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Developing a Service Quality Measurement Model of Public Health Center in Indonesia

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  1 Copyright © Canadian Research & Development Center of Sciences and Cultures ISSN 1913-0341 [Print] ISSN 1913-035X [Online]www.cscanada.netwww.cscanada.org Management Science and Engineering Vol. 7, No. 2, 2013, pp. 1-15 DOI: 10.3968/j.mse.1913035X20130702.1718 Developing a Service Quality Measurement Model of Public Health Center in Indonesia Tri Rakhmawati [a], *; Sik Sumaedi [a] ; I Gede Mahatma Yuda Bakti [a] ; Nidya J Astrini [a] ; Medi Yarmen [a];  Tri Widianti [a] ; Dini Chandra Sekar  [a] ; Dewi Indah Vebriyanti [a] [a]  Indonesian Institute of Sciences, Indonesia* Corresponding author. Received 16 March 2013; accepted 14 April 2013 Abstract Many researches were conducted in order to develop service quality measurement model for health service. However, the majority of the researches were conducted in hospital service context and only small numbers of the researches were done in developing countries. Furthermore, the previous researches also have not tested the stability of service quality measurement model because of the differences in socio-demographic profiles (sex, age, and income) of the users. Therefore, this research tried to develop a new service quality measurement model for public health center (PHC) in Indonesia, a developing country.In order to build the model, research data were gathered from 800 PHC users using survey method. The authors applied some statistical analysis, such as: exploratory factor analysis to identify the dimensions of service quality; confirmatory factor analysis to test the goodness of fit, discriminant validity, and convergent validity; Cronbach Alpha analysis to ensure the reliability, and stability analysis based on socio-demographic proles of the respondents.The result shows that service quality measurement model of PHC in Indonesia consists of 24 indicators which are divided into four dimensions, namely the quality of healthcare delivery, the quality of healthcare personnel, the adequacy of healthcare resources, and the quality of administration process. This service quality measurement model has not only met the criteria of goodness of fit, discriminant validity, convergent validity, and reliability  but also proved to be stable tested against respondents’ sexes, ages, and incomes. Key words: Service quality; Public Health Center; Measurement instrument; Developing countries Tri Rakhmawati, Sik Sumaedi, I Gede Mahatma Yuda Bakti, Nidya J Astrini, Medi Yarmen, Tri Widianti, Dini Chandra Sekar, Dewi Indah Vebriyanti (2013). Developing a Service Quality Measurement Model of Public Health Center in Indonesia.  Management Science and Engineering, 7  (2), 1-15. Available from: http://www.cscanada.net/index.php/mse/article/view/j.mse.1913035X20130702.1718 DOI: http://dx.doi.org/10.3968/j.mse.1913035X20130702.1718 1. INTRODUCTION 1.1 Background In service sectors, quality is already identied as a variable with important roles (Yusoff and Ismail, 2008). Many researches proved that service quality is an antecedent factor of satisfaction (Lai and Chen, 2011; Olorunnivo et al., 2006; Ojo, 2010; Ravinchandran et al, 2010; Salazar et al, 2004; Hasan et al, 2008; Ishaq, 2011; Sumaedi et al., 2011) and customer loyalty (Bunthuwun et al., 2010; Kheng et al., 2010; Al-Rousan et al., 2010; Bloomer et al., 1999). Furthermore, service quality also determines the value of products/ services in the eyes of customers (Omar et al., 2010; Ismail et al., 2009; Wen et al., 2005; Kuo et al., 2009; Jen and Hu, 2003; Zeithaml, 1998). In the context of health service, customer perception on service quality is also believed to be a success factor for healthcare organizations. For example, Donabedian (2005) stated that hospital profitability and user satisfaction is affected by users’ perceptions on service quality. Furthermore, perceived service quality is also said to have an impact on customer loyalty and word-of-mouth (Andaleeb, 2001). Therefore, user perception on service quality must always be considered and improved in health service context.Health is an important aspect of national development since it inuences the quality of human resources (Act No. 36 of 2009 concerning Health). In this particular context, healthcare service in Indonesia is a part of public services  2 Copyright © Canadian Research & Development Center of Sciences and CulturesDeveloping a Service Quality Measurement Model of Public Health Center in Indonesia that must be provided by the Government. In Indonesia, Government