assessment of service quality of cambodia_s public & private hospitals

7/30/2019 Assessment of Service Quality of Cambodia_s Public & Private Hospitals

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MINISTRY OF EDUCATION, YOUTH, AND SPORTS

NATIONAL UNIVERSITY OF MANAGEMENTSCHOOL OF GRADUATE STUDIES

An Assessment of Service Quality of Public and Private

Hospitals: Evidence for Cambodia

MAO SAVY

A Proposal Submitted to the School of Graduate Studies of the NationalUniversity of Management in Partial Fulfillment of the Requirements for

the Degree of Doctor of Business Administration

SPECIALIZATION

MANAGEMENT

Supervised by:

Dr. Veasna Ung

Chair of Tourism and Hospitality Faculty

National University of Management

Phnom Penh, Cambodia

Reth Soeng, PhD.

Senior LecturerNational University of Management



Submitted 20 March 2013


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An Assessment of Service Quality of Public and Private

Hospitals: Evidence for Cambodia

MAO SAVY

1. Introduction

Services have been viewed as an important sector, making up the majority of the

economies of many developed countries (Jensen, 2011). The share of service sector

contributing to output and employment is also growing, which is confirmed by

Soubbotina (2004) who reported, for the world economies, that the share of services inthe total output and employment was 43 percent for low-income countries, 55 percent

for middle-income countries, and 64 percent for high-income economies.1

In the case of

ASEAN, Petri et al. (2012) also reported that the contribution of service sector to GDP

rises, and that the service sector had become the important contributions to income

growth in all large ASEAN countries in the late 1990s. The shift towards service sector

might be true for the case of Cambodia whose income per capita has gradually increased

from around 230 US dollars in 1993 to about 300 US dollars in 2000, and reached 990

US dollars in 2012. It is expected that Cambodias GDP per capita will reach more than

1,000 US dollars in 2013.2

Services delivery is becoming increasingly a vital element of a national economy, and it

is crucial to appreciate the distinguishing qualities of services, as well as the resulting

management implications, with the specific focus on healthcare services (de Jager and

du Plooy, 2011). The recognition and identification of the poor quality of healthcare

delivery in developing countries (Devarajan and Reinikka, 2004) has led to the adoption

of new efforts to measure and monitor healthcare service quality. In developing

countries, such as Cambodia, health care is a necessity or a basic need, involving a

1It is the facts showing that agricultural sector is most important for developing countries. However, as

per-capita income increases, the agricultural sector loses its primacy to the industrial sector, which in turn

loses its importance to the service sector (Soubbotina, 2004).2

The data are obtained from the Cambodian Ministry of Economy and Finance (various years).


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physiological cure, rather than care as such, while in the developed world, health care is

often seen as a luxury.

People in the developing world are at times concerned with finding the best ways to

meet their health care needs without a compromising quality. Quality patient care is the

underlying principle of any nations health system, which needs to be constantly

improved through developing an effective, systematic approach for monitoring and

evaluating of health services rendered (Sutherasan and Aungsuroch, 2008). As health

care sector has become a more highly competitive and rapidly growing service industry

around the world, the major challenges faced by healthcare markets is to measure and

evaluate the rendered service quality (Irfan and Ijaz, 2011). The quality of service, both

technical and functional, is a key ingredient in the success of service-providingorganizations (Grnroos, 1984). There is no exception for the quality of health care

service. Technical quality in health care is defined primarily on the basis of the

technical accuracy of the diagnosis and procedures. Functional quality, in contrast,

relates to the manner of delivery of health care services.

The delivery of quality healthcare services and the integration thereof in healthcare

policies is a concern shared by health sector worldwide (James, 2005). Quality of health

services is believed to directly influence health outcomes, health-related behaviors and

patient satisfaction. Patient perceptions are considered to be the major indicator for

assessing the service quality of a healthcare organization (Cronin and Taylor, 1992;

OConnor et al., 1994). It means that patient satisfaction is the major device for critical

decision making in selecting a healthcare services (Gilbert et al., 1992) and quality of

services delivered to the customers should meet their perceptions (Parasuraman et al.,

1985, Reidenbach and Sandifer-Smallwood, 1990; Babakus and Mangold, 1992;

Zeithaml et al., 1993).

