neither satisfied nor dissatisfied with cost (neutral).

Table 1- Descriptive Statistics of Bangladeshi patients’ satisfaction with each service quality dimensions

Service dimensions Mean Std. Deviation Nreliability 4.0923 .60962 390responsive 3.7667 .64487 390assurance 4.3697 .47779 390tangible 4.2248 .51834 390communication 4.2009 .62267 390empathy 3.6850 .58462 390process 3.9987 .48565 390cost 3.0790 .68575 390access 3.8564 .53738 390billing 4.0615 .46751 390outcome 3.9936 .60786 390

To identify the overall level of satisfaction of Bangladeshi patients with the

service quality of Thai private hospitals, the researcher used descriptive statistics to

compute the means of overall satisfaction of Bangladeshi patient satisfaction. As per

the results shown in table 5.11, the mean score is 3.8882, which belongs in the range

of 3.41-4.20. Hence, according to Anderson et al. (2002), the researcher can conclude

that the Bangladeshi patients who received treatment at the two private hospitals

during the time of survey were satisfied with the overall service quality of the two

private hospitals. According to the survey, there were 333 “satisfied” and 53 “very

satisfied” Bangladeshi patients that accounted for nearly 86.2% of respondents. Three

9

patients were neutral in their opinion, that is 0.8%. Only 1 patient was “dissatisfied”,

that is 0.3%.

Table 2- Regression analysisM

odel

Unstandardized Coefficients

Standardized Coefficients

t Sig.

Collinearity Statistics

B Std. Error Beta Tolerance VIF1 (Constant) .721 .152 4.747 .000

reliability .073 .026 .130 2.803 .005 .354 2.824

responsive .058 .018 .110 3.301 .001 .687 1.456

assurance .019 .035 .027 .547 .585 .320 3.129

tangible .076 .028 .116 2.724 .007 .426 2.349

communication .060 .032 .110 1.856 .064 .219 4.567

empathy .074 .028 .128 2.650 .008 .328 3.045

process .138 .023 .197 5.963 .000 .701 1.427

cost .087 .023 .176 3.770 .000 .353 2.834

access .104 .026 .164 3.963 .000 .447 2.236

billing .078 .025 .107 3.092 .002 .634 1.578

outcome .046 .027 .082 1.727 .085 .336 2.979

ValidityThe model is a valid one to explain Bangladeshi patient satisfaction. The R

value is 0.843 and R2 is 71.1%. The Durbin Watson value is 1.506. Value between 1

and 3 is good (Durbin & Watson, 1951). The model has no multicollinearity and

singularity. Tolerance statistic shows that all the values are greater than 0.2. If the

value is above 0.1 then it is acceptable, although above 0.2 is better (Field, 2005).

Variance Inflation Factor (VIF) values are less than 10. VIF values should be less

than 10 (Field, A., 2005).

Equation:Y = a + b1X1+ b2X2+ b3X3 + b4X4+ b5X5+ b6X6 +b7X7+ b8X8+ b9X9 +b10X10+ b11X11

Where Y= Bangladeshi Patient satisfaction (Dependent variable)

X1 = Reliability (Independent Variable); X2 = Responsiveness (Independent

Variable); X3 = Assurance (Independent Variable); X4= Tangibility (Independent

Variable); X5 = Communication (Independent Variable); X6 = Empathy

(Independent Variable); X7 = Process features (Independent Variable) ; X8 =

Cost (Independent Variable); X9 = Access (Independent Variable); X10 = Billing

10

services (Independent Variable); X11 = Treatment outcome (Independent

Variable)

Y= 0.721+.073 X1+ .058X2+ .019X3 + .076X4+ .060X5+ .074X6 +.138X7+ .087X8+

.104X9 +.078X10+ .046X11

From the table-2, it can be observed that Bangladeshi Patient satisfaction have

high positive relationships with treatment outcome, responsive, billing, process,

tangible, assurance, access, reliability, cost, empathy, communication as R is equal to

0.843 which is close to “1= strong relationship”. Moreover, Bangladeshi patient

satisfaction was explained by all Independent variables equal to 71.1% (R2 = 0.711).

