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A Critical Review of the Service Quality And its Measurement in Indian

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International Journal of Business and Management Invention
ISSN (Online): 2319 – 8028, ISSN (Print): 2319 – 801X
www.ijbmi.org || Volume 6 Issue 8 || August. 2017 || PP—76-87

A Critical Review of the Service Quality And its Measurement in

Indian Healthcare Sector
Raed Mohammed Ali Al-Daoar1m.Jamal Mohamed Zubair2
1
(Research Scholar, Management studies, B.S. Abdur Rahman Crescent University, India)
2
(Asst Professor (S.G), Management studies, B.S. Abdur Rahman Crescent University, India)

Abstract: The objective of this paper is to critically review the established various studies conducted across the
India on the subject of health care service quality dimensions and measured. The Studies collected from
literature databases such as Emerald Insight, EBSCO, and Google scholar. The review of thirty studies shows
that the number of service quality dimensions differs from study to study. Self-administered questionnaire
technique mostly used for collecting the data in the various studies. The sample size ranged from 50 to 2,480
respondents in self-administered questionnaires. The range of the scores of the scale used in the studies begins
from two to seven-point likert scale. A twelve studies applied descriptive analysis; seven studies have used
factor analysis; three studies employed exploratory factor analysis (EFA); one study conducted structural
equation modeling (SEM); a confirmatory factor analysis (CFA) was applied by five studies; and eight studies
applied gap scores. In the most commonly for measuring the reliability of the scale researchers were conducting
the Cronbach’s alpha. The review of several studies finds that the SERVQUAL scale was widely adopted or
modified by the researchers to measure the health care service quality. The paper highlights that there is no
general agreement on the number and the types of service quality dimensions in the Indian health care sector,
but there are some common dimensions are used by most of the studies.
Keywords: Hospital service quality, Patients’ perceptions, Health services, Measurement, SERVQUAL, India.
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Date of Submission: 28-07-2017 Date of acceptance: 19-07-2017
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I. INTRODUCTION
India is one of the largest developing countries in terms of population and area. To provide a healthcare
service with a good level of quality to a large population is a major challenge. The main problem of healthcare
service is a measure of the quality of services. There are a few service quality measurement scales are
developed, but they are based on other countries not based in India. A few studies had conducted on healthcare
service quality measurement in India. Hence there is a need for conducting a research in developing a measuring
scale to evaluate the Indian health care service quality. (Akhade, Jaju, & Lakhe, 2016). The health care quality
concept has been defined by many authors; The American Medical Association, defined the health care quality
such as care which consistently contributes to the improvement or maintenance of quality and/ or duration of life
(Piligrimiene & Buciuniene, 2011). Health care is a scarce service that the people need (Berry & Bendapudi,
2007).As we know that the patient comes to hospital with collection of sickness, worry, soreness, scare and
under the stress that need to be treated (Bendapudi, Berry, Frey, Parish, & Rayburn, 2006). The health care
service providers and managers should realize that they deliver health care service with an appropriate quality to
the needs of the customer most important for the success of the business. Many researchers have developed,
modified or adapted a scale to measure the quality of health care service for various types of hospital in different
countries. (Parasuraman, Zeithaml, & Berry, 1988) were developed a measurement scale which called
SERVQUAL to examine the service quality. A SERVQUAL has included five dimensions which namely:
reliability, responsiveness, assurance, empathy and tangibility. A SERVQUAL is found consistently important
for the evaluation of various types of service setting by modifying the service quality attributes according to
(Parasuraman, Zeithaml, & Berry, 1991). The service quality of health care is widely measured through the
SERVQUAL instrument. Continuously assessing the health care service quality and understanding the needs of
patients completely leads to improving the hospital service quality, enhance the satisfied and loyal of patients
and attract more customers. This paper undertakes a comprehensive review of the current state of knowledge
regarding quality dimensions of Indian health care service and its measurement.

II. METHODS
A critical review based on searches of the empirical studies and previous reviews of health care service
quality and its measurement from the literature databases Emerald Insight, EBSCO, and Google scholar by
using many keywords example; quality of health care, dimensions of health care service quality, SERVQUAL,
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 A Critical Review of the Service Quality And its Measurement in Indian ….

hospital service quality, and Indian public health care. Our review contains about thirty studies conducted in
various states of India; about 33 percent (ten studies) of the studies were conducted in the state of Tamil Nadu.
The methodological issues identified in this paper can be summarized as: research objective, research methods,
types of respondent, types of providers, sample methods and size, method of data collection, survey
administration, items of the scale, validity and reliability of the scale which used in the studies.

