| 1.1 IntroductionIn the tourism context,service offerings that are based on health and wellness have become an important fragment of an international service industry that is growing in the rapid pace.Although patients from the less developed countries have often visited developed countries for advance medical facilities and to avail themselves to the access of reputable and skilled doctors in the early days,this trend began to reverse since the early 1990s whereby more and more patients begin to travel to developing countries for the purpose of medical services attributable to the improving healthcare infrastructures and lower medical costs in these countries(Rogers,2008).This trend was distinctively known as medical tourism and it commonly occur when people travel beyond their national border for medical treatment,while simultaneously being holidaymakers(Connell,2006).Since then,medical tourism became an emerging phenomenon in the healthcare industry,which resulted from the high worldwide demand(Yu&Ko,2012).Over the last three decades,service quality has been a controversial issue for researchers,and most of the research has focused on measuring this factor.This has recently led to an increase in studies in the field of medical tourism.Past research,has linked service quality to customer satisfaction and purchase intentions(Zeithaml,Berry&Parasuraman,1996).A few researchers have suggested that patients' perception of service quality is a key determinant of a health care organization's success due to its primary role in achieving patient satisfaction and hospital profitability.However,there is no consistent finding found in different services industry.Thus,the main objective of this study is to answer the question;how far the healthcare service quality dimensions influence on medical tourists' satisfaction and medical tourism in Sri Lanka.Although many studies have examined the relationship of medical tourists' satisfaction and perceived quality services and behavioral intentions internationally,no study that investigates the mentioned relationship in the Sri Lankan health care industry was found.Thus,this study attempts to examine the influence of the perceived services quality on medical tourists' satisfaction1.2 Literature Review1.2.1 Definition and Characteristics of ServicesAccording to Kotler et al.,(2013)service is "any intangible act or performance that one party offers to another that does not result in the ownership of anything".Services are the production of an essential benefit,either in its own right or as a significant,not incidental,element of a tangible product,which through some form of exchange satisfies an identifiable customer need(Miller&Layton,2000).In all,service can also be defined as an intangible offer by one party to another in exchange of money for pleasure.According to Zeithaml et al.,(1985)services are characterized by the following elements:intangibility,heterogeneity,inseparability and in some cases perishability(Hartman&Lindgren,1993),although this is not a pre-determinate factor constituting a service.For the past decades,the concept of service quality has attracted the attention among managers,practitioners,and researchers,due to its extensive effect on customer satisfaction,business profitability,lowering operational costs,customer loyalty,and the improvement of business performance(Naik,Gantasala,&Prabhakar,2010).With that,service quality was acknowledged as a main competitive strategy for many business organisations as it has direct influences on customer purchasing behaviour and organisation performance(Kayaman&Arasli,2007;McCain,Jang,&Hu,2005).Due to the importance of service quality for any firm,this concept was studied across industries in the recent decades(Ekinci,Dawes,&Massey,2008).Moreover,service quality was always prioritised in firm's operation strategy owing to the fact that service quality can directly influence the success of one's business entity.1.2.2 Customer SatisfactionThe customer satisfaction has become important to the extent that some service institutions consider it as a key element in their marketing strategies,as the term "post-marketing" is used widely to mean to focus attention and efforts on current customers in order to maximize the level of satisfaction they have and ensure keeping them(Havra,1995).Many studies have addressed the definition of customer satisfaction.Customer satisfaction has been defined as:the feeling or attitude of customers about the product or service after use,so that the satisfied customer about a service or product will use it once again,in addition to the transfer of such good feeling to others and encourage them to experience this item or service(Anderson&Mittal,2000).1.3 Research Methodology1.3.1 Formulation of Conceptual Model and Hypothesis DevelopmentBased on the extracts of literature review the conceptual framework was developed.The customer satisfaction as dependent variable,and the service quality dimensions as independent variables.Independent variable-Service Quality:service quality is the difference between customers' expectation and perceptions of services delivered by service firms.Nitecki&Hemon(2000)defined service quality in terms of "meeting or exceeding customer expectations,or as the difference between customer perceptions and expectations of service".In addition,one of important definitions is that the quality of service as perceived by customer is the result of an evaluation process in which they compare their perspective of service outcome against what they expected(Gronroos 2001).In this research service quality is the independent variable which has five dimensions,such as,tangibility,reliability,responsiveness,assurance and empathy.Dependent Variable-Customer Satisfaction:Kotler defined customer satisfaction as the extent to which a product's perceived performance matches a buyer's expectations.If the product performance falls short of expectations,the buyer is dissatisfied.If