From the F-test, the Alternative hypothesis can be accepted, which means that at least

one of independent variables (outcome, responsive, billing, process, tangible,

assurance, access, reliability, cost, empathy, communication) has influence on

Patient(Bangladeshi) satisfaction (F = 84.342, Sig. = 0.000) at 0.05 confidence levels.

Impact of the service quality dimensions:

From the beta value from Table 2, it can be observed that, process features have

the greater impact on patient satisfaction, beta value is equal 0.197; followed by Cost,

beta value is equal 0.176; access, beta value equal 0.164; reliability, beta value equal

0.130; empathy, beta value equal 0.128; tangible, beta value equal 0.116;

responsiveness, beta value equal 0.110; billing services, beta value equal at 0.107.

Hence, based on the beta values the dimensions can be ranked as: 1. Process features;

2. Cost 3. Access 4. Reliability 5. Empathy 6. Tangible 7. Responsiveness 8. Billing

services.

Discussion and conclusion

The research was conducted to construct a predictive model of satisfaction of

Bangladeshi patients in two selected private hospitals in Thailand. In order to do that,

the research focused on identifying the key service quality dimensions that affect

patient satisfaction and assess how Bangladeshi patients’ rate the service quality

dimensions of two selected private hospitals in Thailand. The study constructed a

model and revealed that 8 dimensions of the service quality of two selected Thai

private hospitals including reliability, responsiveness, tangibles, empathy, process

features, cost, access and billing services have positive impact on the patient

(Bangladeshi) satisfaction. Assurance, communication and treatment outcome have no

11

impact on patient (Bangladeshi) satisfaction. As the study revealed, process feature

has the strongest impact on Bangladeshi patient satisfaction. The beta value is equal to

0.197. Bangladeshi patients travel to Thailand for better treatment and they go to

private hospital for better services and care. The study indicated that the Bangladeshi

patients were satisfied with process feature as the mean score is 3.9987. As the

process feature includes the willingness of the admission staff of helping and

providing information, the survey participants included the service of the interpreters.

The interpreters generally assist the patients with the process feature. The Bangladeshi

patients perceived them as part of the staff. So, the performance of the interpreters

impacts the satisfaction. The better the performance of the interpreters, the higher the

satisfaction will be. That is for, 1 standard deviation of process feature increase will

result in 0.197 standard deviation increase of satisfaction if all other variables are

constant. According to the study, cost has the second strongest impact on satisfaction.

The beta value is equal to 0.176. The study indicated that the Bangladeshi patients

were neither satisfied nor dissatisfied with cost as the mean was 3.0790. The mean of

“Cost of medicine” is 2.07, which falls in the range of dissatisfaction. The cost of

medicine is affecting the cost factor with satisfaction level. The study revealed that

access has strong impact on Bangladeshi patient satisfaction as beta value is equal to

0.164. The mean value is 3.8564, hence it falls in the “satisfied” range. Access

includes the operating hour of the hospital and telephone inquiry service. On

Saturdays and Sundays the hospital does not operate in full capacity. Some of the

patients traveling to Thailand on Fridays face some problems. Telephone inquiries are

some times concern for decrease in satisfaction. These features clearly impacts

satisfaction. The study revealed that empathy has a positive impact on the satisfaction

as the beta value equals to 0.128. That is for, 1 standard deviation of empathy increase

will result in 0.128 standard deviation increase of satisfaction if all other variables are

constant. The mean value is 3.6850. The nurses create some language barriers.

Empathy includes the nurses understanding the patients’ problems; the mean score is

2.96, that is “neutral”. Communication, more specifically the language barrier impacts

the satisfaction level. Interestingly, communication, treatment outcome and assurance

had no impact on patient satisfaction. The study indicated that the mean of

communication is 4.2009. Bangladeshi patients were strongly satisfied with

communication. The mean of treatment outcome was 3.9936, indicating “satisfaction”

.Assurance falls in the range of “strongly satisfied” as the mean was 4.3697.