III. THE REVIEW

3.1the Categories Of The Studies
The studies which contained in our paper can be classified into five classes according to the purpose of
the studies; first, the studies which aimed to compare the level of quality of health care service among the health
care providers, such as the studies which done by (Irulappan, 2014; Karekar, Tiwari, & Agrawal, 2015;
Mahapatra, 2013; and Pramanik, 2016). Second, the studies which aimed to apply the SERVQUAL to the
healthcare sector, such as the studies which conducted by (Brahmbhatt, Baser, &Joshi, 2011; and Gerald, &
Panchanatham, 2013). Third, studies which aimed to identify and evaluate the dimensions of service quality of
the healthcare sector, such as the studies which done by (Amjeriya & Malviya, 2012; Chakraborty, &
Majumdar, 2013; Kavita, 2012; Rathee, Rajain, & Isha, 2015; and Umath, Marwah, & Soni, 2015). Fourth, the
studies which aimed to develop a new scale for assessing the service quality of the healthcare sector, such as the
studies which conducted by (Aagja, & Garg, 2010; Itumalla, Acharyulu, & Shekhar, 2014). And the last one,
studies which aimed to measure the relationship between service quality and other aspects like patient
satisfaction, trust, behavior intention, and loyalty such as the studies which done by (Dave, & Dave, 2014;
Dheepa, Gayathri, & Karthikeyan, 2015; Padma, Rajendran, & Sai Lokachari, 2010; and Puri, Gupta,
Aggarwal, & Kaushal, 2012).

3.2dimensional Structure Of The Healthcare Service Qualityin The Studies

Table 1: summarizes the final number of service quality dimensions in the Indian health care sector that
conducted in the study. The dimensions, number starts from four (Puri, Gupta, Aggarwal, & Kaushal, 2012);
five (Pramanik, 2016); sex (Thangaraj, & Chandrasekar, 2016); seven (Aiswarya, 2015); eight (Padma,
Rajendran, & Sai Lokachari, 2010); twelve (Amjeriya, & Malviya, 2012). About twenty studies (66 percent) are
found with five dimensions; two researchers used four dimensions; two studies with six dimensions; four
researchers employed seven dimensions; one study with eight dimensions; and one study with twelve
dimensions. The five dimensions of the SERVQUAL instrument most widely used by many researchers in the
questionnaire or reported in some other form. From the thirty studies, we observed that the SERVQUAL
instrument widely adopted or modified by the researchers to measure the health care service quality, A
SERVQUAL as an instrument used in twenty-four studies, about (80 percent). Some studies have found that the
SERVQUAL scale is not much sufficient to assess the quality of health care service. Few researchers had
developed their own scale for measuring the quality of health care service; (Itumalla, Acharyulu, & Shekhar,
2014) has been developed a scale of (HospitalQual) for measuring the in-patient service, (Aagja, & Garg, 2010)
developed a scale which called (PubHosQual) to measuring the quality of the public hospital service in the
Indian context. The researchers depending on the culture, environment, awareness, and other factors which
influence the perception of patients have used new dimensions, like the study which done by. (Padma, et al.,
2010) added hospital image and trustworthiness of the hospital.Several researchers have added new dimensions
to their studies. (Padma, Rajendran, & Sai, 2009) reported that one of the criticisms on SERVQUAL was it
focused only on the functional aspects of the service but not on the technical aspects. From several studies on
Indian health care service quality dimensions and measurement which reviewed in this paper, it found that there
is no general agreement on the number and the types of service quality dimensions in the health care sector but
there are some common dimensions are used by most of the studies. All the studies which reviewed in this paper
mentioned the number of dimensions range from four to twelve.

Table 1: Summary of Health Care Service Quality Dimensions in the Studies

S.No. Author, Year, State Service Quality Dimensions
1 Itumalla, et al, 2014 Telangana Seven dimensions- Medical, nursing, support,
patient safety, administrative services,
communication and hospital infrastructure
2 Mahapatra, 2013 Delhi Six dimensions- Tangibles, reliability,
responsiveness, assurance, assurance accessibility
and affordability
3 Sreenivas, and Bdabu, 2012 Andhra Pradesh Seven dimensions- Admission procedure,
physical facilities, diagnostic services, behavior of
the staff, cleanliness, dietary services and
discharge procedure
4 Thangaraj, and Chandrasekar, 2016 Tamil Nadu Six dimensions- Responsiveness, infrastructure,
skilled and trained doctors, advancement of

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 A Critical Review of the Service Quality And its Measurement in Indian ….
technology, quality of treatment, availability
5 Dave, and Dave, 2014 Gujurat Five dimensions -Tangibility, reliability,
responsiveness, assurance, empathy
6 Rathee, et al, 2015 Haryana Five dimensions -Tangibility, reliability,
responsiveness, assurance, empathy
7 Narang, 2011 Uttar Pradesh Five dimensions -Health care delivery,
interpersonal and diagnostic aspect of care,
facility, health personnel conduct and drug
availability, financial and physical access to care
8 Padma, et al 2010 Tamil Nadu Eight Dimensions- Infrastructure, personnel
quality, safety indicators, process of clinical care,
administrative procedures, hospital image, social
responsibility, trustworthiness of hospital
9 Rao, et al 2006 Uttar Pradesh Five dimensions - Medicine availability, medical
information, staff behavior, doctor behavior,
infrastructure
10 Kavita, 2012 Tamil Nadu Five dimensions -Tangibility, reliability,
responsiveness, assurance, empathy
11 Kumaraswamy, 2012 Tamil Nadu Four dimensions - Physician behavior ,
supportive staffs , atmospherics, operational
performance
12 Rohini, and Mahadevappa, 2006 Karnataka Five dimensions -Tangibility, reliability,
responsiveness, assurance, empathy
13 Umath, et al 2015 Madhya Pradesh Five dimensions- Tangibility, reliability,
responsiveness, empathy, assurance
14 Amjeriya, and Malviya, 2012 Madhya Pradesh Twelve dimensions- Reliability, responsiveness,
assurance, empathy, empathy, access,
competence, courtesy, communication, credibility,
security, understanding
15 Aagja, and Garg 2010 Gujarat Five dimensions- Admission, medical service,
overall service, discharge, social responsibility

