Background to the study
Patient loyalty is when individuals consistently choose a particular hospital, speak positively about it, and refer others to it because they are satisfied with the service. This loyalty is crucial because it leads to ongoing patronage, high ratings, positive reviews, and favorable word-of-mouth promotion for the hospital and its services.
Experiences patients have with the hospital, whether positive or negative are what strengthen patient loyalty. A patient's ultimate behavior stage is loyalty; if they are loyal, they won't switch to other services. It's frequently more difficult to keep existing consumers in an industrial business setting than it is to draw in new ones. The cost of acquiring new patient is significantly higher compared to the costs associated with maintaining existing ones (Hadi et al., 2019). Patient loyalty to service is very difficult to be shifted as long as such service remains superior to others. Only services offering the same satisfaction with less expense can take the position (Elizar et al., 2020).
Studies has shown that delivering quality service has a significant relationship with patient satisfaction, retention, loyalty, costs, profitability, service guarantees and the financial performance of the service businesses (Al-Damen, 2017; Alshrbaji et al., 2022; Asnawi et al., 2019; Emon et al., 2023). This forces businesses to develop a better understanding of what service quality means to patient and how it could best be measured (Al-Damen, 2017). Unlike products, where quality can be easily assessed, service quality is an elusive and abstract concept that is difficult to define and measure.
According to (Koce et al., 2020) major factor leading patients to bypass primary healthcare facilities and refer themselves directly to secondary and tertiary care is the scarcity of healthcare providers at local facilities in Nigeria. Inadequate access to essential equipment, uneven distribution of resources, and inconsistent operating hours at primary healthcare facilities are also seen as influential factors contributing to this trend. Also, according to (Nwokoro et al., 2022) primary health care services utilization among adults is low at 46.2%. The study also reported that the low utilization of primary health care services may be an indicator of the low confidence that the people have in the services offered at the primary health care level in Nigeria, thus making them seek primary care at higher level hospitals or other places. Another study conducted in Nigeria by (Adepoju & Oladimeji, 2023) reported that majority of households in Nigeria preferring to utilize patent medicine vendors or pharmacies other than primary health care facilities as the first line of therapy. The preference for patent medicine stores as the first choice when seeking health care services has been suggested to be an indicator that the people utilize health services for curative as opposed to preventive purposes.
Primary health care is the backbone of strong health systems worldwide. It is about giving people basic, affordable health services like promoting good health habits, caring for mothers and children, giving vaccines, and treating common illnesses at every stage of life. Primary health care service is becoming more crucial as more people deal with long-term health issues (Hanson et al., 2022). Patient satisfaction is believed to be an important indicator of healthcare quality. Many health organizations including primary health centers are searching for ways to change the delivery of patients care through improved quality initiatives (Santarsiero et al., 2023). It is without any doubt to say that there is very poor research done in order to find the service sector quality levels with regard to primary healthcare in Nigeria. This fact is the main reason for undertaking this research in order to render social service for Nigerians. The public and private healthcare service is very poor in terms of quality service and patient satisfaction and loyalty. For which reason, primary healthcare centres need to have deep research and knowledge on service quality and know the delivering high level of service quality is the only one mystery that can lead to patient loyalty and satisfaction (Mehmood et al., 2022).
Many authors in the literature believe that patient loyalty, patient satisfaction, and service quality are closely related to one another and essential to an organization's success. In Nigeria, there is a lack of sufficient emphasis on linking service quality at primary healthcare centers to patient loyalty, with satisfaction serving as the mediating factor. Due to restrictions on advertising via media platforms, primary health centers cannot promote themselves as providing exceptional service, making word-of-mouth recommendations the primary means of spreading awareness. This study aims to address this gap by exploring the relationship between service quality, patient satisfaction, and loyalty.