12

Bangladeshi patients are attracted to Thai private hospitals because of doctors, so

assurance does not have an impact. Most of the Bangladeshi patients come to

Thailand after initial treatments in Bangladesh. Treatment outcome is attained so they

come as most of the patients surveyed are not first timers. They are frequent patients

of the Thai private hospitals. Communication covers the doctors’ performance so

satisfaction is not affected as the patients are regular.

Recommendations

The study suggests that the managers of Thai private hospitals should pay

adequate attention to the service quality dimensions which will increase the

satisfaction of Bangladeshi patient, eventually increasing the number of Bangladeshi

patients. The Bangladeshi patients perceive the Bangladeshi interpreters as part of the

staff. The current workforce should be monitored as the interpreters are linked with

the process feature and the overall service of the hospital. The interpreters handle the

communication between Bangladeshi patients and hospital personnel. They guide the

patients though all the steps of treatment. The nurses, pharmacy and billing section

are weak in communication. Without the interpreters, there will be a communication

gap and misunderstanding which will eventually reduce the satisfaction and result in

loss of patients. If the interpreters are not active, the Bangladeshi patients will not get

the full extent of service provided by the hospital. Their performance will impact the

overall performance. Their negligence may result in losing valuable patients for the

hospital. The job description of the interpreters can be modified. Their job currently is

only limited to interpretation but the patients perceive them as an important part of the

hospital service. The interpreter work force should be more trained, efficient and

professional. An evaluation of the current workforce should be done. If necessary the

hospitals should hire more professional and efficient workforce. Otherwise they can

re-evaluate the current workforce and increase their efficiency. The Bangladeshi

interpreter workforce should be young, energetic, efficient and sympathetic. Lack of

empathy and efficiency will reflect poorly on the hospital. The price of medication is

perceived as very costly even in comparison to other places in Thai market. The

hospitals can look into the matter. They can offer promotions to give discounts for

medicines to the frequent visitors or collaborate with Bangladeshi sponsors to offer

discounts. In collaboration with Bangladeshi service providers such as mobile

companies, banks and airlines, the hospitals can offer discounted rates on medicines

The Bangladesh offices should make the patients aware that Saturdays and Sundays

13

are weekends unlike Bangladesh where Thursdays and Fridays are weekends. They

should inform the patients to arrange their traveling plans to avail the services in week

days and avoid the unnecessary discomfort of visiting the hospitals on weekends. The

Bangladesh office should inform the patients of the cost in advance to reduce

confusion. In general, cost of medical tests and medicine cost should be informed in

advance. So, the patients can be mentally ready. Increase in advertising budgets for

this purpose would be a good solution. Though some of the hospitals have multi

lingual telephone service, the efficiency should be increased. The hospitals can

outsource this service. Otherwise, they can increase they service quality by hiring

more efficient workforce. The hospitals should increase the comfort of the waiting

rooms. The waiting area seats can be made more comfortable, may be the color of the

room can be modified to increase the patients’ comfort. Relaxing music may be

played to reduce the tension of the patients. By consulting human behavior

psychiatrists the waiting rooms can be rearranged to increase the physical and mental

comfort of the patients. Nurses pose some problems related to empathy factor. So,

their English proficiency can be increased. New recruitments can screened for that. If

the interpreters are increased they can solve this problem. More interpreters or more

active workforce can solve the problem.

Limitations of the Study The study has some limitations. Firstly, only two private hospitals in Bangkok

were targeted. Secondly, only Bangladeshi patients visiting the two hospitals were

targeted. Thirdly, only outpatients are targeted. The results may not be representative

for inpatients in the hospitals or generalizable to all the Bangladeshi patients in other

Thai private hospitals. Fourthly, the study is being conducted from September 2007 to

October, 2007. In this case, it becomes a limitation of this study in that the findings

can not be generalized for the Bangladeshi patients visiting around the year. Despite

these limitations, the researcher believes this study could provide some valuable

insights to Bangladeshi patient satisfaction with Thai private hospitals and hopefully

such limitations could encourage further studies.

