India is currently undergoing a triple transition–economic, demographic and epidemiological–presenting challenges and opportunities, as it seeks to transform its health sector (1). Users of health services in India face major challenges related to physical access to services, a lack of affordability and inadequate quality of care. While challenges in physical access and adequate availability of quality health services act as major deterrents to people in accessing public health facilities, quality and cost tend to be more salient in the private sector. In the private sector, where providers involved in health-care delivery are quite diverse, compromises on the quality of services provided, including irrational, unnecessary and expensive interventions, are quite common (2). Although the health sector is the largest sector in terms of revenue and employment in India, unfortunately, the quality of health care services here is miserable and far from customers satisfaction (3). In this context, Gronross (4) developed the definition of quality for the first time for the service sector. He stated that quality is the consequence of an evaluation process, where the quality users relate their expectations with the perceptions that they received from the product or services. According to Zeithaml et al. (5) service quality is based on customers’ judgments of how services fulfil or exceed their expectations.
Hospitals typically strive to deliver services in accordance with objective standards of quality because patients expect error-free care. However, these services might not always live up to the expectations of patients, which suggests that patients' expectations matter when the quality of the services is determined. In fact, patients today possess sufficient knowledge to evaluate quality by comparing a hospital's services to those of other hospitals. Therefore, hospitals benefit from a clear awareness and consciousness of patients’ perceptions and expectations of their services (6).
Existing models for measuring service quality:
The process of measuring service quality is extremely intricate. Researchers have developed several methods over time for evaluating and quantifying the quality of services. Five models have been identified for measuring the quality of healthcare services in the literature, namely, Donabedian’s model of care (7), and the SERVQUAL, SERVPERF, HEALTHQUAL, PubHospQual, HCSQ and HospitalQual models (8). SERVQUAL is considered a comprehensive measure for assessing the expected and perceived quality of services. Parasuraman et al. (9) who developed the SERVQUAL, considered service quality in different sectors as the gap between customers’ expectations of service quality and their perception of service quality. Gilbert et al. (10) stated that the SERVQUAL model is more aligned with the identification of patients’ expectations than with patients actually experienced in service delivery. The criticism of the SERVQUAL model is that it does not illustrate service gaps (11,12). According to Cronin et al. (13) the main criticism of the SERVQUAL model is that, rather than only measuring attitudes, it adapts its expectation-disconfirmation model SERVQUAL's conceptualization and operationalization, as it is now sufficient. Since SQ is solely a patient attitude, critics contest that a performance-based measure is better appropriate for assessing SQ (14). Several researchers have also been forced to let go of their expectations when evaluating SQ due to the intangible nature of the service. According to Sharma et al., (15,16) research, the main predictor of customer satisfaction is service performance. With the rapid growth and necessity of hospitals and health care services, it has become vital to understand patients’ expectations of service delivery reliability, responsiveness, assurance, and empathy (17,12). This is why SERVQUAL is still the recommended model for assessing SQ in the healthcare sector, despite criticisms in the service quality literature (18). The final SERVQUAL model comprises of twenty-two paired items covering five dimensions that are used to measure the gap between the expected service quality and the received service quality, and this questionnaire has been widely adopted for explaining consumer perceptions of service quality. The final five dimensions are as follows (19,20):
1. Tangibles (physical facilities, equipment and appearance of personnel).
2. Reliability (ability to perform the promised service dependably and accurately).
3. Responsiveness (willingness to help customers and provide prompt service).
4. Assurance (including competence, knowledge and courtesy of employees and their ability to inspire, trust and confidence, credibility and security).
5. Empathy (including access, communication and understanding the customer).
Rationale of the study:
Very few studies in India, such as Pramanik (20), have explored the obstacles that hinder service quality in urban and rural hospitals and examined the difference in the quality of healthcare services using existing tools. Tripathi et al. (21) assessed the technical quality of services via SERVQUAL, and data were collected only from healthcare employees. To the best of our knowledge, only one study, Chahal et al., (22), has focused on developing a multidimensional scale for healthcare service quality (HCSQ) in the Indian context. The limitation of this study was that it was performed in only one public hospital in North India. Additionally, the study fails to include/highlight significant regional indicators of service quality in their developed HCSQ model. Keeping this in mind, this study developed and validated the SERV-INDIA model as a tool specifically designed by incorporating regional indicators such as baksheesh which can affect service quality and explore the gap between patients’ expectations and their perceptions (23).