Service quality at a military hospital

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2.7 THE MILITARY HOSPITAL IN GABON

The idea to establish the military hospital dated back from the late 1970s to early 1980s.The project was inaugurated in 2005, and the facility has been officially operating since 31 December 2007.The initial ideology was to provide medical services merely to the military forces in the country. This idea was later transformed in a way anyone can have access to medical services provided by the medical facility. The military hospital was financed by major international organisations such as the French Collaboration (F.C), regarded as one of the main contributors. The hospital team is a mixture of local and international qualified medical professionals, mostly French nationals. Each department within the hospital is equipped with advanced medical equipment ranging from ultramodern air conditioners, computers, X-ray machines, scanners, audiometric, echo graph, electrocardiograph, radiology, endoscope to echocardiograph machines (Historique, 2010).In addition, five ambulance vehicles and a helicopter are available 24 hours a day and seven days a week to deal with emergencies (Service d'accueil, 2010).

The hospital executive panel is composed of the Chief Medical Director (CMD), who is both a medical specialist and the general director of the hospital, the head of the department of radiology, the head of department of internal medicine and the head of the department of Ear, Nose and Throat as well as medical specialists. There are eight main clinical departments in the military hospital. Each of these departments will be briefly highlighted in the following Tables (Historique, 2010).

Table 2.1: Department of emergency

DEPARTMENT OF EMERGENCY

It works 24 hours a day and seven days a week. An ambulance vehicle and a helicopter are available to patients in case of emergencies. The department delivers a fast and reliable service to patients (Service d'accueil, 2010).The department of emergency is composed of:

A reception

This provides excellent services to patients.

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A consultation and emergency room This facility is able to deal with all types of emergencies ranging from medical to chirurgical emergencies. It is equipped with modern technologies such as electrocardiographs and echocardiographs to provide assistance to patients in critical conditions (Service d'accueil, 2010).		A temporary admission room Patients can first access the temporary admission room while they wait to be transferred to the emergency room. The room has a total capacity of 10 patients and is divided into two sections to separate male and female patients. The facility is able to provide intensive care services (Service d'accueil, 2010).
A room to disinfect patients In that room patients are cleared from any bacterial transmitted infection before they are moved to the temporary or emergency room (Service d'accueil, 2010).
A surgery room Patients admitted in that facility require an operation (Service d'accueil, 2010). The emergency team is composed of medical experts that shift day and night. This includes general practitioners, specialists, anaesthetists, paramedics and nurses (Service d'accueil, 2010).

Table 2.2: Department of medical analysis

DEPARTMENT OF MEDICAL ANALYSIS

The department of medical analysis includes subunits such as haematology, immunology, bacteriology and mycology.

Haematology This unit includes up-to-date medical equipments to analyse blood composition and to detect any anomalies or sicknesses in blood

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(Laboratoire d'analyses médicales, 2010).		Immunology This unit aims at detecting and analysing viral, parasitic and bacterial infections found in blood. The unit addresses three major forms of health issues such as: viral serology (which includes HIV/Aids and hepatitis B and C), parasitic serology (which includes bilharzia and toxoplasmosis) and bacterial serology (that comprises syphilis and chlamydia). In addition, this unit works jointly with the HIV/Aids national programme in the fight against AIDS (Laboratoire d' analyses médicales, 2010).
Bacteriology This section analyses viral and parasitic infections in urine. Additionally, women can also be treated for early signs of breast and womb cancer (Laboratoire d'analyses médicales, 2010).
Mycology This unit includes medical equipment such as advanced microscopes to detect viral and parasitic infections in blood. As a result, patients are often successfully treated and cured from trypanosomes, cryptosporidiosis and other related bacterial infections (Laboratoire d'analyses médicales, 2010).

Table 2.3: A pharmacy

A PHARMACY

A pharmacy is located within the military hospital, and medicines are available to patients after they have been consulted. A range of tablets is available to treat most diseases, and medicine stocks are frequently renewed (Pharmacie hospitalière, 2010).

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Table 2.4: Department of internal medicine

DEPARTMENT OF INTERNAL MEDICINE		It includes a head of department, and a team of medical specialists such as dermatologists, cardiologists and nurses. The department of internal medicine also has a programme to provide teachings and trainees to medical students (Médécine interne, 2010). The department includes four main units:
A unit that treats patients suffering from the most common diseases affecting the country such as malaria and yellow fever. The facility has a capacity of 200 people (Médécine interne, 2010).
A unit that treats only patients suffering from heart-related diseases. A team of cardiologists is constantly available to provide intensive care to admitted patients. The unit has a total capacity of 70 people (Medicine interne, 2010).
A unit that monitors the health of patients who are admitted. The unit comprises of echocardiograph and electrocardiograph equipment to assess patients' health (Médécine interne, 2010).
A VIP unit which is only designed for special clients such as heads of states, ministers and other important clients.

Table 2.5: Department of surgery and orthopaedic

DEPARTMENT OF SURGERY AND ORTHOPAEDIC

Patients who require surgery are often admitted in that facility. The department is known to provide surgery of the digestive system as well as urologic, visceral and thoracic surgery. The facility has a maximum capacity of 32 patients (Chirurgie générale, 2010).

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Table 2.6: Department of ophthalmology

DEPARTMENT OF OPHTALMOLOGY		It includes 3 main units such as: A consultation room which offers eye tests and treatments to patients. The unit includes advanced eye equipment and is known to provide superior services to customers (Ophtalmologie, 2010).
A surgery unit where major eye problems such as cataracts and glaucoms can be removed via surgery (Ophtalmologie, 2010).
An admission room where patients in critical conditions can be admitted. A team of ophthalmologists is available to provide excellent services to patients. The unit has a maximum capacity of 16 patients (Ophtalmologie, 2010).

Table 2.7: Department of Ear Nose and Throat (ENT)

DEPARTMENT OF EAR NOSE AND THROAT (ENT)

This department is divided into two major units: A unit that tracks hearing disorders in patients. The facility includes advanced medical equipment such as audiometers to detect hearing problems in both young and adult patients (Orl & Ccf, 2010).

A unit that treats throat diseases and speech disorders. That section encompasses spectrograph equipment to detect and examine anomalies in the throat and speech of patients. The medical team in that unit comprises general practitioners, paramedics, nurses and specialists who provide daily care and assistance to patients. A surgery room is also available to patients who require a throat operation (Orl & Ccf, 2010).

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Table 2.8: Department of radiology

DEPARTMENT OF RADIOLOGY

The radiology department includes: a unit for chest radiology, a unit for bones radiology and an ultrasound room. The facility includes advanced X-ray and scanner equipment and provides superior services to patients (Radiologie et imagérie médicale, 2010).

For the purpose of this study, the focus will be on the Department of internal medicine since during a telephone interview conducted on 4 June 2012 it was regarded as the one receiving the largest number of patients. Patients in that department were also required to stay over in the hospital for at least one night.