develops public health centers (PHC) to ensure the availability of healthcare service for its citizens (The Decree of Indonesian Minister of Health No.279/MENKES/SK/IV/2006 concerning the Guideline for Implementing Public Healthcare Effort in Public Health Center). Unfortunately, until now, harsh complaints and criticisms towards PHC in Indonesia are still vibrantly heard. Given this, PHC service quality improvement must be a mandatory agenda. With that in mind, user  perception of public health center in Indonesia, especially the way they measure service quality, is essential, urgent and interesting to be studied. This because the knowledge on quality measures (quality dimensions) will help  practitioners and policy makers in public health center clearly assess what needs to be monitored, analyzed, maintained, and xed regarding to service quality. 1.2 Literature Review and Research Gaps Service quality is one of the most discussed topics among practitioners and scholars in the field of service management (Yusoff and Ismail, 2010). Many researchers try to dene service quality. Although different, generally, researchers agree that service quality must be seen from the view of users/customers (Clemes et al., 2008). Zeithaml (1988) dened it as “the consumer’s judgment about a [service]’s overall excellence or superiority”. Hence, we can conclude that healthcare service quality is referred as consumer overall evaluation on healthcare service performance given by health care service provider.Quality is an abstract concept, making it hard to be measured and it is currently seen using various points of view (Lee et al., 2000). It is more complex in service context because of the unique characteristics of service quality, which are intangibility, inseparability, variability, and perishability (Kotler and Keller, 2012). Hence, many researchers have tried to develop ways to measure service quality including in the context of healthcare service. Surprisingly, until now, there is no agreement on how to measure service quality (Jain and Gupta, 2004; Parasuraman, 1985; 1988; 1994; Cronin and Taylor, 1992; Clewes, 2003), including in the context of healthcare service (Pai and Chary, 2012).Service quality measurement model, which consists of dimensions and indicators of the dimensions, illustrates how service quality is evaluated by service consumers. Service quality dimension is aspects that are deemed as relevant  by consumers in evaluating service performance (Clemes et al., 2008). Literatures show that service quality has been agreed as a multidimensional concept (Berry et al., 1985 and Parasuraman et al., 1985), but there is no consensus on what are the dimensions of the construct (Brady and Cronin, 2001).Many researchers have proposed service quality measurement model that is specific to the context of healthcare service. For examples, Lim and Tang (2002) suggested seven service dimensions of healthcare service quality, namely reliability, assurance, tangible, empathy, responsiveness, accessibility and affordability. Other researchers, Reidenbach and Sadifer-Smallwood (1990), argued that service quality should be consisted of seven dimensions, which are patient confidence, empathy, quality of treatment, waiting time, physical appearance, support services, and business aspects. Haddad et al. (1998) saw that service quality dimension only has three dimensions, namely delivery, personnel, and facilities. Van Duong et al. (2004) mentioned that service quality has four dimensions (healthcare delivery, health facility, interpersonal aspects of care, and access to services). More completely, Table 1 summarizes studies that  proposed service quality dimensions that are specific to the context of healthcare service.Referring to previous explanation, the majority of the researches on health care service quality measurement model was in the context of developed countries, while researches in developing countries are fairly limited (van Duong et al., 2004). To our knowledge, there was no empirical study in Indonesia that specifically conducted to develop healthcare service quality measurement model. Meanwhile, it is generally known that culture in a country can inuence service quality dimensions that are appropriate for service context in that country (van Duong et al., 2004; Herbig and Genestre, 1996; Witkowski and Wolfinbarger, 2002). Thus, service quality measurement model generated from studies on certain countries needs to be tested and adjusted for others (Malhotra et al., 1994; Cui et al., 2003).Previous researches that developed healthcare service quality measurement model were also mostly carried out for hospital service