16 Gerald, and Panchanatham, 2013 Tamil Nadu Five dimensions -Tangibility, reliability,
responsiveness, assurance, empathy
17 Karekar, et al 2015 Mumbai Five dimensions -Empathy, tangibles, assurance,
timeliness, assurance
18 Chakraborty, and Majumdar, 2013 West Bengal Five dimensions -Tangibility, reliability,
assurance, responsiveness, empathy
19 Sharmil and Krishnan, 2013 Tamil Nadu Five dimensions- Empathy, assurance, tangible,
timeliness, responsiveness
20 Dheepa, et al 2015 Tamil Nadu Five dimensions -Tangibility, reliability,
assurance, responsiveness, empathy
21 Duggirala, et al 2008 Tamil Nadu Seven dimensions-Infrastructure, personnel
quality, process of clinical care, safety indicators,
social responsibility, administrative procedures,
overall, experience of medical care received
22 Pramanik, 2016 Maharashtra Five dimensions -Tangibility, reliability,
assurance, responsiveness, empathy
23 Sangwan, 2012 Delhi Five dimensions - Treatment quality, behavioral
aspects, medical information, structural aspects,
financial aspects
24 Pandit, 2015 Kolkata and West Five dimensions -Tangibility, reliability,
Bengal assurance, responsiveness, empathy
25 Brahmbhatt, et al 2011 Gujarat Five dimensions - Physical aspects, reliability,
process, encounters, policy
26 Aiswarya, 2015 Karnataka Seven dimensions- Reliability, assurance,
assurance, empathy, responsiveness, accessibility,
price
27 Narang, 2010 Uttar Pradesh Five dimensions - Reliability, responsiveness,
assurance, empathy, tangibles
28 Narang, et al 2015 Finland , India, Five dimensions - Employees, drugs and
Nigeria and China diagnosis, environment and access, atmosphere,
outcomes
29 Puri, et al 2012 North India Four dimensions- Prescription quality,
availability of facilities, signage display, patient-
doctor interaction
30 Irulappan, 2014 Tamil Nadu Five dimensions -Tangibility, reliability,
responsiveness, assurance, empathy

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1.1. Types Of Research Approaches In The Studies

Table 2: summarizes the types of research approaches which applied in the studies. In general, there are
two types of research methods or approaches that used in the previous studies which namely; qualitative method
and quantitative method. The majority of the studies which are contained in this paper were used a quantitative
method such as (Pramanik, 2016., Narang, Polsa, Soneye, & Fuxiang, 2015; Dheepa, Gayathri, & Karthikeyan,.,
2015; Karekar, Tiwari, & Agrawal, 2015; Umath, Marwah, & Soni, 2015; Rathee, Rajain. & Isha 2015; Pandit,
2015; Aiswarya, 2015; Irulappan, 2014; Dave, & Dave, 2014; Chakraborty, & Majumdar, 2013; Sharmil &
Krishnan, 2013;Gerald, & Panchanatham, 2013; Mahapatra, 2013; Sreenivas, &Bdabu, 2012; Kavita, 2012;
Kumaraswamy, 2012; Amjeriya, & Malviya, 2012; Puri, et al., 2012; Brahmbhatt, 2011; Padma, et al., 2010).
Only two studies had used the qualitative method (Thangaraj, & Chandrasekar, 2016; and Duggirala, Rajendran,
& Anantharaman, 2008) and seven studies had mixed between the quantitative and qualitative methods
(Itumalla, et al., 2014; Rohini, & Mahadevappa, 2006;Narang, 2011; Narang, 2010;Sangwan & Arora,
2012;Aagja, & Garg 2010;and Rao, Peters, & Bandeen-Roche2006) to identify and measuring the of health care
service quality dimensions using. From the studies which included in this paper, we observed that the research
methods which used to measure the dimensions of Indian health care service quality had differed from study to
study, depending on objective, environment, awareness and other factors that may influence on the patients’
perception.

Table 2: Types of Research Methods in the Studies

S.No. Author State Research Methods
1 Itumalla, et al, Telangana Qualitative and Quantitative
2 Mahapatra, Delhi Quantitative
3 Sreenivas, and Bdabu Andhra Pradesh Quantitative
Thangaraj, and
4 Chandrasekar Tamil Nadu Qualitative
5 Dave, and Dave Gujurat Quantitative
6 Rathee Haryana Quantitative
7 Narang Uttar Pradesh Qualitative and Quantitative
8 Padma, et al Tamil Nadu Quantitative
9 Rao, et al Uttar Pradesh Qualitative and Quantitative
10 Kavita Tamil Nadu Quantitative
11 Kumaraswamy Tamil Nadu Quantitative
Rohini, and
12 Mahadevappa Karnataka Qualitative and Quantitative
13 Umath, et al Madhya Pradesh Quantitative
14 Amjeriya, and Malviya Madhya Pradesh Quantitative
15 Aagja, and Garg Gujarat Qualitative and Quantitative
Gerald, and
Tamil Nadu
16 Panchanatham Quantitative
17 Karekar, et al Mumbai Quantitative
Chakraborty, and
West Bengal
18 Majumdar Quantitative
19 Sharmil and Krishnan Tamil Nadu Quantitative
20 Dheepa, et al Tamil Nadu Quantitative
21 Duggirala, et al Tamil Nadu Qualitative
22 Pramanik Maharashtra Quantitative
23 Sangwan Delhi Qualitative and Quantitative
Pandit
Kolkata and West Bengal
24 Quantitative
Brahmbhattet al
25 Gujarat Quantitative
26 Aiswarya Karnataka Quantitative
27 Narang Uttar Pradesh Qualitative and Quantitative
Narang, et al Finland, India, Nigeria and
28 China Quantitative
29 Puri, et al North India Quantitative
30 Irulappan Tamil Nadu Quantitative