Several techniques for measuring technical quality have been proposed and are

currently in use in healthcare sector. However, it has been recognized in the empirical

studies that SERVQUAL method, originally developed by Parasuraman et al. (1985), is

probably the most comprehensive scale to empirically estimate and measure the level of


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quality services delivered to customers, and it is best suitable in the hospital

environment as well (Babkus and Mangold, 1992).

Since its inception, the service-measuring technology of SERVQUAL has been used in

many settings in both developed and developing world. Voluminous studies also have

shown that provision of high-quality services is directly related to increase in profits,

market share, and cost savings (Devlin and Dong, 1994). With competitive pressures

and the increasing necessity to meet patient satisfaction, the elements of quality control,

quality of service, and effectiveness of medical treatment have become vitally important

(Friedenberg, 1997). This study intends to investigate the factors that may exert an

influence on patient satisfaction, using the augmented SERVQUAL methodology to

measure and evaluate the services rendered by Cambodias private and public hospitals.

2. Review of Related Literature

Service quality can be defined as the ability to meet the customers needs and

expectations (Lim and Tang, 2000). As cited by Lim and Tang (2000), Lewis and Booms

(1983) and Webster (1989) define service quality as a measure of how well the service

level delivered matches the consumers expectations. It has been revealed as a key factor

in search for sustainable competitive advantage, differentiation and excellence in the

service sector (Jabnoun and Al Rasasi, 2005; Jun et al., 1998). Service quality has also

been recognized as critically important for satisfying and retaining the existing customers

(Spreng et al., 1996; Reicheheld and Sasser, 1990).

A number of competing models have been developed to measure and evaluate service

quality as well as explain its vital importance in the commercial service-providing

businesses. Subsequently, in particular following the development of SERVQUAL model

by Parasuraman et al. (1985, 1988), a great deal of research has been undertaken to

address and assess various aspects of service quality. Basically, the model was that

consumer perceptions of quality emerge from the gap between performance and

expectations, as performance exceeds expectations, quality increases; and as performance

decreases relative to expectations, quality decreases (Parasuraman et al., 1985, 1988;


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Asubonteng et al., 1996). Thus, performance-to-expectation gaps on attributes that

consumers use to evaluate the quality of a service form the theoretical foundation of the

SERVQUAL technology.

To measure non-commercial services such as services delivered by library, the

Association of Research Libraries in collaboration with Texas A&M University

developed the library-measuring model, now better known as LibQUAL3 (Edgar, 2006),

which is conceptually based upon the widely-used SERVQUAL technology used to

measure general commercial services rendered by service business organizations.

LibQUAL is perceived as a valuable means of assessment for academic libraries

service quality (Blixrud, 2002; Nicol and OEnglish, 2012). Similar to SERVQUAL

model, LibQUAL underwent four refinements (Yu et al., 2008). The first one was made

over 1999-2000 in its 13 member libraries, with 41 pairs of statements related to five

service quality dimensions, followed by the second round of refinements, which was

tested in 2001, with more member libraries included and 56 statements of service

quality dimensions. The third modification was made in 2002 with participation of 164

member libraries, containing 25 pairs of statements relating to four service quality

dimensions. The final refinement was undertaken in 2003 in 308 member libraries,

containing 22 pairs of statements which were related to three dimensions. LibQUAL

has become a standardized model for assessing and measuring service quality of

libraries (Blixrud 2002).

In general, service quality is viewed as a success factor of a firms endeavors to

differentiate itself from its rivals in the increasingly competitive market. Service quality

has been approached as a multidimensional construct. At the earliest stage, the

SERVQUAL initiated by Parasuraman et al. (1985) introduced ten potentially

overlapping components (Soeung, 2012). These dimensions include tangibles,

reliability, responsiveness, communications, credibility, security, competence, courtesy,

understanding the customer, and access. Later, in their subsequent studies, Parasuraman

et al. (1988, 1990) reduced the aforementioned ten potentially overlapping dimensions

3LibQUAL+ was developed in late 1999. It is a joint effort of Texas A&M University and twelve

additional US educational institutions (Cook and Thompson, 2001).


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to five testable dimensions. Collapsing from ten to five dimensions was made after

rounds of purifications by Parasuraman et al. (1988, 1990), who detected some degrees

of overlap among their original ten dimensions. After stages of refinements,

Parasuraman et al. (1988) found that assurance and empathy contain items representing

the seven original dimensions: communications, credibility, security, competence,

courtesy, understanding or knowing customers and access. In other words, assurance

dimension contains items representing communications, credibility, security,

competence, courtesy while empathy contains items representing understanding or

knowing customers and access (Zeithaml et al., 1990; Soeung, 2012).