BIBLIOGRAPHY

14

Andaleeb S. S. (1998). Determinants of customer satisfaction with hospitals: a

managerial model. International Journal of Health Care Quality Assurance:

11/6 pp.181-187. MCB University Press.

Andaleeb S. S. (2000). Public and private hospitals in Bangladesh: service quality and

predictors of hospital choice. Health Policy and Planning; 15(1): pp.95-102.

Oxford University Press 2000.

Andaleeb, S. (2001), “Service quality perceptions and patient satisfaction: a study of

hospitals in a developing country”, Social Science and Medicine; Vol. 52 No.

8, pp. 1359-70.

Andaleeb S. S., Nazlee S., Khandakar S. (2007). Patient satisfaction with health

services in Bangladesh. Health Policy and Planning: pp.1-11. Oxford

University Press in Patient satisfaction with health services association with

The London School of hygiene and tropical medicine.

Andaleeb S. S., Nazlee S., Khandakar S. (2007). Doctors’ service orientation in

public, private and foreign hospitals. International Journal of Health care

Quality assurance : Vol. 20, No. 3, 2007, pp.253-263.

Anderson (1996). Fundamentals of Educational Research. Falmer Press. pp.202.

Anderson, D.R, Sweeney, D.J. and Williams, T.A. (2002). Statistics for Business and

Economics (8 th ed.) United States: Thomson Learning.

ADB and World Health Statistics 2007: (www.adb.org) &

(http://www.who.int/countries/bgd/en/ ); accessed on 17/07/’07.

Babakus, E., Mangold, Glynn W. (1992). Adapting the SERVQUAL scale to hospital

services: an empirical investigation. Health Services Research:1992. American

College of Healthcare Executives, Gale Group.

Bolton, R.N., & Drew, J.H. (1991, March). A multistage model of consumers’

assessment of service quality and value. Journal of consumer research, 17.

pp.375-384.

Bopp, K. D. "How Patients Evaluate the Quality of Ambulatory Medical Encounters:

A Marketing Perspective." Journal of Health Care Marketing 10, no. 1 (March

1990): pp.6-15.

Burns, A.C and bush, R.F.(2005). Marketing Research- Online Research Applications

(4th ed.) Philadelphia: Open University Press.

15

Casarreal, K. M., J. I. Mills, and M. A. Plant. "Improving Service through Patient

Surveys in a Multihospital Organization." Hospital & Health Services

Administration 31, no. 2 (March/April 1986):pp. 41-52.

CIET, Canada and Ministry Health and Family welfare, Government of Bangladesh,

2004. Bangladesh Health and Population Sector programme, 1998-2003. The

third service delivery Survey 2003, final report. Dhaka: CIET Canada and

Government of Bangladesh: pp. xi.

Clow, K.E., Fischer, A.K, and O'Bryan, D. (1995). Patient Expectations of

Dental (Services. Journal of Health Care Marketing, Fall, 15 (3). pp.28.

Churchill, G.A., Jr. and Surprenant, C.F. (1982). “An investigation into the

determinants of customer satisfaction”, Journal of Marketing Research

20(November), pp.491-504.

Cronbach, L.J. (1951). Coefficient alpha and the internal structure of tests.

Psychometric, 16, pp.297-334.

Cronin, Jr., J.J., and Taylor, S.A. (1992, July). Measuring service quality: A

reexamination and extension. Journal of marketing, volume: 56(3), pp.55-68.

Croucher R. (1991). The performance gap. Patients' views about dental care and the

prevention of periodontal disease. London: Health Education Authority,

Research Report No. 23.pp.55.

Curbow B.(1986). Health care and the poor: psychological implications of restrictive

policies. Health Psychol: 5.pp. 375-391.