1.2. Types Of Respondents In The Study

Table 3: summarizes the types of respondents in the studies, the stakeholder of the health care system
involves patients, patient’s relatives, visitors, doctors, nurses, pharmacists, technicians and not technical staff,
administrators and managers of health care systems. The majority of the studies has used variations of
respondent, such as (Aiswarya, 2015; Dheepa, et al., 2015; Itumalla, et al., 2014; Mahapatra, 2013; and
Sreenivas, & Bdabu, 2012) were used only inpatients perspective to find out the level of health care service
quality. (Padma, et al., 2010; and Aagja, & Garg 2010) have employed both patients and their attendants.

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Thirteen studies (43 percent) used general patients and not clearly mentioned type of their respondents. One
study had mentioned that they mixed between inpatients and outpatients (Rao, et al., 2006); also one study, only
used the students who was inpatients during the past six months (Narang, et al., 2015). Narang, (2011)
employed the patients who have taken health care services within the period of six months from survey period.
Three studies (Sangwan & Arora, 2012; Umath, et al., 2015; and Kavita, 2012) used the perspective of both
patients and doctors in their studies to explore the level of service quality in health care sectors. (Rohini,
&Mahadevappa, 2006) had used the patients and hospital executives to measure the service quality,
(Chakraborty, & Majumdar, 2013) used the patients and nursing homes, (Sharmil, & Krishnan, 2013) employed
inpatient and employees, (Pandit, 2015) used patients and visitors in their studies to find out how the health care
providers deliver their service with an acceptable level of quality. Some of the studies used the help of
physicians, health care professional managers and administrators to collect the data from the inpatients. From
the studies which reviewed in this paper, we observed that the right choice of respondents for measuring the
health care service quality which delivered by hospitals is the inpatient because inpatients have direct interaction
with the entire service provider during their stay in hospital.

Table 3: Types of Respondents in the Studies

S.No. Author State Types of Respondents in the study
1 Itumalla, et al, Telangana In-patients
2 Mahapatra, Delhi In-patients within six months
3 Sreenivas, and Bdabu Andhra Pradesh In-patients
4 Thangaraj, and Chandrasekar Tamil Nadu Patients
5 Dave, and Dave Gujurat Patients
6 Rathee Haryana Patients
7 Narang Uttar Pradesh Patients who used Health services in past six months
8 Padma, et al Tamil Nadu In-patients and attendants
9 Rao, et al Uttar Pradesh In-patients and out-patient
10 Kavita Tamil Nadu In-patients, doctors
11 Kumaraswamy Tamil Nadu Patients
12 Rohini, and Mahadevappa Karnataka Patients and hospital executives
13 Umath, et al Madhya Pradesh Patients, doctors, nurses and other staffs
14 Amjeriya, and Malviya Madhya Pradesh Patients
15 Aagja, and Garg Gujarat Patient and attendants
Gerald, and Panchanatham
16 Tamil Nadu Patients
17 Karekar, et al Mumbai Patients
18 Chakraborty, and Majumdar West Bengal Patients and nursing homes
19 Sharmil and Krishnan Tamil Nadu In-patient and employees
20 Dheepa, et al Tamil Nadu In-patients
21 Duggirala, et al Tamil Nadu Patients
22 Pramanik Maharashtra Patients
23 Sangwan Delhi Patients and doctors
Pandit Kolkata and West
24 Bengal Patients and visitors
25 Brahmbhattet al Gujarat Patients
26 Aiswarya Karnataka In-patients
27 Narang Uttar Pradesh Patients
Narang, et al Finland , India,
28 Nigeria and China Students who was inpatients during the past six months
29 Puri, et al North India Patients
30 Irulappan Tamil Nadu Patients

