Service Quality, a Correlation of Customer Expectation and Customer Perception of Services Received Responsiveness and Empathy in Shisong Hospital

Although Universal Health Coverage (UHC) is of the expectation that health services whether promotive, preventive, curative, rehabilitative or palliative, are of sufficient quality to be effective (WHO, 2010), there has been a common phenomenon in most health communities to find patients moving from one health service facility to another in search for better quality of services, which is defined by their expectation from the health institution and the perception after receiving the health services. Shisong hospital in Kumbo East Health District, Bui Division of the Northwest Region of Cameroon is no exception to these experiences, given that it competes with other health instructions in, around and away from Kumbo. While some patients perceive that the quality of services of Shisong hospital meet their expectations, some perceive that they are yet to receive a commensurate quality of services from Shisong hospital. It was important to find out if the ways employees of Shisong hospital respond and empathise with clients relate the expectations and perception of clients. And investigation was done by administering a unique close ended questionnaire to 425 clients who have used the services of Shisong hospital to test the relationship between their expectation and satisfaction with these two facets of service quality, Responsiveness and Empathy in this hospital through some sub derivatives. Correlation analysis showed that there is a moderate significant relationship between employee responsiveness with clients and customer satisfaction, and a strong significant relationship between employee empathy with clients and customer satisfaction. Based on responsiveness and empathy, service quality in Shisong hospital has been described as ‘satisfactory’. The study recommends that the hospital should improve on these facets of service quality (responsiveness and empathy), given that customer satisfaction falls below their expectations, especially by raising customer perception to be ‘very satisfactory’, in match with the common expectation that has been ‘very good’

Background and Research Problem. Just like with other business organisations, the world over, health service organisations have recently been facing serious challenges on how to get their customers to believe in their services. Given the global health challenges, the surge in the number of diseases and pandemics as well as how these challenges are handled by health experts has instilled so much scepticism in the minds of the folk customer on which health facility to go to or not to visit. This worry has been strongly based on their past and shared experiences with the health facilities. These experiences are issues related to the way these clients are handled initially from the frontline, which is the customer relation management (CRM) level of the organisation. Bitter experiences have pushed customers away while nice ones have made them want to repeat their use of the services of these organisations. It is generally vital in every case to first of all find out if there exist a relationship between the quality of these services and customer satisfaction. This is so because in some cases, organisations could be gunning from a monopolistic point, leaving customers with no objective position as to what they expected and how satisfied they are with the services they receive from such an organisation. Shisong hospital is located in Kumbo, Bui Division of Cameroon and is one of the hospitals that serves people not just from Kumbo but from Cameroon, West and Central Africa, given that it runs the lone cardiac centre in the country and the two sub regions. This hospital competes with two other hospitals; Banso Baptist Hospital (BBH), Kumbo District hospital and a host of health centres and clinics in and around Kumbo. Going by the common man in Kumbo, some believe Shisong is the best hospital and offers the best services while some say it is otherwise. What therefore could be the relationship of the quality of services and specifically its responsiveness and empathy with this satisfaction or dissatisfaction?

1.2.
Objectives of the study The general objective of this study is to investigate what customers expect and how they perceive the quality of services they receive from Shisong hospital.
And specifically:i.
To attempt a theoretical and an empirical discussion of a. the concepts of service and service quality b. the relationship between service quality and customer satisfaction ii.
To investigate the expectation, perception of these variables by customers and the significance of the above mentioned relationships in the management of Shisong hospital; iii.
To come up with recommendations, from this investigation that can be included in policy to improve on the performance of this hospital and as well be used as key areas for further research in this field.

1.3.
Research questions  How do customers of Shisong hospital expect its quality of services to be?  How do customers of Shisong hospital perceive the quality of services they receive from this hospital?  Is there a significant relationship between service quality (responsiveness and empathy) and customer satisfaction in Shisong hospital?
1.4. Hypothesis  H1: There is a significant relationship between service quality (responsiveness and empathy) and customer satisfaction in Shisong hospital.  H2: Customers of Shisong hospital perceive the quality of services they receive as very satisfactory.  H3: Customers of Shisong hospital expect its quality of services to be very good.