Statement of the problem
Numerous nations are making concerted efforts to align with the demands of healthcare delivery, recognizing that the endurance and prosperity of a nation's economic and societal advancement hinge on the robustness of its healthcare sector. Poor healthcare can have a significant impact on the economic and social expectations of a nation's citizens (Oleribe et al., 2019), they also pointed that some of the problems of the Nigerian health sector includes inadequate budgetary allocation, inadequate human resources for health, ineffective leadership and management, poor data quality, lack of political will, limited access to healthcare, inadequate healthcare infrastructure, weak healthcare systems, and professional rivalry. Oleribe et al., (2019) also stated that the Nigerian health system is facing numerous problems such as inadequate funding, a shortage of healthcare professionals, poor infrastructure, low health literacy, and a lack of access to quality healthcare services. According Adejoro, (2023) the poor healthcare delivery in Nigeria is associated with poor regulation; the findings also stated that lack of regulation is stalling the growth of the healthcare system in the country.
The quality of primary health center services has consistently maintained a keen focus among researchers and institutions. For instance, (Kress et al., 2016) found that lack of infrastructure; drugs, equipment, and finance are major challenges of primary healthcare service in Nigeria. Similarly, (Rahimi & Haghdoost, 2022) identified governance, manpower, resources, financial management, services delivery and social and cultural as the challenges of primary healthcare system. The dire condition of primary healthcare in Nigeria is widely acknowledged, years of disregard by governmental authorities, at both the state and local levels, who bear the responsibility for delivering primary healthcare services, have led to ineffective and substandard service provision throughout the nation. This inefficacy exacts a daily toll on vulnerable individuals, including pregnant women and children (Abubakar, 2022). This research tries to fill the gap by empirically investigating the effect of service quality on patient satisfaction and loyalty in primary health centres, from the point of view of patients, because of the limited literatures in Nigerian context (Agwu, 2020). Most of the available literatures on this topic focus on general healthcare settings, including teaching hospitals and general hospitals. Such as the study of (Ibrahim et al., 2015; Potluri et al., 2018; Umoke et al., 2020; Almomani et al., 2020).
Many studies have been conducted in order to identify service quality dimensions affecting different types of services sectors. The study of (Darmawan et al., 2017; Kasiri et al., 2017; Saneva & Chortoseva, 2020; Supriyanto et al., 2021) has identified that service quality has a significant impact on customer satisfaction. Similarly, the work of (Jamal Ali et al., 2018; Setiono & Hidayat, 2022; Waluyo & Waluyo, 2020) revealed that empathy, responsiveness, assurance, and tangibility have a positive relationship with customer satisfaction. However, the findings of (Mahmud, 2022) stated that tangibility and reliability have a positive but insignificant effect on customer’s perception of service quality and customer satisfaction, while empathy and responsiveness significantly affect customer's perception of service quality and patient customer.
The main reason for this study is how service quality dimensions affect patient’s satisfaction and patient loyalty in primary health centers. When considering sensitive services like health sector, service quality plays a crucial role.
Some of the findings reveal a significant relationship between service quality, patient satisfaction and patient loyalty. Some researches signify no relationship between service quality and patient loyalty but patient satisfaction mediates the relationship between service quality and patient loyalty. So also, some studies signify that patient satisfaction does not influence patient loyalty. Also, some studies indicate service perception is lower than service expectation. Most of the studies indicated among all the service quality dimension assurance has the highest significant level followed by reliability and tangibility. Also, some studies indicate service quality has a significant and an insignificant relationship with patient loyalty, but those that are insignificant found that assurance is significant and positively related to patient loyalty and that all other dimensions are insignificant.
Most of the research gaps found include the use of small sample size, such as (Febres-Ramos & Mercado-Rey, 2020; Meesala & Paul, 2018). So also the work of (Nwokoro et al., 2022) focuses on respondents' memory, potentially introducing recall bias, and the possibility of social desirability bias in reporting satisfaction with services, while this research work will focus on patients recently treated in primary health centers rather than relying on respondents' memories, addressing limitations like recall bias.
Moreover, The study of (Meesala & Paul, 2018) did not utilize the SERVQUAL dimensions. Therefore, this research aims to employ service quality dimensions to gauge patient satisfaction, addressing a gap in existing literature.
Research questions
The following are eleven research questions established for the purpose of this study;
To what extent does tangibility affect patient satisfaction at Sheka PHC?
To what extent does reliability affect patient satisfaction at Sheka PHC?
To what extent does responsiveness affect patient satisfaction at Sheka PHC?
To what extent does assurance affect patient satisfaction at Sheka PHC?
To what extent does empathy affect patient satisfaction at Sheka PHC?
