VIMS Journal: July 2016

Special Article

SERVQUAL: A Service Quality Model to Measure Performance of Eye Hospitals for VISION 2020

Dr. Bhaskar Mukherjee, Dr. Malini Majumdar

Introduction :
Marketing of healthcare services focuses on identifying marketing opportunities, Zeroing on the target market, strategising marketing efforts and implementing and controlling them. In this respect,we propose that a model study can be done to analyze services marketing measures adopted by Kolkata eye hospitals in cases of cataract surgery and whether they are at par with the objectives of VISION 2020, formulated by WHO.

The healthcare market in India, with a population of 121 million growing at an average rate of 1.96% per annum, has the potential to become a huge market.[1] The National Health Accounts Report 2004-05 predicted that the cost associated with health infrastructure would grow at an average of 5.8% per annum between 2009 and 2013, covering all the states of India, while the total expenditure in 2013 stood at USD 14.2 billion.[2] However, in 2012, the sum of public and private health expenditure stood at 4% of GDP, which indicates of having only USD 157 as per capita expenditure on health.[3]

The National Health Accounts Report covers 32 states, and West Bengal figures as one of the six states forecasted to account for approximately 50% of this expenditure.[4]

Among all the non communicable diseases leading to decrease of manpower of a nation & DALY (Disability adjusted life year), blindness due to cataract is one of the most important diseases.[5]

90% of blindness in South East Asian region is avoidable i.e preventable & curable. The prevalence of cataract in India increases with each decade of life. From a low of 3.1% in the age bracket of 40-49 years, it progressively increases to 75.2% in the age bracket of 70-80 years. It is said that every individual will ultimately develop a cataract provided he lives a long life.[6]

Measure of prevalence for cataract as a disease causing blindness indicates that approximately 7 million people suffer from cataract-induced blindness whereas these cases are added by 6.15 million every year, which can be termed as incidence.[7]

Key Word :
SERVQUAL - Performance of Eye Hospitals - Vision 2020.

Cataract :
Cataract is a condition in which the clear lens of the eye loses its transparency to become progressively opaque.

The Procedure - Cataract surgery procedures are of three types.
1. Extra capsular cataract extraction-ECCE.
2. Small incision cataract surgery-SICS or Manual Phaco
3. Phacoemulsification
4. Femto second laser cataract surgery.
However, despite increase in the number of cataract operations, the cataract surgery rate remains low as there is a rapid increase in the number of new cataract cases as a result of the growing population, particularly the geriatric population.

The cataract surgical rate in India is about 3400 per million of population. The principal cause of blindness in India today is cataract, responsible for about 62.6% of all cases.[8]

In India, as per the statistics published by the National Programme for control of blindness (report as on 30-9-2013), national target of cataract operation is 7000000. Number of Cataract operations achieved till date (National) is 1716582. In the year 2011-2012, number of cataract operations done (National) was 6349205.[9]

Similarly in West Bengal target for cataract operation in West Bengal (2013-14) was 529820 and the number achieved as on 30/9/2013 was 69367. Target for cataract operation in West Bengal in 2011-2012 was 456000 and achieved was 345352.[10]

These figures show that there exists a backlog in cataract surgery. More emphasis has to be given on cataract surgery at optimum cost in high volumes.

Phacoemulsification is considered as the "gold standard" for cataract surgery. However, it is neither practical nor feasible to adopt this for the entire population suffering from cataract. SICS, on the other hand, is as a low cost, but equally effective technique and thus is a viable alternative for a country like India, where developments are unequal across categories of population.

As the life expectancy of the population increases, more & more patients with cataracts will be identified. If surgical performance does not keep pace, the backlog of operable cases will continue to increase. The backlog of cataract cases is more prevalent in the rural areas, especially among females, schedule castes & labourers.