performance matches or exceeds expectations,the buyer is satisfied or delighted(Kotler et al.2013).Based on the literature,the following hypotheses were developedHal:There is a significant relationship between tangibility and Medical Tourists'Satisfaction.Ha2:There is a significant relationship between reliability and Medical Tourists'Satisfaction.Ha3:There is a significant relationship between responsiveness and Medical Tourists'Satisfaction.Ha4:There is a significant relationship between assurance and Medical Tourists'Satisfaction.Ha5:There is a significant relationship between empathy and Medical Tourists'Satisfaction.1.3.2 Sampling and Data collectionSample size is defined as-the number of units to be included in a study(Malhotra et al..,2006).Currently,the issues of sample size still remain as a subject of debate in the research community(Evans&Rooney,2013).There are different versions of methods in determining sample size in the research platform.As for this research,the numbers of sample size were based on the consideration from the following studies.For example,Manning and Munro(2007)asserted a rule of thumb regarding sample size,whereby the size exceeding 300 is considered-good,200 is considered as-fair,and 100 is considered as-poor.Green(1991)claimed that the minimum sample size of 50 is needed in order to examine relationships with regression or correlation statistically analyses.Moreover,Saunders et al.(2012)reported that a sample size of 350 is considered reasonable to represent a large population.The method of data collection was the survey method.Hawkins et al.(2007)suggest that surveys are systematic ways of gathering information from a large number of people through the use of questionnaires.The questionnaire is by far the most common instrument.The researcher has chosen a self-administered questionnaire as a tool for the data collection.The questionnaire was in the form of closed-ended(or structured)questions in which respondents were asked to make the choice from a list of possible responses.Close-ended questions are also easy to administer and usually evoke rapid response(Schmidt&Hollensen,2006).To make the study more effective and efficient,questionnaire consists of closed ended question and five point Likert scale questions.Respondents can easily pick up any answers from the five-point Likert-type scale.1.4 Data Analysis1.4.1 Descriptive StatisticsThe research focused on some background variables of respondents such as gender,age,marital status,employment status,educational qualifications,and number of time travelled to Sri Lanka,arrangement of their trip and medical treatment seeking in Sri Lanka to get some insights of the sample in terms of this research.Out of 369 respondents,52%of the tourists were males and 48%of respondents were females.Majority of the respondents'average age was in between 31-40 years counting of 35.2%of total,similarly around 88%of the respondents were in the age of 26-50.96%of the respondents were married and 50%of the respondents are professional and 29%of the respondents have postgraduate qualifications while only 6%constitute school leavers,it means most of the educated tourists are travelled to Sri Lanka for the purpose of getting various types medical treatment.The number of times they travelled to Sri Lanka for medical treatment,61.5%of the respondents were travelled two times,it witnesses that they are happy with the service rendered to them by the Sri Lankan hospital when they visited first time,hence they ready to travel again and 38.5%of the respondents were travelled first time to Sri Lanka for getting medical treatment.44.4%of respondents are self-employed while the remaining 42%from private sector and 12%working in government sectors.Further,around 52%of respondents visit Sri Lanka for sight treatment and comprehensive medical checkup,Orthopedic and Fertile care includes 22.5%and 20%only.5%of the respondents visited for Cosmetic/plastic/reconstructive surgeries.Accordingly,it is clearly witnesses that Sri Lanka is not popular for oncology,cardiovascular and plastic surgeries.1.4.2 Reliability Analysis of Inter-item ConsistencyThe Cronbach's Coefficient Alpha is used to test the degree of the inter-item consistency of an instrument and how well it positively correlated to one another.Closer the Cronbach's alpha is to 1,the higher the internal consistency reliability(Sekeran&Bougue,2013).The Cronbach's alpha of the independent variable Tangibility was 0.659,Reliability was 0.843,Responsiveness was 0.608,Assurance was 0.789,and Empathy was 0.796.In overall Cronbach's alpha for all the variables in the instrument were higher than 0.6.Suggesting that the instrument' internal consistency reliability was higher and satisfactory.1.4.3 Measure of Central TendencyThe degree of occurrence or the level of existence of each variable in the sample was analyzed in terms of the degree of agreement of the respondents with the help of descriptive statistics.The researcher used the mean and median as the measure of central tendency and standard deviation as the measure of dispersion for this analysis.These two statistics were used to analyze the degree of occurrence or level of existence of each variable in the entire sample.Mean value of all variables is 3.8(Tangible 4.48,Reliable 4.71,Responsiveness 4.84,Assurance 3.80,Empathy 3.84 and Customer Satisfaction 4.42)higher than the mid value.It is a good representative of the data values to describe the variable.The Median values of all variables are close to the mean of the respective variable.Median values of variables such as Tangible 4.50,Reliable 4.75,Responsiveness 4.00,Assurance 3.75,Empathy 3.75 and Customer Satisfaction 4.50.Since,the mean and median values are very close to each other,perhaps the data is normally distributed.The standard deviation has a slightly higher value of 0.58 explaining that,the data values are scattered but closer to the mean.The mean values of independent variables(Tangibles,Reliability,Responsiveness,Assurance and Empathy)and the dependent variable(Customer Satisfaction)were indicated that it has the ability to describe the variables itself and having fairly good predictive ability to describe about variables.Except empathy all the other variables such as tangibles(-1.00),reliability(-0.515),responsiveness(-.491),assurance(-.206)are negatively skewed while empathy(.313)is positively skewed.The skewness values of all variables within ±1,hence the data can be assumed to be normally distributed but except tangibility and reliability,all the other variables have negative Kurtosis values.The values for asymmetry and kurtosis between-2 and +2 are considered acceptable in order to prove normal univariate distribution(George&Mallery,2010).George,D.,&Mallery,M.