1.3. Sample Size And Techniques In The Studies

Table 4:summarizes the techniques of sampling and sample size of the studies. Only one study have not
clearly reported the techniques of sampling adopted (Thangaraj, & Chandrasekar, 2016); ten studies mentioned
random sample sampling method (Sreenivas, & Bdabu, 2012; Narang, 2011; Rohini, & Mahadevappa, 2006;
Umath, et al., 2015; Amjeriya, & Malviya, 2012; Karekar, et al., 2015; Chakraborty, & Majumdar, 2013;
Sharmil & Krishnan, 2013; Duggirala, et al., 2008; and Irulappan, 2014); five studies have used the purposive
sampling technique (Narang, et al., 2015; Aiswarya, 2015; Kumaraswamy, 2012; Narang, 2011; and Itumalla, et
al., 2014); eleven studies have used the convenience sampling technique (Mahapatra, 2013; Dave, & Dave,
2014; Padma, et al., 2010; Kavita, 2012; Aagja, & Garg 2010; Dheepa, et al., 2015; Pramanik, 2016; Sangwan
& Arora, 2012; Pandit, 2015; Rao, et al., 2006; and Brahmbhatt, 2011); only one study has mentioned the
judgment sampling method (Gerald, & Panchanatham, 2013); one study has mentioned the quota sampling
method (Rathee, et al., 2015); and only one study carried out multi-stage cluster sampling method (Puri, et al.,
2012). The sample size of the studies which reviewed in this paper as presented in the table 4 start from under
50 to above 2,000 respondents. Twenty three studies were employed a sample size of range begins from 100 to
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500; followed by three studies used more than 500 and less than 1000; followed by two researches used less
than 100; one study used 1000; and one more than 1000 respondents.

Table 4: Sample Method and Size in the Studies

Sample Sampling Technique
S.No. Author State Size
1 Itumalla, et al, Telangana 246 Purposive sampling
2 Mahapatra, Delhi 192 Convenience sampling
3 Sreenivas, and Bdabu Andhra Pradesh 230 Stratified random sampling
Thangaraj, and 50 Non – probability sampling
4 Chandrasekar Tamil Nadu
5 Dave, and Dave Gujurat 100 Convenience sampling
6 Rathee Haryana 200 Quota sampling
Narang 500 Random sampling and
7 Uttar Pradesh Purposive sampling
8 Padma, et al Tamil Nadu 408 Convenience sampling
9 Rao, et al Uttar Pradesh 2480 Convenience sampling
10 Kavita Tamil Nadu 450 Convenience sampling
11 Kumaraswamy Tamil Nadu 200 Purposive sampling
Rohini, and 540 Random sampling
12 Mahadevappa Karnataka
13 Umath, et al Madhya Pradesh 340 Random sampling
Amjeriya, and 62 Random sampling
14 Malviya Madhya Pradesh
15 Aagja, and Garg Gujarat 200 Convenience sampling
Gerald, and 300 Judgment sampling
Panchanatham Tamil Nadu
16
17 Karekar, et al Mumbai 1000 Random sampling
Chakraborty, and 100 Random sampling
West Bengal
18 Majumdar
Sharmil and 320 Random sampling
19 Krishnan Tamil Nadu
20 Dheepa, et al Tamil Nadu 286 Convenience sampling
21 Duggirala, et al Tamil Nadu 100 Random sampling
22 Pramanik Maharashtra 368 Convenience sampling
23 Sangwan Delhi 607 Convenience sampling
Pandit 150 Convenience sampling
Kolkata and West Bengal
24
Brahmbhattet al 246 Convenience sampling

25 Gujarat
26 Aiswarya Karnataka 875 Purposive sampling
27 Narang Uttar Pradesh 500 Random sampling
Narang, et al Finland , India, Nigeria and 315 Purposive sampling
28 China
29 Puri, et al North India 360 Cluster and Random sampling
30 Irulappan Tamil Nadu 456 Random sampling

1.4. Types Of Providers In The Studies

Table 5:summarizes the types of providers of health care service. In the health care sector, there are
many types of providers such as primary health care centers, public or government hospital, private hospitals,
general hospitals, medical college and hospitals, clinics, and specialty hospitals. The respondents from all types
of health care providers should be used for developing an appropriate scale to measure the health care service
quality. Fifteen studies had mixed between public or government hospitals and private hospitals (50 percent
studies) for assessing the level quality of service and make a comparison to developing the service quality. The
studies which done by (Sharmil & Krishnan, 2013; and Dave, & Dave, 2014) had focused only on private
hospitals. The scale which developed based on the data from the only private hospital may not suitable for other
types of health care providers because the private hospitals are purely profiting making hospitals. (Itumalla, et
al., 2014; Narang, 2011; Aagja, & Garg 2010; Narang, 2010; and Dheepa, et al., 2015) had conducted a study in
public or government hospital. Two studies (Amjeriya, & Malviya, 2012; Umath, et al., 2015) have not clearly
mentioned the type and number of the hospital. Two studies (Chakraborty, & Majumdar, 2013; and Aiswarya,
2015) had collected the data from the educational medical hospitals. Two studies (Aagja, & Garg 2010; and
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Gerald, & Panchanatham, 2013) were conducted in the Multi-specialty hospitals. In primary health care center,
the patient does not need to stay more than one day to get the service also; some services cannot judge its quality
in one day. In this case, only one study had been taken which conducted by (Rao, et al., 2006). Two studies
(Thangaraj, & Chandrasekar, 2016; and Kumaraswamy, 2012) conducted in corporate and non-corporate
hospitals. Only one study (Narang, et al., 2015) has done a cross-cultural study, which collected the data from
the patients from Finland, India, Nigeria and China.