while similar researches for PHC are small in numbers. That was indicated by the difficulty in looking for PHC service quality measurement model in some large data bases and publisher (Emeraldinsight, Science Direct, JSTOR, Taylor & Francis Online). Service characteristics in PHC are different with the ones in hospitals. In Indonesia, public health center focuses on  basic health treatments. Besides, public health center is the responsibility of Indonesian Government so that it is more social-oriented than profit-oriented (Deber, 2002). These characteristics create implication that service mix, marketing programs, and even resources managed by PHC are different with hospital. This condition will differentiate the user perceptions of roles and functions between PHC and hospitals. Therefore, it becomes important to build an appropriate model for the context of healthcare service in PHC in Indonesia.Besides above gaps, from the methodology aspect, the previous researches utilized the method proposed by Parasuraman et al. (1988; 1991) in developing healthcare service quality measurement models. Researchers generally did some explorations to identify the dimensions of service quality using factor analysis. After that, every  3 Copyright © Canadian Research & Development Center of Sciences and CulturesTri Rakhmawati; Sik Sumaedi; I Gede Mahatma Yuda Bakti; Nidya J Astrini;Medi Yarmen; Tri Widianti; Dini Chandra Sekar; Dewi Indah Vebriyanti (2013). Management Science and Engineering, 7  (2) , 1-15 dimension was tested for its validity and reliability (for examples, see Reidenbach and Sandifer-Smallwood, 1990; Haddad et al., 1998; Baltussen et al., 2002; Van Duong et al., 2004; Narang, 2011). Related to the use of factor analysis, Hair et al. (2006)  pointed out some important points for considerations as follows: “[t]he researcher must …ensure that the sample is homogeneous with respect to the underlying factor structure. It is inappropriate to apply factor analysis to a sample of males and females for a set of items known to differ because of gender. When the two subsamples (males and females) are combined, the resulting correlation and factor structure will be a poor representation of the unique structure of each group. Thus, whenever differing groups are expected in the sample, separate factor analyses should be performed, and the results should be compared to identify differences not reected in the results of the combined sample.” (Hair et al., 2006) Unfortunately, the previous researches have not tested whether service quality dimensions used in the model were stable across various socio-demographic profiles, such as sex, age, and income. Meanwhile, literature on consumer behavior discusses that socio-demographic characteristics of consumers can affect their attitude and  purchasing behavior (Al-Khayri and Hassan, 2012; Farah et al., 2011; Akman and Rehan, 2010; Abreu and Lins, 2010). For example, women tend to consider hedonic service elements as more important than functional utilitarian elements and men tend to think the other way around (Jen-Hung and Yi-Chun, 2010; Alreck and Settle, 2002). More specically, in the context of service quality, Zeithaml (1993) and Joseph et al (2005) argued that consumer evaluation on service quality will be affected  by their socio-demographic profile. Thus, the results of  previous researches are questionable since they have not considered the possibility of different service quality dimensions among respondents with different socio- demographic proles. 1.3 Research Objective In order to ll the gaps in the literature, this research aims to build service quality measurement model that is both stable and appropriate for PHC in Indonesia, a developing country. More specifically, this research tries to answer the question of what are the appropriate dimensions and indicators to measure service quality of PHC in Indonesia.After the introduction, this paper is organized as follows. First section is a literature review related to service quality and service quality measurement model in healthcare service. Second part will confer about research methodology and the third will present research results and the implications. The last section of this  paper will discuss the conclusion, limitations, and next research agenda. 