Table 2.9: Military hospital

DEPARTMENT OF EMERGENCY		It is operational 24 hours a day and seven days a week. An ambulance vehicle and a helicopter are available to patients in case of emergencies. The department delivers fast and a reliable service to patients. The department of emergency is composed of a reception, a consultation and emergency room, a temporary admission room, a room to disinfect patients and a surgery room (Service d'accueil, 2010).
DEPARTMENT OF MEDICAL ANALYSIS The department of medical analysis includes subunits such as haematology, immunology, bacteriology and mycology (Laboratoire d'analyse médicales, 2010).
A PHARMACY A pharmacy is located within the military hospital, and medicines are available to patients after they have been consulted. A range of tablets is available to treat most diseases, and medicines stocks are frequently renewed (Pharmacie hospitalière, 2010).
DEPARTMENT OF INTERNAL MEDICINE It includes a head of department, and a team of medical specialists such as dermatologists, cardiologists and nurses. The department of internal medicine also has a programme to provide teachings and training to medical students. The department includes four main units: A unit that treats patients suffering from the

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most common diseases affecting the country such as malaria and yellow fever; a unit that treats only patients suffering from heart-related diseases, a unit that monitors the health of patients who are admitted, and a VIP unit which is only designed for special clients such as heads of states, ministers and other important clients (Médécine interne, 2010).		DEPARTMENT OF SURGERY AND ORTHOPAEDIC Patients who require surgery are often admitted in that facility. The department is known to provide surgery of the digestive system as well as urologic, visceral, and thoracic surgery. The facility has a maximum capacity of 32 patients (Chirurgie générale, 2010).
DEPARTMENT OF OPHTALMOLOGY It includes 3 main units such as: A consultation room which offers eye tests and treatments to patients a surgery unit where major eye problems such as cataracts and glaucoms can be removed via surgery, and an admission room where patients in critical conditions can be admitted (Ophtalmologie, 2010).
DEPARTMENT OF EAR NOSE AND THROAT (ENT) This department is divided into two major units: A unit that tracks hearing disorders in patients and a unit that treats throat diseases and speech disorders (Orl & Ccf, 2010).
DEPARTMENT OF RADIOLOGY The radiology department includes a unit for chest radiology, a unit for bones radiology and an ultrasound room (Radiologie et imagérie médicale, 2010).

2.6 CONCLUSION

In this chapter, the focus was to investigate the state of the health industry in Africa and more specifically, in Gabon. The health development initiatives in central Africa were introduced and the relevance of organisational health institutions such as OCEAC, CEMAC, CAMES and the CIESPAC in central Africa was also discussed in details. The chapter discussed the health indicators in Gabon as well as the quality of medical services delivered in the country. This enabled the researcher to assess the strengths and weaknesses of the Gabonese health care system. Following that discussion, a review of the two major health sectors in Gabon, as well as the health developmental

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strategies in the public and private sector were also debated in order to improve the quality of health in Gabon. The last part of the chapter provided a discussion of the military hospital in Libreville, in Gabon as well as a conclusion.

The following chapter will put services marketing, service quality and customer satisfaction in perspective and the advantages of implementing these elements to both the customer and the organisation will be discussed. Chapter Three will also discuss the link between expectations, customer satisfaction and service quality.

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CHAPTER THREE: SERVICES MARKETING, SERVICE QUALITY AND CUSTOMER SATISFACTION

3.1 INTRODUCTION

The purpose of Chapter Two was to examine and have a deep understanding of the nature of the health system in Africa and more specifically, in Gabon. It provided an ²overview of health development initiatives in Africa and concluded with a focus on the military hospital in Libreville in Gabon. Chapter Three provides a theoretical discussion of services marketing, service quality and customer satisfaction. It provides a discussion on the definitions, generic elements and importance of services marketing, service quality and customer satisfaction. Additionally, a discussion on the relationship between expectations, customer satisfaction and service quality will be included in the chapter.

In most countries, people have spent more on services than on tangible goods. Service companies have become major contributors in the world economies. They account for more global outputs and provide work for more individuals than any other sector. By the mid 2000s services represented 33% of the world's Gross Domestic Product which is about $ 6 trillions of additional income, down from about 50% in the 1990s. Worldwide services growth is about 3% more than agriculture which is 1.4%, and the manufacturing industry that is 2.3%. As a result, the services sector expanded significantly from 57% in the 1990s to over 68% in the mid 2000s (World Bank Development Indicators, 2012:1). Compared to other sectors in the world, the services sector has become the largest and the fastest growing one. Some of the reasons for such a rapid growth are mainly due to the increase in urbanisation, privatisation and the increase in demand for intermediate and final consumer services. Accessibility of quality services is fundamental for the well-being of people and the economy. Studies revealed that in most advanced economies, the expansion of the primary sector which makes use of natural resources such as agriculture, mining, forestry, oil and gas and the secondary sector that produce manufactured goods such as goods to the automobile industry, was mainly correlated to the growth of services such as bank, trade, commerce, entertainment and insurance services. In most European economies and

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the USA, the service sector has accounted for more than two-thirds of these countries' Growth Domestic Product (GDP) (Service Sector Around the World, 2012).

In Africa, despite many challenges such as poverty, sicknesses, high mortality rate among children and HIV/Aids affecting countries like Ethiopia, Somalia and Soudan, the continent's Gross Domestic Product (GDP) rose significantly from the early 2000's to 2011 which amounted to $1.6 trillion. Since the 2000s, real GDP has increased by almost 5% yearly. This represents almost more than twice its pace between the 1980s and 1990s. Africa's growth is mainly due to the primary sector through commodities like oil and minerals. This represented almost 40% of the global GDP. The remaining 60% contribution to the African GDP comes from secondary sources namely industry 32% and services 28%. Since the 2000s, the service sector has grown at a slower pace compared to other sectors in Africa (Leke, Lund, Roxburgh & Van Wamelen, 2010).

The primary sector is perceived as the main source of economic expansion in Gabon, with the export of raw material such as manganese, and timber oil, representing over 43% of the gross domestic product in 2012. The secondary sector such as manufacturing represented 25%, and services such as hotels, transport, information, finance and business services represented over 32% of the country's Gross Domestic Product (Trading Economics, 2012).The country' s real GDP growth has decreased considerably from 8.6% in 2007 to 4.4% in 2012. As a result, since 2009, the state has launched various strategies to improve the country's economy, including boosting the services sector to create more jobs. These measures led to more employments in some services such as the hotel and transport industries. This led to a sharp rise of 7% growth in services over the secondary sector (Gabon Economic Outlook, 2012).

An important approach to assess the structure of a country's economy is to evaluate the share of its three major sectors namely: agriculture, manufacturing and services, to see which sector has the largest total output and employment. Initially, agriculture was perceived as a country's most important developing sector. But with the increase of the per capita income, it weakened, giving rise to the manufacturing sector followed by the rise of the service sector. These two major changes are ascribed to industrialisation and post-industrialisation. All developing economies are expected to follow these stages characterised by shifts in the consumer demand and in labour productivity of the three sectors. Advanced economies such as those in North America, Western Europe and Japan are currently post-industrialising; becoming more focused on services and most developing economies such as those in Africa, Asia and Brazil and are currently

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industrialising; becoming more focused on industry. However, data revealed that even in low income countries such as in Kenya, the contribution of the service sector to the country's Gross Domestic Product (GDP) is increasing faster than the other sectors of the economy. For instance, from 2000 to 2010 services growth was about 3.2% compared to manufacturing 1.9% and manufacturing 1.1%. Growth in services represents nearly two third of the world's Gross Domestic Product, which amounts to almost 64% of the global GDP (Service Sector Around the World, 2012).

As the service sector is becoming an important component of most countries' economies, it is projected to grow at a faster rate in the future. Service users are currently exposed to a larger range of services and services are becoming more available to them. Consumers often value services based on the manner that it has been marketed to them and on the benefits these services are providing (Londre, 2010:1). Quality service is perceived as the major cause of customer satisfaction. Hence providing quality service to customers is vital to build long-term relationships with both consumers and the organisation. These relationships can lead to increasing profitability and customer retention (Olusoji, 2009:7).

To be globally competitive, service organisations should develop knowledge and insight into three major aspects of service such as services marketing, service quality and customer satisfaction (Naik, 2010: 242).These aspects are consecutively discussed.