SERVQUAL has been extensively accepted and utilised as a generic instrument that

captures the multidimensionality of service quality. Parasuraman et al. (1985)sSERVQUAL has become operationalized in five dimensions that included 22-items

(Parasuraman et al., 1988). These five dimensions include tangibles (physical facilities,

equipment and appearance of personnel); reliability (ability to perform the service

accurately and dependably); responsiveness (willingness to help customers and provide

prompt service); empathy (caring and individualised attention paid to customers) and

assurance (employees knowledge, courtesy and ability to convey trust and confidence).

Soeung (2012) indicated that SERVQUAL suffers from some criticisms on the

theoretical and operational grounds, in particular operationalization of expectations,

reliability of instruments difference score formulation and scales dimensionality across

industrial settings (Sureshchandar et al., 2001; Baumann et al., 2007). Buttle (1996),

however, offers some future research directions; of which a direction is to continue to

examine the relationships between service quality, customer satisfaction, behavior,

customer retention, behavioral intention, word-of-mouth communications and market

share.

Although SERVQUAL have suffered from criticism, the models core content remains

unchanged and has been used for studies of commercial service-providing business

organizations in many countries. This model is also found to be superior, with respect to

the measurement of service quality in developing economy (Angur et al., 1999).


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Parasuraman et al. (1990) claim that, with appropriate adaptation of SERVQUAL

model, it can be used in many settings to ascertain the quality of service rendered

(Dhurup and Mohamane, 2007). Similarly, Nyeck et al. (2002) indicate that SERVQUAL

remains the most complete attempt to conceptualize and measure service quality. In their

study on service quality of Iranian private hospital, Zarei et al. (2012) contends that the

SERVQUAL model is a valid, reliable and flexible instrument to monitor and measure

the service quality in private hospitals in Iran. The reliability and validity of SERVQUAL

instrument is also emphasized by Al-Borie and Damanhouri (2013) who compared patient

satisfaction with service quality in both Saudi Arabian public and private hospitals.

Research has shown that good service quality leads to the retention of existing customers

and the attraction of new ones; the improved customer satisfaction; the enhancedcorporate image and positive word-of-mouth recommendations; as well as the enhanced

profitability of firms (Cronin et al., 2000). Concerning health care industry, a number of

empirical studies were undertaken, using the SERVQUAL scale, to evaluate both public

and private hospitals. For Bangladesh, Andaleeb (2000) carried out a comparative study

on the service quality rendered by public and private hospitals in urban areas, using a

modified SERVQUAL technology, with 25 statements representing five aspects of

service quality dimensions, namely responsiveness, assurance, communications,

discipline, and devotion or dedication. Using a data set from 216 inpatient respondents,

Andaleebs study suggested that private hospitals delivered better service than their public

counterparts in rural Bangladesh. Lim and Tang (2000) studied, for Singapore, the

inpatients expectations and satisfaction by also utilizing a modified SERVQUAL scale,

with 25 items representing tangibles, reliability, assurance, responsiveness, empathy,

accessibility and affordability dimensions. Their results, using data from 252 inpatient

respondents, showed that there was a service quality gap between in-patients

expectations and their perceptions.

A similar study was conducted by Jabnoun and Chaker (2003) for the United Arab

Emirates. They made comparison with respect to the quality of delivered services

between the private and public hospitals. Using a modified SERVQUAL, Jabnoun and

Chaker incorporated 23 statements representing six dimensions of service quality, namely


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empathy, tangibles, reliability, level of administrative response and support skills, and

found that inpatients were more satisfied with service quality of public hospitals than that

rendered by the private counterparts. Based on the work of previous authors, Arasli et al.

(2008) attempted to develop and compare determining factors of service quality in both

public and private hospitals of North Cyprus, using a data set collected from 454

inpatients respondents. Employing a modified SERVQUAL, with 48 statements

representing six service quality dimensions, they identified six factors concerning quality

of service perceived in both public and private hospitals. The six factors include empathy,

giving priority to the inpatients needs, relationships between staff and patients,

professionalism of staff, food and physical environment. Arasli et al. (2008) also found

that inpatients expectations have not been satisfied in either public or private hospitals.