(2010).1.4.4 Correlation and Regression AnalysisThe correlation analysis results indicated that all the independent variables,Tangibles,Reliability,Responsiveness,Assurance,and Empathy have positively correlated with customer satisfaction(p<0.05)at 1%significant level.The regression analysis was conducted to reveal how different service quality attributes affect the customer satisfaction.Several independent variables may contain information about the variables that are trying to predict or understand.In such cases,it may be worth to formulate a model that allows considering the relation of variable of interest with the set of independent variables.The overall model explains the fit for the research,R2 shows this aspect.The coefficient R2 is an extension to multiple regression of the coefficient of determination r2 in a simple linear equation.This coefficient is a measure of how well the regression equation fits the data.The R2 is 0.712(71.2 percent),hence,the regression equation apparently have a perfect fit with the data.It can be predicted that 71%of the variance(R-square)in dependent variable has been significantly explained by the five independent variables(Tangibles,Reliability,Responsiveness,Assurance and Empathy).Here,p = 0.000<0.05 and ANOVA table shows that the F value of 179.223 is significant at the 0.000 level.So the model is significant and model exists.1.5 ConclusionIn conclusion,reliability,assurance and empathy have significant impact on customer satisfaction with regard to the services of Sri Lankan hospitals to medical tourists.According to the pearson correlation analysis,all the service quality dimension have positive association with customer satisfaction.However,there cannot be one particular service quality dimensions that work best in every circumstance.Five hypotheses were proposed to investigate the relationship between service quality and customer satisfaction,and the results of the hypotheses tests supported three hypotheses and two were rejected.These results provided valuable insights for understanding the stimulus of customer satisfaction in services provided by the Sri Lankan hospitals.This is consistent with results of past studies reporting a significant positive association between the two variables of service quality and customer satisfaction.Cecilia et al 2017 confirmed the direct impact of service quality dimensions on customer satisfaction.Similar to the above,Hashi et al 2015.Found out that there is a positive relation between the service quality and customer satisfaction.It is also analyzed by the results that service quality has high impact on customer satisfaction.Waiel Alkayed(2014),indicated that service quality is an important antecedent of customer satisfaction.It is apparent that the managers and decision makers seek to improve the elements of service quality that make the most significant contributions to customer satisfaction.1.6 Recommendation and Strategies for improving service qualityFirst and foremost,Sri Lankan hospitals need to constantly improve service quality to enhance customer satisfaction,especially improving the quality of human resources and increase the use of modern equipment and technologies.It is important to have enough human resources and also improve the capabilities of human resources.Employees must be knowledgeable,professional and equipped with soft skills i.e.communication skills.Simultaneously,the Hospitals staff should also have good service attitude,be polite,enthusiastic to meet customer's expectation and to shape positive behavior and attitude in customer service among their employees.The hospitals continuously improves the level of modern technology.The technological capabilities and people using that technology play a crucial role in the quality of service.Technology creates rapid advancement and enhances the ability to meet customer expectations.The trust and loyalty of customers depend on modem technology,as well as the value added services for customers.Hospitals,especially where conducting transactions with customers should be decorated beautifully,have eye-catching and harmonious color combinations,with easily recognizable and distinctive decorations.Hospital branches in the region should have a logo and slogan statement in ensuring quality services.The staff uniform also creates a comfortable and friendly atmosphere for customers and makes customers more assured when meeting hospital employees.Hospitals should regularly communicate with customers.Exchanging information with customers plays an important role in understanding and meeting customer expectations.Information exchange can be carried out in various forms and can be implemented parallel to each other such as customer conference,advertising programs,promotion of products and services,survey of customer needs,and hotline set up etc.By doing these,hospitals transmit to customers information about services,handle customer requests and collect feedback as well as customer complaints related to their activities.Sri Lankan hospitals also needs to store centralized data about customers to facilitate customer service. |
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