Camilleri, D. and O’Callaghan, M. (1998), “Comparing public and private care

service quality”, International Journal of Health Care Quality Assurance, Vol.

11, 4, pp. 127-33.

Durbin, J. & Watson, G.S. (1951). Testing for serial correlation in least squares

regression II. Biometrika, 38, 159-177

Field, A. (2005). Discovering Statistics Using SPSS (2nd ed.). Sage: London

Gronroos, C. (1982). Strategic Management and marketing in Service Sector.

Helsingfors: Swedish School of Economics and Business Administration,

Sweden.

Gronroos, C. (1984)."A Service Quality Model and Its Marketing Implications."

European Journal of Marketing: vol.18, 4 pp.36-44.

Gronroos, C. (1988). Service quality: The six criteria of good perceived service

quality. Review of Business: Vol. 9.3. pp.10-13.

16

Gronroos, C. (1990). Service Management and Marketing: Managing the moments of

truth in service Competition (1 st ed.) Massachusetts/ Toronto: Lexington

Books.

Grove, S.J. and Frisk, R.P. (1983). The Marketing of Services Exchange: An

Analytical Framework for Services Marketing. In Lovelock, C.H. (Ed),

(1991), Service Marketing (2 nd ed.) (pp.39-47). New Jersey: Englewood Cliffs,

prentice Hall.

Gilmore, A. (2003). Service Marketing and Management (1 st ed. ). London: Sage

Publications.

HEU, 2003b. Bangladesh National Health Accounts 1999-2000. Dhaka: Health

Economics Unit, Ministry of Health and family welfare, Government of

Bangladesh, pp.63-71.

Hughes, J. (1991). Satisfaction with Medical care: A review of the field.

www.changesurfer.com/Hlth/Patsat.html. Retrieved at 03.35; July 17, 2007.

Hasin, M.A.A., Seeluangsawat, R. and Shareef, M.A. (2001), “Statistical measures of

customer satisfaction for health-care quality assurance: a case study”,

International Journal of Health Care Quality Assurance, Vol. 14 No. 1, pp. 6-

14.

Joint Commission for Accreditation of Healthcare Organizations. "Agenda for

Change (Update)." Newsletter 1, no. 1 (September 1987): pp.1-4.

Kotler, P., Bowen, J., Makens, J. (1996). Marketing for Hospitality & Tourism. The

United States of America: Prentice-Hall.

Lehtinen, U., and Lehtinen J.R. (1982). “Service Quality: A study of Quality

Dimensions.” Unpublished working paper, Helsinki: Service Management

Institute, Finland OY.

Likert, R. "A Technique for Measurement of Attitudes." Archives of Psychology

monograph no. 140 (1932).

Lovelock C.H. (1991). Service Marketing (2 nd Ed.) . New Jersey Eaglewood Cliffs,

Prentice Hall, pp.35.

Lim, P.C. and Tang, N.K.H. (2000), “A study of patients’ expectations and

satisfaction in Singapore hospitals”, International Journal of Health Care

Quality Assurance, Vol. 13, 7, pp. 290-9.

LeKim, N. (2005). Inpatients’ satisfaction with service quality: A study on the

Transport Hospital in Hanoi, Vietnam.

17

MacDaniel,C. and Gates, R. (2001). Marketing Research Essentials (3rd ed.) Ohio:

Thompson Learning, South-Western College Publishing.

Malhotra, N.K. (2004). Marketing research: An applied orientation (4 th ed.). New

Jersey: Prentice Hall, Pearson Education Inc.

Marshall, G., and Murdoch. I. (2001). Service Quality in the Marketing of Consulting

Engineers.http://www.brookes.ac.uk/other/conmark/IJCM/Vol3-1/Vol3-

paper5.htm. Accessed on 9/6/’07.

Madden, Normandy(2003).Thailand sells sun and surgery. Advertising Age,

00018899, 6/9/2003, Vol. 74, Issue 23.