Using SERVQUAL scale and a data set from 983 patients of 8 private general hospitals,Zarei et al. (2012) found that three factors (reliability/responsiveness, empathy, tangibles),

explaining 69% of the total variance. The total mean score of patients expectation and

perception was 4.91with standard deviation of 0.2 and 4.02 with standard deviation of 0.6,

respectively. The highest expectation and perception related to the tangibles dimension

and the lowest expectation and perception related to the empathy dimension. There was a

significant difference between the expectations scores based on gender and education

level. They also concluded that SERVQUAL is a valid, reliable and flexible instrument to

monitor and measure the service quality in private hospitals in Iran.

In the most recent study, Al-Borie and Damanhouri (2013) compared patient satisfaction

with service quality in Saudi Arabian public and private hospitals using SERVQUAL

scale with 1000 inpatients respondents, they found that here were significant differences

in the service quality between public and private counterparts. Private hospitals service

quality was higher than public and these differences were statistically significant. Their

result also suggested that the best three dimensions in the public hospitals were tangibles,

empathy and security, whereas in private hospitals the best three dimensions were

security, empathy and tangibles. The reliability dimension was fourth, followed by

responsiveness in all public and private hospitals. The best service quality dimension in

public hospitals was tangibles. This dimension included hospital staff appearance,

convenient and easily accessible locations, followed by modern equipment and


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technology. The best service quality in private hospitals was convenient and easily

accessible locations followed by medical staff cordiality and friendliness when dealing

with patients.

In the globalized world, like other service-providing organizations, Cambodias health

care sector has faced with a stiffer competition after the country further liberalized its

economy including trade in goods and services to foreign competition. Using our

conventional wisdom, we expect that the increased foreign completion in health sector

will force the countrys health care providers to search for competitive advantages to

remain in todays competitive market. Comparing to foreign health care services, health

care rendered by Cambodian public and private hospitals may suffer from the issues of

less qualified health professionals, medical technology and medical staff withprofessional ethics, which are a key to success and profitability of hospital operations.

These issues often arise in a relatively less developed nation.

3. Problem Statement

Over decades, the Royal Government of Cambodia has made great efforts to fulfill their

important tasks and obligations by improving the health care provisions as it is

considered to be a central sector in a countrys development process. In this regard, the

health care service areas were reformed in order to deliver good health service to the

general public, in particular to the Cambodian people. Many of the existing hospitals

have been upgraded and modernized. The hospitals aim at providing basic specialized

health care services. Further, the training of health personnel has also been intensified,

and medical as well as paramedical staff members were appointed to many hospitals

across Cambodia. Moreover, the intensive care and laboratory facilities have

continuously been expanded with appropriate technology to meet the rising demand for

health cares.

Despite all aforementioned commitments by the Royal Government, especially by the

Cambodian Ministry of Health, notable deficiencies still prevail with respect to the

health care services, delivered by the both public and private hospitals in Cambodia.


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There have been quite a large number of complaints filed by the public due to delays in

taking appropriate actions with regards to delivering services to them by hospitals. The

wide spread of world-of-month and headlines of domestic newspapers also highlighted

complaints from the public, regarding their deep dissatisfactions with the hospitals

services. In other words, hospitals service quality is not as expected by the customers,

due to its low quality. This matter is a concern to the public since they are taxpayers and

they therefore expect that good services are delivered to them as the return.

Many of the hospitals are reported to ignore the non-health expectations of the people

such as basic human needs, dignity, kindness and compassion, proper communications

with the patients. This combined with less quality of health care service has encouraged

more and more people to treat and/or receive medical checkups of their health abroad,especially in neighboring countries such as Vietnam, Thailand and Singapore. There are

some reported complaints about the death of a patient, due to inappropriate care and

negligence.

Although hospitals do provide valuable health services to the public, the services

delivered are not well recognized, due to negligence and failure to strict adherence to

professional ethics and the like. Yet, some public and private hospitals are reported to

have taken the initiative to enhance the quality of their services by improving

infrastructure, modernizing medical technology, reviewing monthly performance,

preparing manuals and guidelines, initiating productivity improvement programs, and so

on.

The current study is carried out in order to measure and evaluate the quality of service

delivered by both Cambodian public and private hospitals in urban area of Phnom Penh.

It also intends to identify the most important service quality dimensions, which

contributes significantly to patients satisfaction.

4. Research Questions

The above discussion has provided a brief good overview of how important service


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quality is to the success of the operations of hospitals in Phnom Penh. Of course,

general descriptions need to be made in detail. Research questions need to be identified

and formulated, and vigorous analysis needs to be made in order to rigorously answer

the questions before any sound managerial and policy implications can be offered.