3.2. SERVICES MARKETING

3.2.1 Definition of services marketing

With the rapid growth in the service sector, most service organisations such as insurance, telecommunications and hospitals have recognised the importance of services marketing to promote the value of their services to customers to increase their profitability. Organisations are becoming interested in learning how far this development is reflected within their marketing curriculum. Increasing organisational profit requires a strong coordination between the marketing department and customers to provide customer satisfaction (Verma, 2012:33). The application of services marketing is vital as it will push and persuade customers to purchase services. Hence, the concept is often

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connected to terms such as communication, sales and advertisements (Kasper, Helsdingen & Gabbott, 2006:76).

From the discussion provided, the definitions of services marketing can be presented in Table 3.1:

Table 3.1 Definition of services marketing

Definition	References		Descriptions	A
Services Marketing (2012)	Services marketing relates to promoting economic activities to customers. It might involve selling services such as health, telecommunications, insurance, education, air travel, electricity and water to customers.		B
Jupiter (2011)	Services marketing refers to the process of persuading prospective customers to purchase a business service. Services marketing comprises the techniques used in the overall marketing plan of production, pricing, promotion and distribution.		C
Zeithaml & Bitner (2007:22)	Services marketing involves providing services that actually satisfy the needs, wishes, whims and the preferences of present and future customers. To accomplish this mission, an organisation must select a target group and address their needs accordingly.

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D	Kasper et al. (2006:76)		Services marketing refers to a set of functions such as communication, advertising,
	and delivering service value to
	consumers and for managing
	customer relationships in order
	to increase a firm's profitability.

From the definitions provided in Table 3.1, services marketing can be viewed as a subfield of marketing that consists of the marketing of services by an organisation to its customers.

3.2.2 Generic elements of the definition of services marketing

From the definitions provided in Table 3.1, some generic elements of services marketing will now be discussed.

? Promoting customer satisfaction through the creation, distribution, promotion and pricing of services

Services marketing is first an instrument for promoting customer satisfaction through the creation, distribution, promotion and pricing of service. It is a continuous process of convincing potential consumers to buy an organisation's services (Jupiter, 2011). The core idea is that for a service organisation to grow, its customers must be satisfied. Happy customers are more likely to return to the organisation to repeat purchases. Customers spend their money to acquire services that must satisfy their needs. Such services must have optimum level of quality, reliability and must be offered to consumers at the right price and advertised effectively to attract them (Fornell, Rust & Dekimpe, 2010:29).With the current global competition, services marketing requirements have considerably changed. As a result, a current effective way to keep customers satisfied, rarely has longevity. For example, old cassette decks no longer satisfy the needs of most music listeners, they have been replaced by compact discs and mp3 music players. They have thus replaced the dominant share of Samsung`s range. Therefore, services organisations must constantly assess and address their

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customers' services needs and be ready to adjust the marketing of their services accordingly (Grönroos, 2007: 266).

? A tool for managing, identifying and satisfying customer requirements profitability

Secondly, services marketing can be seen as a tool for managing, identifying and satisfying customer requirements. It concentrates on the distinctive features of services and how they can be properly managed in order to impact both the consumer behaviour and the entire organisation (Lovelock & Wirtz, 2011:45). Understanding consumers' service needs and anticipating their requirements are fundamental aspects of the marketing of services. Service organisations must be aware of market trends and developments that may have an influence on both consumers' views and the activities of organisations operating in that specific marketplace. These changes can be referred to as social, technological, legal and regulatory changes, as well as political developments and competition in the market. Thus businesses must offer services, with alternative solutions to consumers' specific needs, in line with all trends in the market. The competitive nature of the market must be of a major importance to services marketers. Organisations must make use of their internal resource base to determine which path to take in order to be successful. Therefore, an effective marketing of services will rely on the successful evaluation of customers, the market environment, competition and the company's internal resources (Zeithaml et al., 2006:8).

? A system that fits the service product to the customer

Thirdly, services marketing can be regarded as a system which fits the service product to the customer. It is regarded as an activity that identifies the service needs and preferences of a target group and addresses those needs accordingly (Zeithaml & Bitner, 2007:22). For an organisation to address this issue, it must create a marketing strategy where the goal is to identify groups of customers with similar needs and develop services to address those needs. As a result, each population group may then be proposed a specifically tailored service, according to their specific requirements. However, for organisations to effectively propose services to customers, they must focus primarily on the segments of customers they are capable of serving and who will provide satisfactory returns. The limited resources will not allow organisations to target all groups in the market. As a result, service organisations have to select an appropriate

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service positioning framework to have a competitive advantage over rivals in the market (Zeithaml et al., 2006:8).

? Services marketing as a set of tools and activities

Fourthly, services marketing can be perceived as a set of designed tools, techniques and activities such as pricing, promotion and distribution of services to prospective customers (Savescu, 2011:39).

This constitutes a major part of marketing since it is the one to which consumers are exposed. Marketing of services should not only involve acquiring customers, promotion, pricing, and distribution of services, but also include keeping and building a solid customer relationship (Temesgen, Negi & Ketema, 2010:51). Thus, three major levels of the marketing of services have been identified: recruiting customers, keeping customers and growing customers. Regarding the recruitment of customers, a service organisation will develop activities such as the marketing, delivery and pricing of their service product to persuade prospective customers than the service provided is better than the competitor's one (Jupiter, 2011).

In order to keep customers, an organisation can develop its customer contacts during the service delivery process in a way to impact a customer positively and influence him or her to continuous purchasing. Finally, to grow customers, an organisation has to sustain a real relationship with a customer, where the customer feels emotionally attached to the organisation (Grewal, Chandrashekaran & Citrin, 2010:612).To achieve this, an organisation has to develop a relational approach when proposing its services. During this approach the organisation must show the customer its willingness to take care of him. In addition to providing services, the customer must perceive it to have a satisfactory outcome-related technical and process-related functional quality. If the customer is happy with the perceived services, then he may probably prolong his relationship with the organisation (Grönroos, 2007:270).

3.2.3 The importance of services marketing

Services marketing is fundamental to services organisations; it refers to the promises made and promises kept to consumers. Good marketing of services often results in organisations' development. If organisations are able to innovate their services

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marketing, then the socio-economic change will arise at a faster pace (Gilaninia, Almani, Pournaserani & Mousavian, 2011:787). One of the major boosts to services marketing is technological developments. These developments offered opportunities to organisations to market and carry out services in a manner that the consumer's physical presence is no longer a requirement. For example, Internet technologies have enabled customers to access services using their computers. This has significantly improved the traditional way of providing services (Hoffman, Bateson, Wood, & Alaxandra, 2006:15).

The Internet has been used to assist in the service process such as selling, communicating, making payments and conducting market research. It is perceived as a marketing channel where most service interactions can be performed. The Internet has been involved in the service delivery process by offering help-desk services and support services to customers (Grönroos, 2007:283). Another consequence of information technology development is the rise in value-added and service quality. This aspect is merely crucial for organisations which compete by differentiating their products via offering superior service. New technology developments such as ATMs have enhanced services in the financial sector by substituting the traditional bank counters. ATMs are known to providing fast and high quality service to customers (Kasper et al., 2006:325).

High technology services such as e-commerce in general can be perceived as time saving for both the service producer and the customer. Services can be accessed seven days of the week without any requirement for the consumer to go to the service organisation. An additional advantage is the creation of the place utility, where services can be accessed from anywhere, such as by laptop or mobile phone (Kasper et al., 2006:325).Additionally, the use of technological services can provide a competitive advantage in various ways. One of the benefits is the substitution of labour, which can significantly lead to an organisation's cost reductions. This aspect can enable organisations to become more competitive and to increase profitability (Kasper et al., 2006:324).