Table 5: Types of Providers in the Studies

S.No. Author State Types of Providers
1 Itumalla, et al, Telangana Public hospital
2 Mahapatra, Delhi Private and public hospitals
Sreenivas, and Bdabu Government general, general, and
3 Andhra Pradesh private hospitals
Thangaraj, and Corporate hospitals and health care
4 Chandrasekar Tamil Nadu centers
5 Dave, and Dave Gujurat Private hospitals
6 Rathee Haryana Government and private hospitals
7 Narang Uttar Pradesh Public health care centers
8 Padma, et al Tamil Nadu Government and private hospitals
Rao, et al Primary health centers, district
hospitals, community health centers,
9 Uttar Pradesh and female district hospitals
10 Kavita Tamil Nadu Private and public hospitals
11 Kumaraswamy Tamil Nadu Corporate and Non-corporate hospitals
Rohini, and Specialty private, general missionary,
Mahadevappa general, private, government, general
12 Karnataka and multi-specialty Private hospitals
13 Umath, et al Madhya Pradesh Hospitals
14 Amjeriya, and Malviya Madhya Pradesh Hospitals
15 Aagja, and Garg Gujarat Multi-specialty public hospitals
Gerald, and
16 Panchanatham Tamil Nadu Multispecialty hospitals
17 Karekar, et al Mumbai Government and private Hospital
Chakraborty, and
West Bengal Government medical college hospitals
18 Majumdar
19 Sharmil and Krishnan Tamil Nadu Private hospitals
20 Dheepa, et al Tamil Nadu Government hospitals
Duggirala, et al Government hospitals and private
21 Tamil Nadu hospitals
Pramanik Government hospitals and private
22 Maharashtra hospitals
23 Sangwan Delhi Private and public hospitals
Pandit Kolkata and West Private super-specialty, private
24 Bengal general, government medical hospitals
25 Brahmbhattet al Gujarat Private and public hospitals
Aiswarya Government, corporate, medical
Karnataka
26 college hospitals
Narang State medical university, missionary
27 Uttar Pradesh hospitals
Narang, et al Finland, India, Nigeria
28 and China Private and public hospitals
29 Puri, et al North India Private and public hospitals
30 Irulappan Tamil Nadu Private and public hospitals

1.5. Data Collection And Analysis In The Studies

Table 6: summarizes the tools and methods of data collection, the number of scale items, and reliability of the
scale.

1.5.1. Method Of Data Collectionin The Studies

In research methodology, there are several of data collection methods and tools such as an online
survey (mail, website), offline survey (postal mail, telephone), focus groups, case study, questionnaire survey
and interview depend on the research approach. In the present review, about eighteen studies (60 per cent
studies) were used questionnaire survey method for collecting the data. Two studies (Narang, 2010; and Narang,
2011) had collected data through focus group discussions, interview, and questionnaire survey. (Irulappan,
2014; Puri, et al., 2012; Sangwan & Arora, 2012; Aagja, & Garg 2010; Umath, et al., 2015; Rohini, &
Mahadevappa, 2006; Kavita, 2012; Rao, et al., 2006; and Itumalla, et al., 2014) were collected data through
questionnaire survey and interview. (Thangaraj, & Chandrasekar, 2016) had used direct interview schedule in
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corporate hospitals and health care centers for collecting the data. From the reviewed of the studies we found
that the response is given higher rate to the face interview based on the survey questionnaire as suitable methods
for collecting a proper data. The techniques of data collection and the reason for selecting the particular data
collection method should be mentioned by the authors.

1.5.2. Number Of Itemsin The Studies

All the studies reviewed in this paper mentioned the number of the scale items ranges from 16 items (Rao, et al.,
2006) to 86 items (Duggirala, et al., 2008). Most of the studies were adopted the SERVQUAL five dimensions
with 22 items.

1.5.3. Scores Used In The Studies

Nineteen studies (63 percent) adopted the five-point likert scale and seven studies (23percent) adopted
the seven-point likert scale. One study (Puri, et al., 2012) used two-point likert scale. One study (Aagja& Garg
2010) has not clearly mentioned the scores of his scale. The scale ranked from two-point (Puri, et al., 2012) to
seven points (Pandit, 2015)
.
1.5.4. Analysis Method In The Studies
A total of twelve studies applied descriptive analysis; seven studies have used factor analysis; three
studies applied exploratory factor analysis (EFA) for assessing their items and dimensions; only one study,
which done by(Sharmil and Krishnan, 2013) carried out structural equation modeling (SEM); eight studies
conducted gap scores analysis; and five studies have used confirmatory factor analysis (CFA);. Out of the five
studies that used CFA, one study (Duggirala, et al 2008) applied both confirmatory factor analysis (CFA) and
exploratory factor analysis (EFA); and other four studies such as (Irulappan, 2014; Aagja, & Garg 2010; Rathee,
et al., 2015; and Padma, et al., 2010) carried out only CFA; and a total of eight studies conducted regression
analysis.

1.5.5. Reliability Of The Studies

The scales of the studies which reviewed in this paper had a good reliability with twenty two studies
provided the value of Cronbach’s alpha, eighteen researches have provided an acceptable value of Cronbach’s
alpha, begins more than 0.75. Such as, study done by (Narang, et al., 2015) found to be reliable to a great extent
with an overall Cronbach alpha value of 0.90; (Puri, et al., 2012) provided an overall Cronbach alpha value of
0.88; (Itumalla, et al., 2014) seven provided a Cronbach alpha value ranging from 0.75 to 0.97; (Padma, et al.,
2010); provided an overall Cronbach alpha value of 0.72 and (Amjeriya, & Malviya, 2012) twelve dimensions
overall 0.95.