While making use of gap analysis to measure service quality of both public and private

hospitals, the present study will also focus on the following four main research

questions:

(1).What does the patients perception meet their expectation on service quality inboth public and private health sector in Cambodia?

(2).Are there any differences between the quality of services of public and privatehospitals?

(3).What are dimensions of the augmented SERVQUAL model that affect patientssatisfaction?

(4).What are the factors that contribute most significantly to the satisfaction ofpatients?

5. The Purpose of Research:

Generally, the main purpose of this study is to determine the relationship between

service quality and patients satisfaction in both private and public hospitals in the urban

area of Phnom Penh. On the basis of its results, this study will propose a service quality

model, with an application to health care service in Cambodia. Second, several factors

related to service quality will be discussed and analyzed, based upon the augmented

SERVQUALs dimensions, namely tangibles, assurance, reliability, responsiveness,

empathy, and accessibility and affordability. Third, the current study also intends to test

the statistical differences between the quality of services of public and private hospitals.

Fourth, it will also identify the dimensions of the augmented SERVQUAL that

contributes most significantly to patients satisfaction.

Improving these factors may help convince the Cambodian people as well as foreign

nationals staying in Cambodia to use the Cambodian hospitals services. This will


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encourage further development and improvements of the health sector in the small, open

economy of Cambodia that had been inflicted by decades of destructive internal

conflicts.

6. Significance and Scope of the Study

To the best of my knowledge, no research has been conducted with respect to the

measure and evaluation of service quality of public and private hospitals in the

Kingdom of Cambodia, especially in the urban area of Phnom Penh. This study

therefore is considered to be critically important as it intends to measure and evaluate

the level of service quality and the level of satisfaction among the patients in both

private and public health organizations, in particular public and private hospitals. Theresult from the study can be used to give valuable information on the elements and the

dimensions, which have been given a priority by patients, Cambodian Ministry of

Health, health policymakers and all stakeholders concerned in assessing the quality of

services rendered by the Cambodian hospitals. In addition, this study will draw

conclusions and offer some recommendations, which are believed to be useful for

Cambodia.

In summary, the findings of the study may be used in many useful ways. First, the

hospitals top managements benefit from the results of study as they can use the

information and the findings of the study to improve their hospitals services rendered

to meet customers needs. Second, hospitals managers and medical staff who are

involved in delivering the hospitals services may also use the information for service

improvements and for increasing their work performances to bring satisfaction of the

rendered hospitals services to the patients. The result of study could also be used as a

guideline to improve other services of public and private hospitals, with respect to

service quality dimensions of tangibles, reliability, responsiveness, assurance, empathy,

and accessibility and affordability.

Concerning the scope of the study, it primarily focuses on services rendered by public

and private hospitals, located in the urban area of Phnom Penh, rather than all public


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and private hospitals in operations in the Kingdom of Cambodia. The collection of the

sample data is obtained from patients who received health care services during last two

months in public and private hospitals in the urban area of Phnom Penh.

7. Formulation of Hypotheses

A hypothesis is basically unproven statement of a research question in a testable format

(Hair et al., 2003). Hypothesis testing is a very effective analytical tool for obtaining

valuable information under a wide variety of circumstances (Webster, 1998). Based on

both theoretical and empirical literature presented above, the following hypotheses are

formulated and to be tested as follows:

Hypothesis H1: Tangibility of both public and private hospitals exerts asignificant positive effect upon patients satisfaction;

Hypothesis H2: Reliability of both public and private hospitals is positivelyrelated with patients satisfaction;

Hypothesis H3: Responsiveness of both public and private hospitals haspositively impacted upon patients satisfaction;

Hypothesis H4: Assurance of both public and private hospitals is positivelyrelated with patients satisfaction;

Hypothesis H5: Empathy of both public and private hospitals has exerted asignificant positive influence on patients satisfaction;

Hypothesis H6: Both public and private hospitals do not meet patientsexpectations;

Hypothesis H7: Private hospitals in Cambodia are more successful than publichospitals in providing health care services for satisfying patients needs;

Hypothesis H8: There is a difference between public and private hospitalsconcerning their quality of services rendered; and

Hypothesis H9: Private hospitals are more successful than public counterparts indelivering heath care services for their patients.