A final observation revealed that technologies used by service organisations such as banks, hospitals, hotels and communications services may be less polluting to the environment as opposed to technologies used in manufacturing organisations which may have a more harmful effect on the environment (Greenstone & Hanna,

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2011:10).It is therefore important to note that although technology development has significantly substituted labour in many service organisations, most organisations such as hospitals still rely heavily on human labour to offer services to patients who feel more comfortable interacting with human beings. In that case the marketing of services relies more on the direct interactions between patients and the medical personnel (Kapoor, Paul & Halder, 2012: 11).

Findings suggested that involving patients in the course of medical care has a significant impact on the medical treatment results. Medical outcomes no longer depend on medical employees' skills only, but may vary depending on the degree of patient participation in the process of care. There is a correlation between patient involvement in the process of care and medical success. In the current millenium, patients are becoming more aware of quality service via the Internet. As a result, they may require superior services in hospitals. This in turn reveals the necessity to foster services marketing in hospitals (Tan, Benbasat & Cenfetelli, 2013: 87-88). Patient satisfaction results from quality in health care through health services marketing where health care institutions can market their offerings to gain more customers and become more competitive. Services marketing has a greater effect on patient behaviour than the costs he or she has to endure in hospitals. As a result, services marketing can portray a positive image of the hospital, which in turn will allow patients to remain more loyal and refer the facility to other individuals. Doctors usually disregard the importance of health services marketing. They usually assume that patient satisfaction merely depends on their technical expertise. As a result, they often underestimate the economic benefits of implementing services marketing in hospitals. Health services are often perceived as a complex mechanism that comprises both the technical abilities of doctors and their ability to market their services to patients (Dosen, 2009:2007).

Rohini (2006:69) indicated that patients' perceptions of service quality are mostly influenced by the ability of medical institutions to market their services. As a result, medical personnel should be able to communicate, support, listen to and notify patients about their health concerns. These service delivery traits are highly rated by patients and display a positive image of the organisation in the mind of a patient. This in turn influences patient choice of health service provider.

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3.3 MANAGING ORGANISATIONS IN A SERVICE ENVIRONMENT

In order to manage services effectively, it is vital for services organisations to have an understanding of the different dimensions involved in a service. The distinguishing elements of services are crucial in the design of a proper marketing mix for the service organisation. The identification of these elements was the preoccupation of much earlier research by Hoffman et al., (2006:26) and conceptual development by Kasper et al. (2006:76) of services marketing. The different elements are known as intangibility, inseparability, perishability, heterogeneity, ownership and service culture (Zeithaml et al., 2006:20). All these elements require the involvement of employees in delivering the service and refer to the hidden part of revealing the brand awareness of the organisation (Conradie, 2011:69). Each of the mentioned elements is briefly discussed next.

3.3.1 Different dimensions when managing an organisation in a service environment

? Intangibility

Intangibility is the main feature of a service. This implies that a service cannot be seen, smelled and touched (Grobbelaar, 2006:5). Health care services result in actions such as surgery, diagnosis, examination and treatment offered by doctors. These services cannot be seen or touched by the patient, although the latter may be able to see or touch some tangible aspects of the service such as medical equipment (Zeithaml et al., 2006:20). However, the intangible nature of services can present major concerns in a way services are not easy to display or to communicate to customers (Grobbelaar, 2006:6). As a result, customers usually use price as a basis for evaluating service quality (Zeithaml et al., 2006:21).

? Inseparability

Inseparability refers to when services are produced and consumed at the same time. Customers generally take part in the course of service delivery and their role is vital in the service production process (Grobbelaar, 2006:7). However, the nature of

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interactions between the service provider and the customer can influence the outcome of the service performance. Service providers are often perceived as the service itself. Therefore firms should recognise their important role in service processes (Zeithaml et al., 2006:22).

? Perishability

This aspect of service implies that services cannot be inventoried, stored or re-used once they are produced (Grobbelaar, 2006:7). This can present major concerns in the supply and demand for services since service failures cannot be recovered to balance their demand and supply. As a result, service marketers must implement strategies to pick up from service process failures. This forces firms to build more efficient capacities to plan and manage future demand (Kasper et al., 2006:60).

? Heterogeneity

Services comprise intangible performance mostly delivered by human being. However, due to the changing nature of people, human performance will frequently vary. As a result, two services cannot be precisely alike. Customers often see the service provider as the service itself and therefore, the service is often perceived as heterogeneous (Grobbelaar, 2006:7).

? Ownership

Since services are produced and consumed at the same time, they cannot be owned or exchanged by consumers. As a result, the purchase of a service provides the right to access the service only, and not its ownership. Customers are usually unsure about the outcomes of a purchased service, and also whether the service will or will not adequately satisfy their needs (Conradie, 2011:72). Since services are perishable, they cannot be returned. This suggests that firms should foster a culture of service excellence to ensure that quality service is provided to customers (Kasper et al., 2006:61).

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? Service culture

Service culture is influenced by the value and culture of an organisation that guides service employee behaviours, which is in turn associated to the organisation's outcomes (Webster & White, 2009:692).Thus, organisational culture is important as it has a large impact on service processes. Given the fact that services are heterogeneous and intangibles, it is not easy for customers to assess the services received as opposed to goods. Customers often take into account other aspects of interaction with service employees such as their behaviour. Employees' behaviour results from an organisational culture (Mosley, 2007).

Service culture usually builds up over time and is relevant when interest in customers is the most critical value in the organisation (Conradie, 2011:72).However, sustaining a service culture in an organisation does not imply that other values are no longer important. Grönroos (2007:418) regards service culture as a culture where providing high-quality service to customers must be the core value of an organisation. As a result, all employees within organisations must be service oriented. This means that service employees must share common values and attitudes so to improve and provide excellent services to customers (Grönroos, 2007:419).

Successful services organisations must have an understanding of the characteristics of services. The distinguishing features of services are important in the design of a proper services marketing mix to address the needs of customers and to remain competitive (Du Plessis, 2010:198). An understanding of the services marketing mix will be provided in the following discussion.

3.3.2 The services marketing mix

Developing a successful marketing plan is vital to maintain a customer orientation. The marketing mix focuses on choosing the right marketing mix elements. It involves combining ideas, concepts and features in order to better address customers' needs in a given market. The marketing mix is composed of four major aspects such as product, price, promotion and place. Unlike the product marketing mix, services marketing is

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characterised by three additional elements such as people, process and physical evidence. These aspects constitute a services marketing blueprint design (Conradie, 2011:72).

Each of the elements is briefly described next.

? Product

The services marketing product mix is usually intangible, which means it cannot be measured. Education, tourism and the health care industry can be perceived as good examples of services marketing mix. Major characteristics of these service products are that they are heterogeneous, perishable and cannot be owned (Hu, 2011:61). In general, a careful design of a service blueprinting is a prerequisite to define the service product. For example, a fast-food blueprint is vital prior to establishing the fast-food business. The service blueprint will describe how the product referred to as the fast-food business will be (Bhasin, 2011).

? Place

Place refers to where the organisation is going to sell its services and where they are going to be implemented (Conradie, 2011:148). For example, a good place to establish a petrol station will be in the urban area. Therefore, an area with low traffic will be regarded as inappropriate for a petrol station. Additionally, a software business will be best suited in a business hub with various organisations around, rather than being isolated in a rural area (Lings & Greenley, 2009:44).

? Promotion

Promotion of services is vital for organisations to survive in the competitive world. Services are easily imitated; therefore organisations have to differentiate and distinguish themselves from the rest through their brand. Thus promotion has become a significant component of the services marketing mix (Hu, 2011:61). IT organisations, hospitals, hotels and banks set themselves above the rest by promoting their services to customers (Kasper et al., 2006:465).

? Pricing

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Service pricing is quite different from product pricing as it takes into account labour, material cost and overhead costs. For instance, a fast-food owner may price his food based on the pleasant ambience the facility may provide to people and the band customers have for the music. Thus, services pricing can be made of all the costs involved to mark up the final service price (Pomering, Noble & Johnson, and 2011:961).