Mushtaque R. C. (2005). Health sector reforms in Bangladesh. ICDDRB Publication.

http://www.icddrb.org/pub/publication.jsp?

pubID=7400&classificationID=0&typeClassificationID=0. Accessed on

03/06/’07.

Mustafa, S., (2002). Service Quality in Higher Education: Expectation versus

experience of MBA student of the University of Dhaka, Bangladesh.

Marisnee, S., (2001). Factor analysis of patient satisfaction dimensions towards

Health care service in private clinics in Samutpakarn province.

Nazlee S. and Khandaker S. A. (2007). Comparison of Public, Private and Foreign

Hospitals from the perspective of Bangladeshi Patients. International Centre

for Diarrhoeal Disease Research, Bangladesh.

Newsome P. R. H. an Wright G. H. (1998). A review of patient satisfaction: 1.

concepts satisfaction. British Dental Journal: volume 186, NO. 4, Feb, 1998.

Nunnally, J. (1978), Psychometric Theory, McGraw-Hill Book Co., New York, NY.

Olson, J. C., and T. J. Reynolds. "Understanding Consumers' Cognitive Structures:

Implications for Advertising Strategy." In Advertising and Consumer

Psychology. Edited by L. Percy and A. Woodside. Lexington, MA: Lexington

Books, 1983.

Oliver, R.L. (1981), “Measurement and evaluation of the satisfaction process in retail

settings”, Journal of Retailing, Vol. 57, Fall.

Paul, Fedoroff (2007) Comparing service quality performance with customer service

quality needs. Explanation of SERVQUAL Methodology of Zeithaml,

Parasuraman, and Berry ('88): www.12manage.com( Accessed on 12.07.’07).

Peoples’ Daily Online: Xinhua:. Apollo hospital makes Medicare breakthrough in

Bangladesh (September 16, 2005).

18

Patterson, P.G. (1993). Expectations and Product Performance as determinants of

satisfaction for a High-involvement purchase. Psychology and Marketing,

Sep/Oct, 10 (5), pp.449-465.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1985, fall). A conceptual Model of

service Quality: Its Implications for future research, Journal of Marketing,

vol:28. No.1. pp.41-50.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1986). SERVQUAL: a multi-item

scale for measuring customer perceptions of service quality. Marketing

Science Institute, Working paper report: No.86-108, August.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1988a, January-February). The

Service quality puzzle. Business Horizons: vol. 31.5. pp.34-35.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1988b, spring). SERVQUAL: a

multi-item scale for measuring customer perceptions of service quality.

Journal of retailing: vol.64.1.pp.12-40.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1990a). Delivering Quality Service,

New York, Free Press.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1990b). An Empirical Examination of

relationship in an extended Service Quality Model. Cambridge, MA:

Marketing Science Institute.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1991, spring). Refinement and

reassessment of the SERVQUAL scale. Journal of retailing: vol. 67. pp.420-

449.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1993, spring). More on improving

service quality measurement. Journal of Retailing: vol.69. pp.140-147.

Parasuraman, A., Zeithaml, V.A & Berry, L.L. (1994, January). Reassessment of

expectations as a comparison standard in measuring service quality. Journal of

Marketing: vol. 58.1. pp.111-124.

Prasad, M. K. (2003). A consultancy project to study International IPD Patients’

Perceptions about The service quality of various departments of Bangkok

Hospital and their level of overall satisfaction with Bangkok Hospital.

Raduan C. R., Fegak Uli, Mohani Abdul and Kim Looi Ng, (2004). Hospital Service

Quality: a managerial challenge. International Journal of Health Care Quality

Assurance V: 17, pp. 3. pp:146-159.

19

Rust, R. T., Zahorik, A. J., Keiningham, T. L. (1996). Service Marketing (1 st ed.) New

York: Harper Collins College Publishers.

Rao K.D., Peters D.H., Bandeen-Roche K. (2006). Towards patient centered health

services in India- a scale to measure patient perception of quality. International

Journal for Quality in Health care, 18: pp.414-21.