2. RESEARCH METHODOLOGY 2.1 Research Design This research was designed as exploratory study using quantitative approach. Following the footsteps of previous researchers (e.g. van Duong, 2004; Vandamme and Leunis, 1993; Narang 2011; Haddad et al., 1998; Ygge and Arnetz, 2001), research was begun with identifying service quality indicators believed to be relevant with the characteristics of PHC. After that, data of consumer perceptions were gathered in a survey using questionnaire as research instrument. Exploratory and conrmatory factor analyses were applied to form service quality dimensions and ensure the validity. Cronbach alpha analysis conducted to test the reliability of the dimensions. Unlike previous researches, service quality dimensions formed were tested for their stability against socio-demographic proles (sex, age, and income). Research design can be seen in Figure 1. 2.2 Service Quality Indicators PHC service quality indicators used in this study were gathered from review on scientic literature, government regulations, and documents currently used by PHC to measure user perception towards PHC performance and the performance of healthcare service in general. Indicators were chosen based on several considerations, which are (1) their appropriateness to be used as evaluation indicators for healthcare service providers that only offer basic medical treatment; (2) their compatibility with social oriented healthcare organizations; (3) their suitability with service providers that serve citizens with lower-middle income. Based on above method, authors chose 29 indicators suspected as PHC service quality indicators. For more details, those indicators can be seen in Table 2. 2.3 Data Collection The respondents of this study were 800 PHC users. The number of sample was bigger than previous researches, such as van Duong et al. (2004) with sample size 396, Narang (2011) with sample size 396, Haddad et al. (1998) with sample size 241, and Ygge and Arnetz (2001) with sample size 624. This sample size also exceeds the requirements of factors analysis and Structural Equation Modelling (Hair et al., 2010). Demographic profiles of respondentss will  be discussed in the result and discussion section.Data collection was done by using survey method with questionnaire as the instrument. The questionnaire consists of two parts, respondent demographic prole and PHC service quality measurement. In the second part, PHC service quality measurement, respondents were asked to express their perception on 29 positive statements regarding the indicators of service quality (see Table 3). The questionnaire used 7-points Likert where 1 represents “totally disagree” and 7 represents “totally agree”.  4 Copyright © Canadian Research & Development Center of Sciences and CulturesDeveloping a Service Quality Measurement Model of Public Health Center in Indonesia   Result : 29 service quality indicators Method : factor analysis   4th Step Confirmatory Factor Analysis Purpose: verify dimensions formed from previous step Method : Structural Equation Modeling   1st Step Identification of Service Quality Indicators Purpose: obtain service indicators that compatible with the characteristics of PHC serviceMethod : review on literature and relevant documentsResult : 29 service quality indicators 2nd Step Data Gathering Purpose: obtain user perception dataMethod : survey using questionnaires (800 respondents) 3rd Step Exploratory Factor Analysis Purpose: classify some indicators which have similar characteristics into one dimensionMethod : factor analysis 5th Step Model Stability Analysis Purpose: check the consistency of dimensiosns validity and reliabilityacross segments (age, sex, and income)Obtain service quality dimensions which have stable validity andreliability across segments. Figure 1Research Design To ensure that respondents were the users of PHC service, survey was carried out in the location of PHC. There were five PHC chosen in Jabodetabek. The sites were prefered because the area is located in Indonesia central government area and considered as metropolitan area which has residents that are highly critical towards healthcare service. Table 1Service Quality Dimensions in Healthcare Service Context AuthorsCountryObjectSampleService quality dimensions Lim and Tang (2000)SingaporeHospital252 patients Tangibility, Reliability, Responsiveness,  Assurance, Empathy, Accessibility and  Affordability Reidenbach and Sandifer-Smallwood (1990)Hospital300 patients from three service area (ER, inpatients service, outpatients service)  Patient condence, empathy, quality of treatment, waiting time, physical appearance, support services and business aspects Jabnoun and Chaker (2003)United Arab emirates Hospital205 inpatients empathy, tangibles, reliability, administrative responsiveness, and  supporting skills   Maxwell (1984)United KingdomHospital - Accessibility, relevance, effectiveness, equity, social acceptability and efciency To be continued
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