? People

People constitute an important constituent of services marketing as they define a service. For instance, nurses and medical people define health services; bank employees will define the type of financial services provided to customers. Thus people employed in services can affect positively or negatively on an organisation (Pomering, Noble & Johnson, 2011:962-963). Various organisations are getting their personnel trained in interpersonal skills and customer service to ensure better service delivery and customer satisfaction. Nowadays, most organisations are getting accreditation in terms of showing that their personnel are better than the rest (Bhasin, 2011).

? Process

Process refers to the manner in which service is provided to the final consumer. For examples, two medical services providers: Milpark and Garden City Clinic hospital thrive on their fast service and the reason they can do that is based on their confidence on their processes. Additionally, the demand for their services is such that they have to provide quality service to their patients. Therefore, the service process of an organisation is vital (Prouse, 2011). It is also part of the service blueprint, in which prior to establishing the service, an organisation has to identify what should be the process of the service product reaching the final consumer (Kasper et al., 2006:465).

? Physical evidence

Physical evidence refers to the final component in the services marketing mix. Since services are intangible in nature, physical evidence of services is vital to create a better consumer experience with the service provided (Lovelock et al., 2009:24). A patient is more likely to choose a private hospital with air conditioner, excellent patient care, advanced medical equipment and a prompt service delivery system than a government hospital. Thus, physical evidence is crucial in the services marketing mix, since it acts as a service differentiator (Bhasin, 2011).

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3.4 THE THREE LEGS OF SERVICES MARKETING

Interaction between the consumer and the service provider is vital in services. These human to human interactions form variability in the service provision for every individual consumer (Olusoji, 2009:27). A structure known as the services marketing triangle highlights the value of people in the ability of organisations to ensure that promises are kept and achieved in building relationships. The services marketing triangle helps marketers in dealing with issues such as understanding consumers' needs and expectations of services, enhancing the value of services to consumers, and ensuring that promises made to consumers are kept (Conradie, 2011:76).

3.4.1 The services marketing triangle

Service triangle is a method used by organisations to highlight the importance of employees and organisations in keeping their promises and building a solid customer relationship. The triangle focuses on three major elements namely the organisation's management, customers and employees. Between each of the three elements of the triangle, there are various marketing processes such as external, interactive and internal marketing. These processes have to be conducted properly for service processes to be efficient and to develop and keep solid relationships with the internal and external customers (Angelis, De Lima & Siraliova, 2010:10).

Figure 3.1: Services marketing triangle

Internal marketing

Organisation management

External marketing

(Enabling the promise) (Making the promise)

Employees Customers

Interactive marketing Delivering the promise

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Source: Zeithaml et al. (2006:23).

From Figure 3.1, the three legs of the services marketing triangle can be explained as follows:

? External marketing

External marketing refers to the service promises made by organisations to customers. It includes service offerings and the way in which they will be carried out. External communication is vital to building customers' expectations, since expectations are influenced by an organisation's direct and indirect marketing message (Kasper et al., 2006:79).Research suggested that many organisations have been investing more in marketing activities such as sales and promotion. This has enabled organisations to obtain and retain customers. However, investing in marketing becomes problematic when the cost associated with promoting a product or service is higher than the profit generated. Thus, it is vital to focus on efficiency and productivity of marketing department within organisations (Grönroos, 2007:267). A successful coordination of internal and external marketing communication can enhance marketing efficiency and ensure higher service delivery to customers (Vrontis, Thrassou & Zin, 2010:26; Zeithaml et al., 2006:496).

For many organisations, the most critical aspects of managing brand image involves coordinating all the external communication channels which send information to potential customers (Lings & Greenley, 2009:44). However, managing all external communication vehicles has become a difficult task. In addition to the traditional methods of communication such as advertising, company website, sales promotion, direct marketing, personal selling proliferation and public relations, new forms of marketing medias such as mobile phones, newspapers, magazines, blogs, Internet, television and radio are currently on the spot. These new medias have made the coordination of the organisation's messages to customers difficult. Therefore, for organisations to attract more customers, marketers have to properly control the timing, creating appeals and placement of all the external communication vehicles (Zeithaml e al., 2006: 497).

? Internal marketing

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Internal marketing acknowledges the importance of employees in delivering services in organisations. By treating employees like internal customers, businesses can achieve high employee satisfaction and productivity. Satisfied workers are more likely to become more customer-conscious and deliver quality service to external customers (Lings & Greenley, 2009:44). Internal marketing not only regards employees as internal customers, it also encourages them to develop a positive behaviour towards services delivery. Additionally, internal marketing focuses on human resource management where the aim is to recruit, train, mobilise, support, motivate and manage all workers within an organisation. This vision can enable an organisation to improve the service strategy for outside customers and internal employees (Shiu & Yu, 2010:796).

? Interactive marketing

Interactive marketing refers to providing excellent services to customers and keeping

the promises made to them. Interactive marketing enables contacts between the
service provider and the service user. It gives the opportunity topeople and companies to interact directly, irrespective of time and distance (Kasper et al., 2006:79). Interactive marketing communication is that area of marketing which involves a change of an organisations' ideology where customers are perceived as partners. It is a strategy that allows customer to provide immediate feedback by means of various forms of communication such as audio, video text, interactive television and virtual reality (Vlasic & Kesic, 2007:111).

Service quality is an important indicator of effectiveness of both employees and organisations in keeping their customers satisfied (Siddiqui & Sharma, 2010:222). It is fundamental to all three legs discussed, since quality results in increasing satisfaction and performance of all parties involved in services. Service quality is an integral component of both internal and external customers on their evaluation of a service. It is an essential aspect to ensure customer satisfaction (Jun & Cai, 2010: 2006). The concept of service quality will be discussed more comprehensively next.

3.5 SERVICE QUALITY

Service quality is often described as the consumers' perceptions of the service received. It is a subjective impression of the relative inferiority or superiority of a service provider

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and its services. Service quality is usually considered comparable to the consumer's attitude with regard to the organisation (Siddiqui & Sharma, 2010:222).

3.5.1 Defining service quality

Achieving customer satisfaction has become a major concern in most service organisations through proving service quality (Irani, 2008:33). A customer's satisfaction level is influenced by his experience with services provided and by comparing that experience with the type of service which was expected. Studies revealed that service quality and customer satisfaction are two major constituents of customers acquisition and retention (Hossain & Leo, 2009:338).

Experts believe that successful organisations are those which remain in the mind of their customers. This can be achievable if they provide excellent services. Thus service quality has become an essential tool to assess organisational performance and to promote customer satisfaction (Rezaei et al., 2011:483).

Various definitions of services quality are presented in Table 3.2:

Table 3.2: Definition of service quality

Definition	References		Descriptions	A
Rezaei et al. (2011:485)	Service quality is the delivery of excellent or superior services relative to customer expectations. There is a positive correlation between service quality and customer satisfaction. As a result, superior service often leads to increase in customer satisfaction.		B
Mohammad and Alhamadani (2011:61)	Service quality is perceived as an intangible economic activity that provides psychological benefits to the customer. It's a type of service provided which meets the external customer's needs.		C
Siddiqui and Sharma	Service quality refers to the

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	(2010:222)		service user's assessment of the service he or she has received. It is a relative evaluation of the superiority or inferiority of a service provider and its services, and it determines the customer's overall attitude towards the organisation.	D
Kasper et al. (2006:178)	Service quality refers to the extent to which the service product successfully serves the purpose of the user during the usage. This implies that happy customers are more likely to repeat purchases and remain loyal to the firm.

From the definitions provided in Table 3.2, service quality can be viewed as an evaluation of how well a delivered service matches the customer's expectations.