8. The Proposed Econometric Model


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Based on the literature review presented above, the augmented SERVQUALs

dimensions, in particular tangibles, reliability, responsiveness, assurance, empathy, and

accessibility and affordability, have been utilized in order to investigate the relationship

between these dimensions and patients satisfaction in both public and private hospitals.

On the basis of the previous theoretical and empirical literature, the following model is

used to examine the service quality dimensions that may affect the overall patient

satisfaction in health care services delivered by Cambodias public and private

hospitals.

uityaffordabilityaccessabilempathy

assurancenessresponsiveyreliabilittangiblesOPS

55

43210

_

where OPS denotes overall patient satisfaction, and u is error term, which is assumed

to be normally distributed.

The data used for the analysis is from a survey of two thousand patients using health

care services delivered by public and private hospitals in operations in Cambodia. Yet,

following cleaning process, a sample of more a thousand patient respondents is

considered to be usable for the analysis. The data set contains detailed information on

the explanatory variables (tangibles, reliability, responsiveness, assurance, empathy, and

accessibility and affordability) which are included in the model presented above.

9. Data and Research Methodology

9.1Data Collection

This study used the modified SERVQUAL, initially developed by Parasuraman et al.

(1988). Relevant information about patient satisfaction, perceptions, expectations and

socio-demographics in both public and private hospitals is obtained by means of a

survey conducted to collect a sample containing the needed information for the analysis.

A survey questionnaire is designed and distributed randomly to target respondents, who

used health care services of public and private hospitals in the urban area of Phnom


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Penh. In order to receive the most accurate responses possible, the questionnaires were

translated into Cambodian language, Khmer.

The questionnaire is classified into five major parts. The first part of the questionnaire

contains respondents expectations of health care services delivered by public and

private hospitals. In the second part, questions were asked to obtain the information on

perceived performance of hospitals services rendered. The third part asks patients

respondents to allocate 100 points to the six factors of service quality. The fourth part

captures the information related to overall satisfaction. Respondents were asked to

respond to each item on the widely used five-point Likert-type scale. The five part of

the questionnaire is used to get the information on the demographic information of the

respondents.

As cited by Soeung (2012), Roscoe (1975) suggests a series of general rules in

determining the acceptable sample size for research, and proposes that for any research

that intends to conduct a multiple regression analysis, a sample size should be at least 10

times as large as that of the number of variables. In order to produce the best estimates

possible, the collection of a reasonably large data set has to be made from the

population. To achieve this, two thousand questionnaires were distributed randomly to

patients who once used to receive hospitals services. The rate of the responses was

about 63%. Following cleaning process of the data, a sample of more than one thousand

respondents is considered usable for the analysis to be carried out. Data collection work

took approximately four months, starting from 25 March 2012 to 22 July 2012.

9.2Measures of the Included Variables

The measures of each key variable are as follows. Patients satisfaction is the measure

of patient satisfaction, which consists of responses to a single question on the patient

satisfaction questionnaires. It is measured, using four items. For instance, Overall how

satisfied were you with the treatment you received at the hospital? Responses for all

satisfaction questions were made on five-point Likert-type scale, labeled 5 very

satisfied and 1 very dissatisfied at each extreme. Tangiblesconsist of up-to-date and


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well-maintained medical facilities and equipment; clean and comfortable environment

with good directional sign; doctors/medical staff being professional and neat in

appearance. It is measured, using five items. For instance, Hospital has up-to-date,

well-maintained medical facilities and equipment. Respondents were asked to respond

to each item on a five-point Likert-type scale. Reliability comprises the ability of the

hospital doctors and medical staff to provide service at appointed time and accurately. It

is measured using five items. For example, Services are provided at the appointed

time. Respondents were asked to respond to each item on a five-point Likert-type

scale. Responsiveness includes the willingness of the hospitals doctors and medical

staff to provide prompt service and be responsive to patients needs. It is measured

using four items. For example, Patients are given prompt services. Respondents were

asked to respond to each item on a five-point Likert-type scale. Assurance includes theknowledge and courtesy of the hospitals doctors and medical staff and their ability to

convey trust and confidence. It is measured using four items. For instance, Doctors and

medical staff are friendly and courteous. Respondents were asked to respond to each

item on a five-point Likert-type scale. Empathy contains the caring, individualized

attention the hospitals doctors and medical staff provides their patients. It is measured

using five items. For instance, Doctors and staff have patients best interests at heart.