Table 6: Data Collection Tools, Final Number of Items, and Reliability of Scale in the Studies
Data Collection Tools and Method of Number
S.No. Author, Year, State analysis of Items Reliability
Itumalla, et al, 2014 Self-administered questionnaire survey of 59 Items Ranges from
seven point Likert scale and Interview. 0.759 to 0.970
EFA, factor analysis, multiple regression,
1 Telangana ANOVA
Mahapatra, 2013 Self-administered questionnaire survey of 26 Items Overall
2 Delhi five point Likert scale. Paired t-test Above 0.60
Sreenivas, and Self-administered questionnaire survey of 38 Items Not Reported
Bdabu, 2012 five point Likert scale. Descriptive
3 Andhra Pradesh analysis
Thangaraj, and Direct interview schedule. Descriptive 21 Items Not Reported
4 Chandrasekar, 2016 Tamil Nadu analysis
Dave, and Dave, Self-administered questionnaire survey of 21 Items Not Reported
2014 five point Likert scale. Uni – Variety
Analysis, Chi-Square test, Paired t-test,
5 Gujurat ANOVA
Rathee, et al, 2015 Self-administered questionnaire survey of 22 Items Overall = 0.96
6 Haryana five point Likert scale. CFA
Narang, 2011 Six focus group discussions and 12 in- 23 Items Overall = 0.96
depth interviews, self-administered
questionnaire survey of five point Likert
7 Uttar Pradesh scale. factor analysis, ANOVA, t-test,
Padma, et al 2010 Questionnaire survey of seven point likert 49 Items Overall = 0.72
8 Tamil Nadu scale. CFA, multiple regression analysis
Rao, et al 2006 Depth interviews, and questionnaire 16 Items Ranges from
survey of seven point likert scale. 0.62 to 0.86
Regression analysis, descriptive analysis,
9 Uttar Pradesh factor analysis

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Kavita, 2012 Personal interviews and questionnaire 44 Items Overall above
Tamil Nadu survey of seven point likert scale. Gap 22 Items 0.70
10 Scores, t’ test
Kumaraswamy, Questionnaire survey of five point likert 34 Items Overall = 0.76
2012 scale. t’ test regression analysis,
11 Tamil Nadu descriptive analysis factor analysis
Rohini, and Personal interviews and questionnaire 22 Items Ranges from
Mahadevappa, 2006 survey of seven point likert scale. Gap 0.76 to 0.86
12 Karnataka Scores , descriptive analysis
Umath, et al 2015 Personal interviews and questionnaire 22 Items Overall =
survey of seven point likert scale. Gap 0.906
Scores , descriptive analysis, correlation
13 Madhya Pradesh analysis
Amjeriya, and Questionnaire survey of five point likert 39 Items Overall =
Malviya, 2012 scale. Multiple regression analysis, 0.950
14 Madhya Pradesh descriptive analysis, correlation analysis
Questionnaire survey and semi-structured 24 Items Overall above
Aagja, and Garg interviews. CFA, EFA ANOVA, 0.90
2010 descriptive analysis, correlation analysis,
15 Gujarat Delphi method
Gerald, and 22 Items Ranges from
Panchanatham, Questionnaire survey of five point likert 0.31 To 0.82
Tamil Nadu
16 2013 scale. ANOVA, descriptive analysis
Karekar, et al 2015 Questionnaire survey of five point likert 22 Items Ranges from
17 Mumbai scale. Mean and standard deviation 0.58 to 0.89
Chakraborty, and Questionnaire survey of five point likert 22 Items Not Reported
West Bengal
18 Majumdar, 2013 scale. Factor analysis
Sharmil and Questionnaire survey of five-point Likert 22 Items Not Reported
19 Krishnan, 2013 Tamil Nadu Scale. SEM, chi-square
Dheepa, et al 2015 Self-administered questionnaire survey of 29 Times Overall = 0.97
Tamil Nadu five point Likert scale. Kaiser-Meyer-
20 Olkin (KMO), correlation, actor analysis
Duggirala, et al Questionnaire survey of seven point likert 86 Items Overall = 0.83
21 2008 Tamil Nadu scale. CFA, EFA
Pramanik, 2016 Questionnaire survey of five point likert 22 Items Overall = 0.76
22 Maharashtra scale. Gap scores descriptive analysis
Sangwan, 2012 In-depth interviews and questionnaire 24 Items Ranges from
survey of five point likert scale, multiple 0.77 to 0.90
regression analysis, regression model,
correlations, mean scores and descriptive
23 Delhi analysis
Pandit, 2015 Kolkata and Questionnaire survey of seven point likert 22 Items Ranges from
24 West Bengal scale. ANOVA, gap scores 0.72 to 0.86
Brahmbhatt,et al Questionnaire survey of five point likert 41 Items Overall = 0.71
25 2011 Gujarat scale. Gap scores, descriptive analysis
Aiswarya, 2015 Questionnaire survey of five point likert 79 Items Not Reported
Karnataka scale. Regression analysis, MANOVA,
26 discriminant analysis
Narang, 2010 Five focus group discussions, ten in-depth 20 Item Not Reported
interviews, and questionnaire survey of
five point likert scale. linear regression
27 Uttar Pradesh analysis
Narang, et al 2015 Finland, India, Questionnaire survey of five point likert 30 Items Overall = 0.90
Nigeria and scale. Regression analysis, ANOVA,
28 China EFA
Puri, et al 2012 Interviews and questionnaire survey of 19 Items Overall = 0.88
two point likert scale. Mean scores, t-test,
29 North India and chi-square test
Irulappan, 2014 Interviews and questionnaire survey of 22 Items Overall = 0.92
five point likert scale, t-test, ANOVA,
30 Tamil Nadu chi-square test, CFA