3.5.2 Generic elements of service quality

From the definitions provided in Table 3.2, some generic elements of services marketing will now be discussed.

? Service quality as a transcendent-based quality

According to this approach, service quality is often described based on individual rather than shared experience. This is often perceived as epiphenomenon, where a person can understand what something is, but is not able to describe it. He or she usually makes use of comparison or reference to something (a comparator) (Benlian, Koufaris & Hess, 2012: 88). For instance, a person may say that the service experience of MTN is better than the Vodacom one without being able to tell why. This approach shows that service quality cannot be described accurately, but only through comparison of one service experience to another. It is then referred to as transcendent (Kasper et al., 2006:178).

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? Service quality is user-based quality

This element highlights the degree to which services successfully fit the customer's purpose during usage. From this point of view, service quality is simply determined by the service user and is very subjective, since every customer has a different approach to quality (Bogomolova, 2011:793). The problem is that this approach emphasises merely on perceived quality that is not a very reliable indicator of the actual service quality. This can be costly for an organisation that wants to please all its customers, but at the same time cannot provide different types of services in response to different types of customer services quality requirements. To resolve this problem, service organisations can provide customised services to their customers. Customisations can be used to ensure individualised service quality and can be a low cost strategy for an organisation. An example of customisation is the Inter-continental five star hotel which has a large range of guest rooms and services customised according to each different class of clients (Grönroos, 2007:73).

? Service quality is value-based approach

In this approach, quality exceeds users' expectations of service. This simply means that the value-based view regards service quality as a function of customer benefit relative to cost (Rust & Huang, 2012:47). In other words, this approach evaluates service quality as the difference between customers' expenses to acquire the service and the actual satisfaction he or she receives from it. The perceived value of service quality can result from a complex evaluation of both the service and service user's attributes. In this regard service quality can sometimes become ambiguous. In airline travel, all passengers are heading to the same destination at the same time, but the service cost will differ according to the different class of travel. Or, in various states, a customer`s bank charges will be higher if he is served by a bank employee rather than if he uses the Internet or an ATM machine (Kasper et al., 2006:178).

3.5.3 The importance of service quality

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Service quality is fundamental for organisational success and survival. It is vital in most service organisations. Fostering service quality is a way services organisations can distinguish themselves from competitors and increase their market share. Researches demonstrated that offering service quality can retain customers as well as attracting new ones. The cost of marketing to old customers is significantly reduced compared to if organisations had to market to new customers. Once customers become familiar with the organisation, they develop trust and their level of risk is significantly diminished. This implies that they are more likely to remain faithful to the organisation (Hoffman et al., 2009:400).

Providing quality goods has been a long-time ideology of the good manufacturing industry. It has led to increasing market share, customer satisfaction level and improving a firm's efficiency. The quality perspective in the good manufacturing firms focuses primarily on improving the quality of goods through eliminating defective products. This philosophy is enforced by careful monitoring and verification of all finished goods before they are delivered to the final consumer. The early development of the concept focuses on ensuring quality during the manufacturing procedure so as to limit the number of faulty products to zero. Recent developments regard quality as providing the right product to the right customer and at the right time, hence expanding quality beyond the good itself, and using internal as well as external assessments to evaluate the firm's overall quality (Golder, Mitra & Moorman, 2012:2).

Service organisations have a different quality system framework. Service quality relies on the customer`s involvement in the production and quality control process. Additionally, achieving service quality must be a daily continuous effort of all employees involved in the management and production of services (Hoffman et al., 2009:400).

3.5.4 The different elements of service quality

A major concern to assess service quality is to identify what elements customers utilise to evaluate quality. The SERVQUAL model was develop to provide a more comprehensive understanding of service quality. The model highlights five major attributes of service quality such as reliability, assurance, tangibility, empathy and responsiveness that have become dominant in service quality research (Kasper et al.,

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2006: 189).These dimensions have been successfully used to assess service quality not only in service industries, but in hospital settings as well (Yesilada & Direktor, 2010).

From the previous discussion, each element of service quality will now be reviewed:

? Reliability: This refers to the ability to provide the service correctly and dependably. In the hospital industry, it is the degree to which the consistency of service promises such as keeping appointment times, completing duties on time and respecting all promises made to patients are met (Basheer, Al-Alak & Alnaser, 2012:157).

? Assurance: This dimension encompasses competence, courtesy, credibility and security. This element involves training of employees to acquire knowledge of the service delivery process and customer relationship. This is a vital aspect to provide excellent services and the perception that the service provider is competent and not going to harm anyone. This can also build trust in the customer's mind (Meng, Summey, Herndon & Kwong, 2009:775).

? Tangibles: This refers to the tangible aspects of service such as the appearance of physical facilities, equipment and personnel. These elements have a significant influence on the perceived service quality. In hospitals for instance, cleanliness of premises, staff appearance, decor, computers and medical equipment can all have a positive or negative impact on the patient's perceptions of service quality (Kasper et al., 2006:189).

? Empathy: This element includes communication, access and understanding. It focuses on the communication aspect between the service provider and the recipient of service. In hospitals, empathy is reflected in the ability of medical personnel to care for their patients (Basheer et al., 2012:157).

? Responsiveness: This refers to the willingness to help customers. Service providers must be willing to respond to individual customer needs such as making sure that customers remain involved and detailing delivery times (Kasper et al., 2006:190).

3.5.5 Failure gaps in service quality

It is often difficult to investigate and apply service quality in organisations. Firstly, service quality perceptions rely on the repetitive comparison of the service user's expectations about a specific service. This means that if a service does not repetitively

match the user's expectations, it will be considered as poor, no matter how good the service is. Secondly, contrary to good products where users only assess the final good, service users assess both the process of the service and its effect. A person having a haircut will assess quality based not only on his perceptions of the hairstyle, but also on whether the hairdresser is welcoming and skilled. Studies revealed that service quality is evaluated from gaps between expectations and perceptions on the side of management, employees and service encounters (Hoffman et al., 2009:403).

The following figure provides an overview of the different gaps that may exist in service quality.

Figure 3.2: Service quality gap model

Source: Rajasekhar, Muninarayanappa and Reddy (2009: 220)

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? Gap 1

It refers to the difference between the customer expectations of service and the management perceptions of the consumer expectations. Often, managers think they know what their customers want, while in fact they are just speculating. In the medical industry, this may lead to the wrong services being offered to patients and dissatisfaction of patients with the service provided. Therefore, minutely detailed knowledge of what patients' needs are will be a prerequisite to close this gap (Holder, 2008:46).

? Gap 2

It is the difference between management's perception of customer expectations and the current standards set for service delivery. To close this gap, when setting standards in the hospitals for instance, managers should identify all key aspects of interactions between employees and patients. Detail standards can be written such as the way employees should operate and behave at each level of the hospital (Hoffman et al., 2009:404).

? Gap 3

It consists of the difference between the current performance of a service and the standard set by the organisation's management. In the medical industry, this gap results from the willingness of medical staff to offer the service according to specifications. The questions can be asked if medical staff wear their uniform before performing the service, and if they thank the patient when the service is completed (Zeithaml et al., 2006:38).

? Gap 4

It is the difference between the promised service of the organisation through its external communication channel and the service that is actually delivered to customers. If an organisation advertises a particular service to customers and that customer receives a different type of service, then the communication gap will widen. To close this gap, managers should work with all departments to make sure that promises made on the advertisements are fulfilled (Kasper et al., 2006:195).

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? Gap 5

It refers to the difference between what service users expect from a service and the actual perceived service. Customers' expectation is a subjective evaluation of a service. Patients often have different expectations, therefore they make different assessments of the service provided, which can lead to dissatisfaction (Holder, 2008:45).