In India, considering its population, even 1% blindness cases (vision 6/60 or less than 6/60) amounts to 1 crore 21 lakhs patients. Approximately 62% of this (7.2 million) are cataract-induced blindness. Incidence rate, as defined before, is 0.4 to 0.5%. Thus the opportunity for fresh cataract surgery cases each year stands at 61.5 lakhs (6.15 million).[11]

Therefore to eradicate avoidable blindness, World Health Organization (WHO) had formulated an action plan named Vision 2020 in February 1999.

Objectives of Vision 2020 – Who Guidelines[12]
1. To increase awareness, among the population, regarding the causes of
2. Avoidable blindness and the solutions to the problem;
3. To advocate for and find the necessary resources to implement the WHO Global Plan 2014-19; and
4. To facilitate the planning, development and implementation of National
5. Vision 2020/ Eye Health programmes in all countries, who are signatories to Vision 2020.
National Programmes have three main elements;
6. To control the disease in a cost effective manner.
7. Development of available human resource.
8. Development of infrastructure and technology.
Achieving the mission of Vision 2020 needs not only the development of affordable technology and infrastructure, but also a successful implementation of the programme through properly managed healthcare support maintaining a considerable level of quality. The stakeholders need to be aware of as well as perceive the quality of the service providers in this regard.

Service Marketing by Eye Hospitals :
"Services are economic activities offerered by one party to another which is often time-based. In exchange for money, time and effort, for which customers expect value from access to goods, labour, professional skills, facilities, networks, systems; but they do not normally take ownership of any of the physical elements involved". Therefore, Health care Marketing by various Eye Hospitals is services marketing.[13]Service Marketing is defined by the American Marketing Association as "a process of planning & executing the conception, pricing, promotion & distribution of services to create exchanges that satisfy individual & organizational goals. Service marketing has increased in importance over the last decade with the advent of competition".[14]

Health care organization has to decide how to divide the total health care marketing budget among the various tools in the marketing mix (the 7 P's)
1. Product
2. Price
3. Place or distribution
4. Promotion (or communication)
5. Process
6. Physical environment
7. People.
Marketing of any service is always associated with ensuring the quality of the delivered service. Service quality, however, is defined as 'customers' perception of how does a service meet or exceed their expectations". Several practitioners define service quality as "the difference between customer's expectations for the service encounter and the perception of service received".[15] Customers judge quality as "low" if performance (perception) does not meet their expectation and judge quality as "high" when performance exceeds expectation.

Servqual :
Service quality is often measured using models, and the most acknowledged and applied model is the SERVQUAL (service quality) model developed by Parasuraman et al (1985), which measures the quality against five dimensions.
These five dimensions are : tangibles (Physical appearance of the facilities, equipments, people and other materials associated with the service delivery), reliability (delivering the service as promised, with accuracy), responsiveness (responding to customers’ queries promptly and willingness to solve customers' problems sincerely), assurance (knowledge, skill and ability of the employees to solve the problems encountered during service delivery and gaining trust and confidence from the customers), and empathy (individual attention to the customers so that everyone feels special). However, among all these dimensions, reliability is considered to be most important in relation to the quality aspect as other dimension will be taken into consideration if and only if a service is reliable.[16]

Research Gap :
Although there are various single speciality (Ophthalmology) and multispecialty hospitals in Kolkata performing cataract surgery on regular basis, yet have no previous study has been conducted on ascertaining the SERVICE QUALITY perception of patients and doctors in relation to cataract surgery performed by Kolkata hospitals. It is also important to find out what measures the hospitals are taking to bridge the gap between perceived and delivered service. Therefore the research gap exists.

Objective of Study Model :
1. To study services marketing strategy related to cataract surgery by various Kolkata based hospitals, in order to verify whether there exist relationship between the 3P's namely process, physical evidence and people.
2. To assess how the important factors influence services quality of these hospitals.
3. To analyze the target markets of these hospitals.
4. To analyze and interpret whether their services marketing techniques is in tune with the increasing social requirements like cataract surgery backlog and recent developments in the medical sciences.
5. To analyze if Kolkata hospitals conducting cataract surgery can deliver the expected service quality, in sync with the objectives of Vision 2020.