1.5.
Research gap Although many studies have been conducted on this topic, few have been done on health service management especially for Africa and Cameroon in particular. Other studies have looked at the relationship between service quality variables without breaking them into some detail for easy understanding by respondents of questionnaires while some have simply done the gap analysis between expectation and perception without looking at the level of satisfaction by customers. This study is done in Cameroon; it breaks the service quality variables for easy understanding of customers and traces the level of satisfaction by customers besides the relationship between customer expectations from the sub-variables and their satisfaction there from.

LITERATURE REVIEW 2.1. Service and Service Quality
Service is generally described as an economic activity whose output is not physical or tangible, and is consumed at the time of production such that it provides some value to the consumer especially at first purchase (Quinn et al 1987). Kotler et al (1999) corroborated with the above view when they saw service as an activity of benefit offered to one party by the other that is not tangible and ends with no ownership of anything. They equally pointed out the following traits of service; intangibility, inseparability, heterogeneity, perishability, ownership. In Line with the above views, Gronroos (2007) saw service as a process which consists of some intangible activities that take place normally but not necessarily in the customer employee interaction or physical resources or goods or systems of the service provider which exist as satisfactions to customer needs. After a fair attempt at determining what a service is, it is important to move further in an attempt to determine what service quality can be. What is service quality? The oxford dictionary defines quality as the standards of a thing when measured against similar ones; or the degree of excellence of a thing. To Anderson et al (2008) quality is the value a customer gets from a particular service or product. Mensah and Richard (2012) agreed with the above but made it clear that quality ought to be defined with the specifications of goods and services; they went forward to borrow from Bitner et al (1994) who viewed quality from a judgmental view, as customers' impression of the relative superiority or inferiority of the organisation and its services. There are mainly three approaches to quality, which are quality assurance (QA), Total quality learning (TQL) and Total quality management (TQM). Quality Assurance (QA) is an approach to quality, which ensures that the quality of the products is in realm with the given system from input, through process to output. This system can be the known requirements and standards expected of the final product. It is a responsibility of all the functions of management and hence called a systematic approach to quality (Collins, 1994). Quality seeks to ensure an end that is justified by a means. It stands for a compatibility between planning and performance. Total Quality Learning (TQL) on its part looks into customer satisfaction and continuous improvement of the product. It differs from Total quality management in that it carries a learning approach to continuous improvement. Rather than exploiting the existing avenues (like TQM) for continuous improvement, it seeks to know the unknown by exploiting mostly the external avenues in search of aspects that can play to the improvement of the product towards a better customer satisfaction (Sitkin, et al 1994). Comparatively, quality assurance has a mechanical and static approach whereas Total quality management is generic and expansionist.
And finally, Total Quality Management (TQM) is built on the importance of organisational culture of designing, producing and improving products and services to the satisfaction of customers; it is mainly customer focused (Jabnoun, 2001). TQM is a combination of quality assurance (QA), which is based on standardization and Quality Learning that is based on continuous improvement towards customer satisfaction (Anderson et al;. What differs TQM from QA is that TQM is based on continuous improvement towards customer satisfaction whereas QA is focused only on set standards. Although quality assurance may seem retardive for organisations, it is important to note that it remains the up-shoot of service quality in modern management. Management planning begins from quality assurance. What then is service quality? Gronroos (1982) perceived service quality as the results of an evaluation process by consumers as they will always make comparisons between the expected services and their perception of the received services. Through a two dimensional (technical quality and functional quality) model, Gronroos (1984) studied service quality and found that the former was the expected outcome of the service where as the latter is the subjective perception of how the service is delivered. After concluding his two models with customer expectation, he concluded that each customer has his own perception of the quality of the service he receives. To him, service quality is a dependent of customer perception or experience from consuming the product or service. In agreement with Gronroos (1984), Auka et al (2013) viewed service quality as the difference between customer expectations for service performance before the service encounter and the final perception after receiving the service (perception before and after the service). They agree with Asubonteng et al (1996) that customer expectation is a foundation for evaluating service quality. They all agree that quality is high when performance exceeds expectation and is low when performance does not meet expectation. Not really deviating from other views, Saravanakumar and Jayakrishnan (2014) viewed service quality as how the service meets requirements, expectations and satisfactions of customers. A very popular definition and model of Service quality is that of Parasuraman et al (1988). They defined service quality as 'a global judgment or attitude relating to the superiority of a service'. Here they based their definition on customer expectation which to them is what a service provider should and not what he would offer. Service quality to them is therefore an outcome of consumers' view of service dimensions which are both technical and functional; in agreement with Gronroos(1984). Auka et al (2013) continue in this perspective but add that this outcome can be value added or quality itself. They added that the process is the role undertaken by a customer. To Parasuraman et al (1988) therefore, service quality is a form of attitude that is related but not equal to satisfaction and outcome from consumption with perceptions of performance. They clearly crowned that service quality is '.......the overall evaluation of a specific service firm that results from comparing that firm's performance with the customers' general expectations of how firms in the industry should perform.......' The SERVQUAL model of Parasuraman et al (1988) has stood the popular support of our time. SERVQUAL denotes the following facets of service quality; tangibility, reliability, responsiveness, assurance, and empathy in an organisation Tangibility -Physical facilities, equipment and appearance of personnel. Reliability -Ability to perform the promised service dependably and accurately. Responsiveness -Willingness to help customers and provide prompt service. Assurance (including competence, courtesy, credibility and security) -Knowledge and courtesy of employees and their ability to inspire trust and confidence. Empathy (including access, communication, understanding the customer) -Caring and individualized attention that the firm provides to its customers (Parasuraman et al.;1988). SERVQUAL has been seen as the instrument most utilized for its confirmatory factor analyses in most cases which has proven to be a parsimonious model that has been used in various service organizations and industries to measure service quality (Kheng et al;. Service quality in hospitals can be defined from three dimensions, which are patient, professional and management (Ovretveit, 2000). Patient quality being what patients want (individualistic); Personal quality being what they think patients need (absolute); and management quality being the use of fewest resources to satisfy needs and wants of patients and professionals with no waste, error, delay, all in respect of policy, law and regulations ( Economic). This study is based on patient quality and will be focused on employee responsiveness and empathy. Responses were representing expectations and perceptions of individual customers in regard to the services they experienced from this hospital.