Respondents were asked to respond to each item on a five-point Likert-type scale.

Accessibility and affordability include adequate parking facilities, accessible location of

premises, and affordable charges for hospitals services. It is measured using three

items. For instance, Affordable charges for service rendered, with accessible location

of premises. Respondents were asked to respond to each item on a five-point Likert-

type scale.

9.3Estimation Techniques

The collected data are imported into statistical packages, namely the Statistical Package

for the Social Sciences (SPSS 16) and/or STATA 12.1 for statistical analysis, which

includes descriptive statistics, gap analysis and multiple regression analysis and other

necessary testing to obtain the best possible results. To report the most accurate results

from the estimation of the regression model, several diagnostic tests need to be carried


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out. Reliability check is to be performed in order to assess the degree to which data

collection method will yield consistent findings, with similar conclusions drawn by

other researchers. In order to test the reliability of the instrument, the reliability

coefficient Cronbachs alpha is used. It is generally agreed that Cronbachs Alpha

should exceed 0.70 to be reliable (Hair et al., 2010). Other statistical diagnostic tests

will also be conducted. These tests include multicollinearity checks, heteroskedasticity

test and model specification test, known as Ramsey (1969)s specification test.

Since the data collected is cross-sectional, heteroskedasticity is often present in such as

data set. This is why the usual OLS estimator is not the best linear unbiased estimator

(BLUE) and the t-statistics are no longer t-distributed. These problems cannot be

resolved by using a large sample size (Wooldridge, 2009). Similarly, F-statistics are nolonger F-distributed.

There are a number of competing tests for heteroskedasticity (Wooldridge, 2009). Only

the modern tests are briefly discussed here. The first one is the Breusch and Pagan

(1979) test for heteroskedasticity (Verbeek, 2004), which is based on an LM statistic,

shown to be equal to 2 2

.u

RnLM , where 22u

R is obtained by regressing the OLS squared

residuals on all k dependent variables, and n being the sample size. Under the null

hypothesis of homoskedasticity, the LM statistic is asymptotically distributed with

kdegrees of freedom. The second test is known as the general White test for

heteroskedasticity and is based on an estimation of the OLS squared residuals on all

independent variables, squares of independent variables, and all their cross products.

The general White test consists of the LM statistic for testing all the coefficients in the

squared residual estimation on all independent variables, their squares and cross

products, being zero, except for the intercept. However, the general White test clearly

suffers from a weakness in the pure form of the test because it employs many degrees of

freedom.

To conserve degrees of freedom, especially when a model consists of a moderate or

large number of independent variables, Wooldridge (2009) proposes the special White

test for heteroskedasticity, which incorporates the Breusch-Pagan and the general White


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tests. The special White test, also based on the LM statistic, suggests testing for

heteroskedasticity by estimating the OLS squared residuals on the fitted values and

squared fitted values. Under the null hypothesis, the LM statistic for the special White

test is chi-square distributed with two degrees of freedom, regardless of the number of

independent variables included in the model. This is why the special White test for

heteroskedasticity is to be preferred and will be used to test for heteroskedasticity in the

study.

A multiple regression model may suffer from functional form misspecification when it

does not or insufficiently account for the relationships between the dependent and

explanatory variables. Important or relevant variables may be excluded from the

regression equation or the model, when a non-linear model is estimated as a linearmodel. Such misspecification will be detected by using the RESET test (F statistic),

which is based on Ramsey (1969). Under the null hypothesis that the model is correctly

specified, the F statistic distribution is approximately 4,3 knF in a large sample.

Rejection of the null hypothesis implies that the model under consideration is

misspecified.

10.Research Structure

The current study consists of five chapters. Chapter 1 covers the problem being studied,

research objectives, research questions, significance and scope of the study, formulation

of hypotheses, and research structure. Chapter 2 carries out both theoretical and

empirical literature review related to service quality and satisfaction in order to provide

background and form the foundation for defining the studys parameters to be

estimated. Chapter 3 deals with overview research design, model development, variable

measurements, sampling method, sample size, questionnaire design, reliability testing,

and data screening. Chapter 4 describes about hospitals profile in Cambodia. Chapter 5

describes result findings, multiple regression analyses and discussion. Chapter 6 draws

conclusion, offer recommendations for health policymakers and all stakeholders

concerned as well as suggestions for future research.


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assessment of service quality of cambodia_s public & private hospitals

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