Research Methodology Model :
Research Design : Research design could be descriptive in nature, highlighting on identifying the factors influencing the service quality for the hospitals and studying their performances in delivering quality service.
Source of Data :The data shall be primary and secondary data. The secondary data shall be institutional and commercial data available publicly and for commercial use from available publications and other official sources. The primary data will be collected through structured interview techniques and non-disguised questionnaire to Medical Superintendent / CEO / HOD of Ophthalmology of various Kolkata based hospitals conducting cataract surgery regularly. Patients undergoing cataract surgery at these hospitals will be interviewed to know the level of customer perception in relation to service quality.
Data Collection Tools : The tools for collecting data shall be structured, undisguised questionnaire. However, sometimes researcher may use depth interviews to unravel the attitudes, as and when required.
Scales- In our study we can use ordinal scales. Sample size - The sample size shall be variable and evolving. The target respondents will include MS/CEO/HOD of Ophthalmology, of Kolkata eye hospitals, and patients undergoing cataract surgery there.
Hypothesis - These will be framed to understand how far the service quality dimensions are important for perception of service quality. Each hypothesis will be tested by using Chi-square test and final inferences can be framed.

Formulation of Hypothesis:
H0- there is a significant difference between services delivered by hospitals and WHO Vision 2020 guidelines.
H1- there is no significant difference between services delivered by eye hospitals of Kolkata and WHO Vision 2020 guidelines.
H2- the service quality dimensions are perceived to be important to fulfil patients' (customers) satisfaction.
Data Analysis Tools - Data analysis shall be carried out using the tools including both of descriptive & inferential statistics.

Conclusion :
This model study could identify the dimensions of service quality that are relevant both for the medical professionals and patients in perceiving the quality of service delivered by the hospitals. The inferences could help the hospitals in finding out where the gap/s lie between perceived and delivered service quality and will definitely serve as a guide for adopting measures appropriate in bridging the gap/s. The study could also qualitatively focus on what measures the hospitals are taking in fulfilling the objectives set by WHO towards achievement of Vision 2020 and how the service quality dimensions are gaining significance in achieving so. This could be the implication of our proposed study.

References
  1. Srinivasan SA, Managing a Modern Hospital, Response Books, New Delhi, 2009;73.

  2. < http://planningcommission.nic.in/reports/genrep/ health/ National_Health_Account_04_05.pdf> accessed on 21.11.2015

  3. < http://www.occd.org/els/health-systems/Briefing- Note-INDIA-2014.pdf> accessed on 21.11.2015.

  4. National Health Accounts publication,2004-05

  5. Park K, Park's Text Book Of Preventive and Social Medicine, M/S Banarsidas Bhanot, Jabalpur,2009;375

  6. Murthy GVS. Primary Eye Care and Epidemiology of Common Eye Diseases.
    National Society for the prevention of blindness India. Quarterly Publication.2013;38(2):4-10.

  7. < http://www.npcb.nic.in> accessed on 20.10.2015

  8. < http://www.npcb.nic.in> accessed on 20.10.2015

  9. < http://www.npcb.nic.in> accessed on 20.10.2015

  10. < http://www.npcb.nic.in> accessed on 20.10.2015

  11. < http://www.npcb.nic.in> accessed on 20.10.2015

  12. < https://www.iapb.org/advocary/who-action-plan> accessed on 12.12.2015

  13. Lovelock C , Wirtz J, Chatterjee J, Services Marketing People, Technology, Strategy, Pearson Education, Noida, 2011;15.

  14. Kotler P, Keller KL, Koshi A, Jha M, Marketing Management-A South Asian Perspective, Pearson Education, Noida, 2009;06.

  15. Munusamy J, Chelliah S, Mun H, Service Quality Delivery and its Impact On Customer Satisfaction in the Banking Sector in Malaysia, International Journal of Innovation, Management and Technology, 2010; 1(4), 398-404.

  16. Parasuraman A, Zeithaml VA, Berry, LL, A conceptual model of service quality and its implications for future research, Journal of Marketing,1985;49(3),41-50.

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