1.5.6. Validity Of The Studies

(Cooper & Schindler, 2003) have been divided validity into three types which namely; face or content
validity; criterion validity; and construct validity.

1.5.7. Face Or Content Validity

For measuring the content or face validity of the scale, the authors applied the conceptual and empirical
analysis experts reviewed from practitioners and academics, pilot study, and interviews with patients for
example the studies which done by (Narang, et al., 2015; Mahapatra, 2013; Itumalla, et al., 2014; Sreenivas, &
Bdabu, 2012; Rao, et al., 2006; Rohini, & Mahadevappa, 2006; Padma, et al., 2010; and Aiswarya, 2015).
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1.5.8. Criterion Validity

According to (Malhotra, 2004) criterion validity reflects whether a scale performs as expected in
relation to other variables selected as meaningful criteria. (Duggirala, et al., 2008) carried out the bivariate
correlation analysis for tested the criterion validity. (Padma, et al., 2010) employed the analysis of bivariate
correlation, among the entire service quality dimension that has significant positive correlations with the patient
satisfaction as well as attendant satisfaction for measure demonstrates concurrent validity.

1.5.9. Construct Validity

The construct validity measure through examining the convergent validity, discriminant and uni-
dimensional, validity (O’Leary-Kelly & Vokurka, 1998). The researchers used the statistical tools of exploratory
factor analysis (EFA) or confirmatory factor analysis (CFA) for examined the uni-dimensional such as
(Duggirala, et al., 2008; Padma, et al.,2010; Aagja, & Garg 2010; Rathee, et al., 2015; and Irulappan, 2014). In
convergent validity the studies which done by (Rathee, et al.,2015 and Aagja, & Garg 2010); were
examinedthroughthe factor loadings in the confirmatory factor analysis (CFA); (Itumalla, et al.,2014;) was
carried out ANOVA; (Sharmil & Krishnan, 2013) was applied structural equation modeling (SEM) test for
discriminant validity; (Narang, 2011; Rao, et al., 2006; and Kumaraswamy, 2012) have conducted factor
analysis, two studies which done by (Duggirala, et al., 2008; and Padma, et al., 2010) have been applied
construct, content, and criterion validity, and. Fourteen studies (46per cent) of the studies mentioned only
content validity, six studies reported both content and construct validity, six studies stated construct validity,
two studies have not mentioned the validity, and two studies have assessed criterion validity.

IV. CONCULATION
An attempt is created during this paper to review several studies on health care service quality
dimensions and measurement in a various states of India. There is a complex on the subject of service quality
depends on the environment, time, need of service, type of the service, culture, economics, education, and other
factors. It is observed that there are no sufficient scales designed for the health care sector. It is observed that
most of the studies were widely adopted or modified a SERVQUAL scale to measure the service quality of
health care sector. From the review of the literature, we conclude that:
 Most of the studies were done in the state of Tamil Naue. Therefore, it's needed to conduct more studies in
other states.
 There is no general agreement on the number and the types of service quality dimensions in the Indian
health care sector, but there are some common dimensions are used by most of the studies.
 The healthcare sector has a different stakeholder but, some of the studies have not clearly mentioned the
types of health care providers.
 It is observed that most of the studies were adopting or modifying the SERVQUAL scale for measuring the
service quality of Indian health, hence there is a need to develop a new scale for measuring the quality of
health care service in Indian context.
 Few studies have been measuring the service quality from the foreigner’s patient perspective. Therefore, it's
needed to conduct more studies on the foreigner’s patient perspective to improve the level of service
quality.
 It is observed that a most of the studies were a quantitative studies. Therefore, it's needed to conduct more
qualitative studies to gain a better understanding of the patients’ needs and deliver a service with a good
level of quality.
 It is found that only a few studies have included both inpatient and outpatient as respondents of the study.
 So far there is no current model or scale was developed in India to measure the service quality of the Indian
private hospital.Therefore, it's needed to develop a new model which can be measure the service quality of
Indian private hospitals.
 The measuring of health care service quality is more important for enhancing the Indian health care service
quality improvement and ensuring the patient’ perception because the perception of patient in term of
service quality may highly influence the choice of hospitals.
 Heath care service quality has been much talked about in the aspects of patient' satisfaction, behavior
intention, trust, and loyalty, but there is a limited knowledge exists on the role of service quality in hospital
choice.

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Raed Mohammed Ali Al-Daoar. “A Critical Review of the Service Quality And its
Measurement in Indian Healthcare Sector.” International Journal of Business and Management
Invention(IJBMI), vol. 6, no. 8, 2017, pp. 76–87.

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