Sampling Technique
The simple random sampling technique was used for the collection of data.

Instrumentation
The instrument used in generating primary data for this study was a uniquely designed closed ended questionnaire regarding service quality expectations and perceptions. Questions were designed using the Likert scale. This questionnaire was designed in parts; part one is focused on the demographic information of the respondents, part two on expectation and perception of variables of service quality.

Presentation and Analysis of Data
Data has been analysed using the SPSS software and presented in tables using correlation analysis. This software and form of presentation have been used because they are very good in analysing and presenting quantitative data in various forms so much that many different minds can interpret it with focus. It also leaves a greater chance for better comparative studies to be made. The fact that this study is meant to inform the informed as well as the uninformed, gives this software and method of analysis and presentation a better chance for the findings of this study to be disseminated in time and space for better use.

Responsiveness and Empathy in Shisong Hospital
IJSSHR, Volume 04 Issue 12 December 2021 www.ijsshr.in Page 3500 Again, 21.9%of those who expected employee willingness to help to be good, felt satisfied at the end while 4.7% of them felt very satisfied, and 0.7% were not satisfied. There was a statistically significant evidence at 1% level between customer expectation of employee willingness to help and their appraisal after the service (p-value <0.001, X 2 = 61.263).The relationship between these two variables was moderate (35.7%). From table 1.c, majority (61.9%) of customers of Shisong hospital expected employee understanding customers' needs to be very good, while 33.2% expected such understanding to be good. Results revealed that 32.2% of customers who expected employee understanding of customers' needs to be very good felt satisfied at the end of the service they received, while 20.0% feltverysatisfied,7.8% were not satisfied and 0.7% felt disappointed. Again, 26.1%of those who expected employee understanding of customers' needs to be 'good' felt satisfied at the end, while 4.2% felt very satisfied, and 2.4% were not satisfied. There was a statistically significant evidence at 1% level that a relationship existed between expected employee understanding of customers' needs and appraisal of employee understanding of customer needs at the end of the service (p-value <0.001, X 2 = 95.715).The relationship between the two variables was moderate (37.3%).  29.6% expected such care to be good. Results revealed that 40.0% of customers who expected employee care to be very good felt satisfied at the end of the service they received, while 25.2% felt very satisfied, 1.9% of customers were not satisfied and 0.7%of customers were disappointed. Again, 24.0%of customers who expected employee care towards customers to be good felt satisfied at the end, while 3.5% felt very satisfied, and 1.9% were not satisfied. There was a statistically significant evidence at 1% level that a relationship existed between expected employee care towards customers' needs and appraisal of employee care towards customer needs (p-value <0.001, X 2 = 81.338).The relationship between the two variables was strong (45.8%).