Service quality is fundamental to every organisation. Organisations that offer better service quality increase demand by increasing customer acquisition, customer retention, and consumer loyalty (Liu & Homburg, 2007). There has been a positive correlation between the service quality provided in organisations and customer satisfaction. This assumption suggests a close relationship between service quality and customer satisfaction (Rust & Huang, 2012:49).The concept of service quality will be discussed more comprehensively next.

3.6 CUSTOMER SATISFACTION

Customer satisfaction is perceived to have an impact on the choices and purchasing behaviour of consumers. Satisfied customers are more likely to increase spending compared to those who are dissatisfied with the service provided. Consequently, satisfied customers can significantly increase an organisation's profit. Evaluating customer satisfaction has become a central philosophy among most organisations (Fornell et al., 2010:29).

3.6.1 Defining customer satisfaction

Customer satisfaction has become a major concern and focus in marketing. Research has shown that satisfaction surveys have been widely used in various organisations to evaluate service quality. Customer satisfaction has an effect on the profitability of nearly every organisation. When customers are satisfied with services, they will more likely tell other individuals. However, a lack of customer satisfaction has a negative effect on the bottom line. Customer satisfaction is an asset that should be monitored and managed just like any physical asset (Bodet & Assolant, 2011:783). Most experts believe that the surest way to success is to make customer happy. Improving satisfaction will result in increased customer loyalty and the financial benefits typically associated with more loyal customers (Forrest et al., 2011: 199).

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For service organisations, customer satisfaction assessment has become a major tool to measure organisational performance (Rezaei et al., 2011:483).

Various definitions of customer satisfaction are presented in Table 3.3.

Table 3.3: Definition of customer satisfaction

Definition	References		Descriptions	A
Hill, Roche and Allen (2012:18)	Customer satisfaction is the discrepancy between customer expectations and perceptions of the current service provided.		B
Grigoroudis and Siskos (2012:1)	Satisfaction is regarded as a customer's feeling that he or she is being well treated.		C
Hoffman et al.(2009:369)	Satisfaction is a function of expectations that the customer believes he should receive. Dissatisfaction occurs when the actual outcome is different from the standard expectation.		D
Olusoji (2009:12)	Satisfaction refers to the consumer's fulfilment response. It is the subjective evaluation that a service offers a pleasurable degree of consumption-related fulfilment.

3.6.2 Satisfaction with care between doctors and nurses

In health care settings, research has indicated that patients tend to be more satisfied with nurses care compared to doctors. However, this does not mean that patients

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preferred. Patient preferences between doctors and nurses may relate to various aspects determining satisfaction with doctors' services and nurses' services. In general, patient satisfaction may arise from the reliability and responsiveness of doctors in terms of the technical or medical aspect of care compared to nurses. Such aspects may include medical treatment, discussing physical complaints, information about the sicknesses and diagnosis (Laurant et al., 2008:2695). However, patient preference for nursing practitioners often relates to the assurance and empathy of nurses in terms of the amount of attention provided to patients, reassurance, and information about dealing with the disease (Zhang, Liu & Ren, 2013:219).

3.6.3 The generic elements to customer satisfaction

From the definitions provided in Table 3.3, some generic elements of services marketing will be discussed next.

? Customer satisfaction seen as an expectancy disconfirmation model

Customers use the disconfirmation paradigm to compare their expectations with their perceptions of service. However, if their expectations coincide with their perceptions, it is said to be confirmed expectations, thus leading to customer satisfaction. If customer expectations differ from perceptions of services, then it is said to be disconfirmed expectations (Cockalo, Djordjevic & Sajfert, 2011:807). There are two categories of disconfirmations: positive and negative disconfirmation (Hoffman et al., 2009:369).

? Customer satisfaction as a negative disconfirmation

Negative disconfirmation occurs when the customer perception is lower than what was expected. In that case, it will lead to customer dissatisfaction with the service provided. This may lead to bad word-of-mouth publicity and a decrease in customer loyalty to the organisation (Orsingher, Marzocchi, & Valentini, 2011:731).

? Customer satisfaction as a positive disconfirmation

A positive disconfirmation occurs when the customers' perceptions go beyond their expectations of services provided. This results in customer satisfaction. Customers are

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more likely to refer the organisation to other individuals and more willing to repeat purchases (Hoffman et al., 2009:369).

3.6.4 Types of customer expectations and the zone of tolerance

Expectations are seen as optimum levels against which present and future service encounters are compared. Expectations of service are often different from present service experience. Research has suggested at least three different categories of expectations such as predicted service, desired service and adequate service (Pradhan & Roy, 2011:79).

Predicted service is a probability expectation which relates to the level of service that service users believe is most likely to encounter. Hospital patients tend to return to the same medical facility over time. Patients become used to dealing with the same medical personnel and, over time, begin to predict certain performance levels. As a result, patient satisfaction evaluations increase by comparing predicted service to perceived service experienced (Grobbelaar, 2006:8). Desired service is an ideal expectation which refers to what service users actually desire, compared with predicted service, which is likely to happen. However, in most cases, desired service leads to higher expectation than predicted service. For instance, a patient desired service would comprise that he receives not only his predicted service, but that the medical staff call him by his first name and warmly greet him as he walks into the medical facility (Hoffman et al., 2009:388).

Adequate service is a minimum tolerable expectation and refers to the level of service a service user is prepared to accept. This type of expectation relies on experiences or norms which develop over time. Most people have received medical services from various different hospitals. Through these experiences, norms develop that patients expect to exist. Therefore, medical services which fall below expected norms will fall below adequate service expectations (Grobbelaar, 2006:8).

Services are known to be heterogeneous, and as a result will differ across employees and service organisations. The degree to which customers are willing to accept these differences is called zone of tolerance, which is the difference between desired service

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and adequate service. The zone of tolerance increases and decreases among customers depending on service quality, price and the conditions in which the service is provided. If service provided expands outside the zone of tolerance (at the desired service), then customers are more likely to be happy with the service. On the other hand, if service goes below adequate service, then customers will more likely be dissatisfied with service (Ince & Bowen, 2011:1772).

3.6.5 Factors influencing service expectations

Satisfaction relates to the post-decision assessment of a service. Such assessments lead to repeated choice and thus impact on an organisation's long-term profitability. Satisfaction is closely connected to expectations. Expectations refer to predictions of the future, an emphasis of which can range from broad beliefs to particular product specifications. In other words, expectations refer to the customers' predictions about how they will be able to match their choices when exposed to a different set of choices. A discussion of the factors influencing service expectations are presented below (Diehl & Poynor, 2010: 313).

3.6.5.1 Desired and predicted service

Desired service expectations are built around six major factors influencing service expectations such as personal aspects, customers' personal needs, explicit service promises, word-of-mouth communications and past experience. Personal aspects develop over time and enhance a customer's sensitivity regarding how service should be offered (Tsai, Hsu & Lin, 2011:217). This factor comprises two categories; the customer's derived expectations and personal views of services (Haseki, 2013: 42-43). Derived expectations are obtained from the expectations of other individuals. For example, if your manager requests you to hire someone to perform a specific task in an organisation, your expectations of the one performing the task will most likely be higher compared to if the person was hired on your own initiative. In order to please your manager, your sensitivity to quality service is high. Also, personal views of services refer to customers' sensitivity regarding the way in which services should be provided. This implies that customers often desire to be treated in the way they believe they treat their customers (Heitzler, Asbury & Kusner, 2008:188).Customers' personal needs imply that some customers are more demanding than others in terms of service quality.

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For example, some patients may be interested in both acquiring excellent medical services and the quality of the tangible aspects of services such as staff uniforms, medical equipment and toilets. Other individuals may simply be looking for a proper medical service delivery. Thus, managing a service organisation can become quite complex (Mitra & Fay, 2010).