Ricardo, B., Hussmann, K., Munoz R., Zaman, S. (2004). Comparative advantages of

public and private providers in health-care service in terms of cost, pricing,

quality, and accessibility. Dhaka: Health economics unit, Ministry of Health

and family welfare, Government of Bangladesh.

Raduan, C. R., Fegak Uli, Mohani Abdul and Kim Looi Ng, 2004. Hospital Service

Quality: a managerial challenge. International Journal of Health Care Quality

Assurance: V: 17, 3. 2004. pp: 146-159.

Sohail, M. S. (2003). Service quality in hospitals: more favourable than you think.

Managing service quality: Volume 13.3. pp. 197-206. MCB UP Limited.

Schneider, B. and Bowen, D.E. (1995). Winning the service game. The United States

of America: Library of Congress Cataloging in publication data.

Swartz, T.A. and Brown, S.W. (1989), “Consumer and provider expectations and

experiences evaluating professional service quality”, Journal of the Academy

of Marketing Science, Vol. 17, 2, pp. 189-95.

Taylor, S.A. and Baker, T.L. (1994), “An assessment of the relationship between

service quality and customer satisfaction in the formation of consumers’

purchase intentions”, Journal of Retailing, Vol. 70,2, pp. 163-78.

Taylor, S. A. and Cronin, J.J.J. (1994). Modeling Patient Satisfaction and Service

Quality. Journal of Health Care Marketing, Spring, 14,1, pp.34-43.

Tudor, R.K. and Carley, S.S. (1995). Time to choose. Journal of Health Care

Marketing Summer, 15,2, pp.48-52.

The Nation-Health Plus: 24 June, 2007.

The Nation-July16th, 2007.

The Nation-April26th, 2002.

The Independent: Editorial; Apollo Hospital, 01/04/2005.

The Independent: Patients prefer treatment abroad-TK. 1200cr in foreign exchange

drained out every year. Wednesday December 15 2004.

20

Vandermerwe, S. and Chadwick M. (1989). The internationalization of services. In

Lovelock, C.H. (Ed), (1991), Service Marketing (2 nd ed.) (pp.39-47). New

Jersey: Englewood Cliffs, prentice Hall.

Vuori H. (1969). Patient satisfaction- an attribute or indicator of the quality of care?

Quality review bulletin, 1987; 13 : pp.106-109.

World Bank, 2003. Private sector assessment for health, nutrition and population

(HNP) in Bangladesh. Report NO. 27005-BD. Washington DC: World Bank,

pp. 6-7.

World-Health-Organization:

(http://www.who.int/whosis/database/core/core_select_process.cfm): accessed

on 15/07/07.

Walker, J. L. (1995). Service Encounter Satisfaction: Conceptualized. Journal of

Service Marketing, 9(1), pp.5-14.

Williams B., (1994) Patient satisfaction: a valid concept? Social Science & Medicine.

Vol.38,NO. 4,pp.509-516.

Youssef, F.N., Nel, D. and Bovaird, T. (1996), ``Health care quality in NHS

hospitals'', International Journal of Health Care Quality Assurance, Vol. 9.1,

pp. 15-28.

Zineldin, M. (2006). The quality of healthcare and Patient satisfaction: an exploratory

investigation of the 5Qs model at some Egyptian and Jordanian medical

clinics. International Journal for Quality in Health care 19: pp.60-99.

Zifko-Baliga, G. M. and Krampf R. F.,(1997). Managing Perceptions of Hospital

Quality. Marketing Health Services, Spring, pp.28-35.

Zeithaml VA, Bitner M.J. (2000). Services Marketing. New York: Mcgraw Hill.

Zeithaml, V., Berry, L.L., & Parasuraman A. (1990). Delivering Quality service:

Balancing customer perceptions and expectations. New York: the Free Press.

Zeithaml, V., Berry, L.L., & Parasuraman A. (1991). The Nature and determinants of

Customer expectations of service. Marketing science Institute. Working paper,

91-113, Cambridge, Massachusetts.

21