Discussion of findings
Looking at responsiveness, which had items such as employee willingness to help, promptness in receiving information, employee understanding of customer need; there proved to be a statistically significant relationship between responsiveness and customer satisfaction, which was generally described as moderate. Customer expectations on this facet of service quality proved to be very good. All levels of expectations were more that 56 %, with employee willingness to help having the highest level of expectation at 63%. Customers were generally satisfied with responsiveness in Shisong hospital. All levels of satisfaction were more than 56%, led by employee understanding of customer need, which was 59.5% From the perspective of empathy, the following areas of employee care and employee sharing with customer worry were studied. There also proved to be a statistically significant relationship between empathy and customer satisfaction that was generally described as strong. Customer expectations on the two items studied under empathy are very good. Levels of expectation were 67.8% and 65.9% respectively. Customers were satisfied with this service quality item in Shisong hospital at levels of 64.7% and 57.4% respectively. To crown it all, most customers (88.0%) of Shisong hospital see its services as patient oriented. Looking at analysis from the customer expectation and perception of service quality items (responsiveness and empathy), there is a significant relationship between service quality and customer satisfaction in Shisong hospital; in agreement with hypothesis one (H1) Most of customer expectation from these service quality items was for provision of service to be very good, most of the customers in an assessment of all the quality items (perception) proved to be satisfied with them. This result holds that hypothesis one (H2) is not true while hypothesis three (H3) of the study is true. Going by Saravanakumar and Jayakrishnan (2014) and Auka (2013) who viewed service quality as how the service meets requirements, expectations and satisfactions of customers; or the difference between customer expectations for service performance before the service encounter and the final perception after receiving the service, the results in hypothesis two (H2) show that the quality of services that is provided by Shisong hospital is satisfactory to its patients. Given that they expect the services to be 'very good' and in turn perceive them as 'satisfied' after experiencing them.
In general, the study shows that although the service quality of Shisong hospital, based on reliability and empathy is satisfactory, going by Asubonteng et al (1996), it can be described as low. Low because customers expected very high levels of service quality from Shisong hospital and are receiving a service quality level that is not commensurate (lower) to their expectations. Asubonteng et al (1996) argued that service quality is low when performance does not meet expectation. Therefore much is left to be desired from Shisong hospital to boost up its service quality level of satisfaction to customers from 'satisfied' to 'very satisfied' in line with their expectations. What will bother one so much is whether a satisfactory result in itself is not really good? Polishing up the quality of services for this hospital to an expected level is a matter of necessity, however tracing its performance in regard to this satisfactory level of satisfaction from many perspectives could polish up on how good this level of satisfaction is to Shisong hospital. The fact remains that all the items of service quality in the study have a relationship with employee satisfaction and must be handled with care.

CONCLUSION, RECOMMENDATIONS AND LIMITATIONS 4.1. Conclusion
In line with the study objectives, the following conclusions can be drawn in regard to Service Quality and customer satisfaction of Shisong Hospital:- Most customers of Shisong hospital have the expectation that the quality of services of this hospital is 'very good' and worth using them.  Although they expect to have very good services from Shisong hospital, they find that the service quality in Shisong hospital is satisfactory; and low in regard to customer expectation.  There is a significant relationship between service quality and customer satisfaction in Shisong hospital  In general, customers think that the quality of services in Shisong hospital is very good, and their experiences have proven that the quality of services from this hospital is just satisfactory. However an improvement in the service quality variables in this hospital can greatly increase customer satisfaction to a high level, given that customer expectation of service quality in Shisong hospital (very Good) is generally higher than the satisfaction received (satisfied), this improvement can greatly improve on its performance -customer satisfaction, loyalty and turnover.