Explicit service promises include the organisation's advertising, personal selling and other forms of communication. In this aspect, customers assess service based on several sources of communication available. Often, the more ambiguous the service, the more customers rely on the organisation's advertising when shaping expectations (Chebat, Sirgy & Grzeskowiak, 2010). If an organisation promotes clean and attracting rooms, customers will expect the rooms to be exactly as advertised. Implicit service promises encompass the tangibles surrounding the service and the price of the service. If the service price rises, customers will expect higher quality service in return. Similarly, if tangibles surrounding a service are lush, then customers will see it as a sign of quality (Hoffman et al., 2009:391).

Word-of-mouth communications are usually entrusted by customers as they believe in information from people who have been through the service experience (Berndt & Brink, 2008:56). This type of information can be provided by family and friends (Kaura & Datta, 2012:66). Past experience is an assessment of service based on a comparison of the actual service encounter, and other encounters with the same provider, other providers in the same industry, and other providers in other industries. Patients evaluate medical service based on their past experience in other hospitals with other medical facilities (Hoffman et al., 2009:391).

3.6.5.2 Adequate service

It refers to the level of service a customer is prepared to accept and is constituted of five factors namely transitory service intensifiers, perceived service alternatives, customer self-perceived service roles, situation factors and predicted service. Transitory service intensifiers are short-term factors which increase the customer sensitivity to service. Patients are usually prepared to wait for their turn to go to the doctor's office. However, in emergency situations they become less patient and expect to receive superior service

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in a short period of time. As a result, their level of adequate service rises, and the zone of tolerance narrows (Hill et al., 2012:17).

The level of adequate service can also be influenced by customers' perception of service alternatives. Customers who think that they can receive similar services elsewhere and / or that they can supply the service themselves, have higher expectations of adequate service compared to those who think they cannot obtain similar service elsewhere (Babin & James, 2010). In a self-perceived service role, customers are often seen as part of the service delivery process. As a result, they can influence the outcome of the service. However, when their self-perceived role in service is high or when they believe their role in the service delivery process is important, their expectations of adequate levels of service rise considerably and the zone of tolerance decreases (Siu, Zhang & Yau, 2013:675-676).

In situational factors beyond the control of the service provider, such as if electricity goes out in a restaurant, customers understand that the problem is beyond the control of the restaurant owner, therefore they are likely to be more tolerant. Then, adequate service expectations decrease and the zone of tolerance will increase (Berndt & Brink, 2008:57-58). Predicted service is the level of service that customers predict to receive. It is the last aspect influencing adequate service. It refers to all service promises that organisations make to customers ranging from word-of-mouth communication to advertisements. Taking these aspects into account, customers make judgments according to predicted services and set adequate service expectations accordingly (Berndt & Brink, 2008:56).

3.6.6 The link between expectations, customer satisfaction and service quality

When assessing service experience, customers always make a comparison between three categories of expectations such as predicted service, adequate service and desired service to the perceived service provided. Customer satisfaction is evaluated by comparing predicted service and perceived service. Perceived service adequacy that complies with adequate service and perceived service, and perceived service superiority, that desired service and perceived service, are measures of service quality (Hill et al., 2012:18). Kasper et al. (2006:105) argued that expectations are a major determinant of satisfaction, and expectations may be influenced by various factors such

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as cultural, race, gender, education, socioeconomic, geographical, education and age differences. Younger patients are more demanding with regard to service quality provided in hospital settings compared to older patients. Additionally, Olusoji (2009:23) viewed that patients with higher educational level, were more informed with regard to medical service quality and therefore were prone to expect better care compared to those with low educational background.

There is other evidence that expectations may differ according to knowledge and prior experience. This means that expectations are likely to change with accumulating experience (Pradhan & Roy, 2011:79). Zeithaml and Bitner (2007:60), for instance, observed that enhancing quality of medical services raises expectations. From this observation, an increased level of expectations of quality among patients may gradually be associated with a low level of satisfaction.

Other writers such as Youl Ha (2006:137) suggested customer satisfaction as being central to an organisation's profit, and that satisfaction is linked to a customer's perception of service provided and the extent to which these services match the customer's expectations.

Bick, Abratt and Möller (2010:14) noted that there is a direct relationship between customers' expectations, service quality, satisfaction and increase of purchase. Raboka (2006:128) suggested that services that match or go above customers' expectations will result in customer satisfaction, and services that go below customers' expectations will lead to customers' dissatisfaction with services provided. Furthermore, satisfied customers are more likely to remain loyal to the organisation and increase purchase. Youl Ha (2006: 137) observed that customers' choice of services provided can be a complicated mental process and may differ from one period to another. As a result, organisations should continuously measure customers' perceptions of services if they strive to remain competitive.

3.7 CONCLUSION

In this chapter the focus was on the concepts of services marketing, service quality and customer satisfaction in perspective. The definitions, generic elements and importance of services marketing, service quality and customer satisfaction have been highlighted. Additionally, a discussion on the relationship between expectations, customer

satisfaction and service quality has been included in the chapter. Recent studies suggested that organisations have shown major concerns about services marketing, quality and satisfaction. It is evident that improving marketing of services and quality in an organisation may possibly increase the levels of customer loyalty, profits and market share (Olusoji, 2009:7).

Chapter 4 will focus on the methodology used to conduct the survey. A comprehensive focus will be provided on the scope of the study, the sampling method, organisation of the survey, validity and reliability of the questionnaire, the data gathering technique, data analyses, as well as the reliability of the results.

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CHAPTER FOUR: RESEARCH METHODOLOGY

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4.1 INTRODUCTION

Any business hoping to attract more customers and to keep them happy must focus on service quality. Service quality can be used as a strategy to attract consumers if companies can understand their behaviour. This understanding is made possible through intensive research (Rezaei et al., 2011:483). Research problems involve proper planning to find solutions. Research involves efficient gathering, evaluation and explanation of information for decision-making. This can be done through scientifically accepted methods. Since research is perceived to be time consuming, researchers must be methodical when collecting data that they must evaluate for the research at hand. The analysis and explanation of data depend on the researcher's own experience and his understanding of the subject of interest (Naidoo, 2008:73).

This chapter offers a theoretical illustration of the research process. It emphasises on the population, the chosen sample, the questionnaire design, the method of data gathering, as well as data analysis. The framework of the research is based on the different stages in the research process as illustrated in Figure 4.1.

4.2 THE RESEARCH PROCESS

A proper recognised research process often involves the different stages as illustrated in Figure 4.1. However, it is vital to know the interdependency of each stage involved in the process. This enables better understanding of the various stages in the research process as discussed next.

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Figure 4.1: Stages in the research process

Source: Cant, Gerber-Nel and Kotze (2005:39)

4.2.1 Step 1: Identify and formulate the problem or opportunity

The first stage while conducting research is to identify and formulate the problem (Malhotra, 2007:10). The problem statement of this research was conducted in Chapter One, section 1.3, and is repeated for ease of reference.

The government of Gabon has improved the health care system in the country through the provision of health care infrastructures, and by increasing the number of government hospitals in the country in order to allow more patients to have access to medical care services. However, there seems to have been a shift of patients from government health care hospitals to the newly established military hospital. The new facility has attracted a large number of patients from various parts of the country. There is no clear understanding of why patients have shifted towards the military hospital.

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During a telephone interview conducted on 6 March 2012, a medical personnel at the military hospital stated that patients seem to have been dissatisfied with services provided in the government hospitals. Moreover, the link between services delivery at the military hospital in Gabon and patient satisfaction has not been yet investigated before. Hence, these two features need to be investigated as the study could offer a way to promoting effectiveness and profitability in medical institutions.