To what extent does patient satisfaction mediate the relationship between tangibility and patient loyalty at Sheka PHC?
To what extent does patient satisfaction mediate the relationship between reliability and patient loyalty at Sheka PHC?
To what extent does patient satisfaction mediate the relationship between responsiveness and patient loyalty at Sheka PHC?
To what extent does patient satisfaction mediate the relationship between assurance and patient loyalty at Sheka PHC?
To what extent does patient satisfaction mediate the relationship between empathy and patient loyalty at Sheka PHC?
To what extent does patient satisfaction affect patient loyalty at AKTH?
Research objectives
The main objective is to find the perceived service quality of the patience in Sheka PHC and patient loyalty with a mediating variable of patient satisfaction. It attempts to find out the extent at which service quality delivery affects patient loyalty among primary healthcare centres in Kano state. Specifically, the research seeks to;
Examine the effects of tangibility on patient satisfaction at Sheka PHC
Determine the effects of reliability on patient satisfaction at Sheka PHC
Examine the effects of responsiveness on patient satisfaction at Sheka PHC
Examine the effects of assurance on patient satisfaction at Sheka PHC
Examine the effects of empathy on patient satisfaction at Sheka PHC
Determine the mediating effects of patient satisfaction on the relationship between tangibility on patient loyalty at Sheka PHC
Determine the mediating effects of patient satisfaction on the relationship between reliability on patient loyalty at Sheka PHC
Examine the mediating effects of patient satisfaction on the relationship between responsiveness on patient loyalty at Sheka PHC
Determine the mediating effects of patient satisfaction on the relationship between assurance on patient loyalty at Sheka PHC
Determine the mediating effects of patient satisfaction on the relationship between empathy on patient loyalty at Sheka PHC
Determine the mediating effects of patient satisfaction on the relationship between patient satisfaction on patient loyalty at Sheka PHC
Statement of the hypotheses of the study
The followings are eleven Null hypotheses established for the purpose of this study;
H01 Tangibility does not significantly affect patient satisfaction at Sheka PHC
H02 Reliability does not significantly affect patient satisfaction at Sheka PHC
H03 Responsiveness does not significantly affect patient satisfaction at Sheka PHC
H04 Assurance does not significantly affect patient satisfaction at Sheka PHC
H05 Empathy does not significantly affect patient satisfaction at Sheka PHC
H06 Patient satisfaction does not significantly mediate the relationship between tangibility and patient loyalty at Sheka PHC
H07 Patient satisfaction does not significantly mediate the relationship between reliability and patient loyalty at Sheka PHC
H08 Patient satisfaction does not significantly mediate the relationship between responsiveness and patient loyalty at Sheka PHC
H09 Patient satisfaction does not significantly mediate the relationship between assurance and patient loyalty at Sheka PHC
H010 Patient satisfaction does not significantly mediate the relationship between empathy and patient loyalty at Sheka PHC
H011 Patient satisfaction does not significantly affect patient loyalty at Sheka PHC
Significant of the study
This research investigates the impact of service quality on patient satisfaction and loyalty within Sheka Primary Healthcare Center, aiming to assess the quality of services offered to patients. Previous research has predominantly explored service quality, patient satisfaction, and loyalty within secondary healthcare hospitals, often drawing data from foreign contexts like Asia and Europe. Few studies exists using data from Nigeria to explore these relationships, particularly within primary health centers, which are presumed to be at an early developmental stage. This makes this study significant and its findings very useful.
This research work shall provide both theory development for academics and practical implication for marketing management in healthcare services. The result is expected to inform the healthcare sector about patient response to the variety of services rendered by the hospital. This shall further help marketers to understand the effectiveness of each marketing strategy from the consumer’s perspective. In the same vain, the outcome can be used by the relevant agencies that regulate the healthcare sector like federal, state and local government health ministries and departments in order to ensure users (consumers) right are protected and served better.
Scope of the study
This study was limited to service quality and patient loyalty via patient satisfaction at Sheka PHC (Outpatient department). The scope shall be limited to the following: Outpatient department (OPD) the unit provides outpatient consultation and management to clients. OPD is the first point of call to patient when they come for treatment before they are referred to various units for special care. Casualty: the service is available 24hours, including weekends. Antenatal and delivery services are also provided to the patient at the centre.
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