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International Journal of Health Care Quality Assurance Patients' satisfaction of service quality in Saudi hospitals: a SERVQUAL analysis Hussein M. Al‐Borie, Amal M. Sheikh Damanhouri,

Article information: To cite this document: Hussein M. Al‐Borie, Amal M. Sheikh Damanhouri, (2013) "Patients' satisfaction of service quality in Saudi hospitals: a SERVQUAL analysis", International Journal of Health Care Quality Assurance, Vol. 26 Issue: 1, pp.20-30, https://doi.org/10.1108/09526861311288613 Permanent link to this document: https://doi.org/10.1108/09526861311288613

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Users who downloaded this article also downloaded: (2010),"Private healthcare quality: applying a SERVQUAL model", International Journal of Health Care Quality Assurance, Vol. 23 Iss 7 pp. 658-673 <a href="https://doi.org/10.1108/09526861011071580">https:// doi.org/10.1108/09526861011071580</a> (2009),"Factors affecting patient satisfaction and healthcare quality", International Journal of Health Care Quality Assurance, Vol. 22 Iss 4 pp. 366-381 <a href="https:// doi.org/10.1108/09526860910964834">https://doi.org/10.1108/09526860910964834</a>

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https://doi.org/10.1108/09526861311288613

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Patients’ satisfaction of service quality in Saudi hospitals: a SERVQUAL analysis

Hussein M. Al-Borie The Research and Consultancy Institute, Jeddah, Saudi Arabia and

Department of Health Services and Hospital Administration, King Abdulaziz University, Jeddah, Saudi Arabia, and

Amal M. Sheikh Damanhouri Department of Business Administration, King Abdulaziz University,

Jeddah, Saudi Arabia

Abstract

Purpose – Saudi Arabian hospital performance, vis-à-vis patient satisfaction with service provision, has emerged as a key policy and planning concern. Keeping in view public and private hospital service quality, this article seeks to provide guidelines to the on-going Saudi Arabian health service reorganization, which emphasizes decentralization, bed-capacity expansion, research-based policymaking and initiatives in the health insurance sector.

Design/methodology/approach – The article outlines an empirical study that compares patient satisfaction with service quality in Saudi Arabian public and private sector hospitals. The authors employ a stratified random sample (1,000 inpatients) from five Saudi Arabian public and five private hospitals. Data were collected through questionnaire using the SERVQUAL scale. For reducing the language bias the questionnaire was translated into Arabic. The response rate was 74.9 percent. Data were analyzed using SPSS and appropriate descriptive and inferential statistical techniques.

Findings – Cronbach’s alpha for five service-quality dimensions (tangibles, reliability, responsiveness, safety and empathy) were high and the SERVQUAL instrument proved to be reliable, valid and appropriate. The results showed that sex, education, income and occupation were statistically significant in influencing inpatients’ satisfaction, and all the null hypotheses were rejected. Only inpatient age was not significant.

Practical implications – The study highlights service quality influence in the design of broader healthcare strategies for Saudi Arabian public and private hospitals. It demands that management researchers and analysts must identify regional service quality consistencies and related inpatient demographic indicators.

Originality/value – The study offers some insights into, and guidance for, hospital quality assurance in Saudi Arabia in general and the urban hospital setting in the Middle-East in particular.

Keywords Patient perception, Patient satisfaction, Service quality, SERVQUAL, Saudi Arabia, Hospitals, Organizational performance

Paper type Research paper

Introduction Providing high quality public or the private hospital services is quite demanding. Measuring patient satisfaction has been an even more challenging task for qualitative and quantitative researchers, government policymakers and planners, mainstream hospital managers and medical professionals. This challenge is derived from the

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IJHCQA 26,1

Received 25 August 2010 Revised 24 April 2011 Accepted 15 May 2011

International Journal of Health Care Quality Assurance Vol. 26 No. 1, 2013 pp. 20-30 q Emerald Group Publishing Limited 0952-6862 DOI 10.1108/09526861311288613

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concepts of satisfaction and quality that are virtually open-ended. Hence, the questions: what must satisfy a patient, and what brings quality in hospital care, are determined by patients’ deep-seated psyches and philosophical contestations on the one end to human needs theories and open-market economics on the other. We examine Saudi Arabian hospital service quality and outline several inpatient satisfaction and quality determinants. We focus on variability in satisfaction and quality with a view to the contextual variations in public and private hospitals and their implications for hospital planning and management.

Saudi Arabian hospital service concerns The Saudi Arabian hospital bed capacity in 2007 was 53,519; most – 31,420 (58.7 percent) under the Ministry of Health (MoH) control; 10,828 (20.2 percent) spread over the other government departments; and 11,271 (21.0 percent) in the private hospitals (MoH, 2007; Oxford Business Group, 2009). Saudi Arabia allocated 52.3 billion SAR ($14 Billion) to develop its healthcare industry, which is about 11 percent of its 2009 budget. Hence, future healthcare planning in Saudi Arabia must comply with the service quality demands (Mufti, 2000; Al-Shekh, 2003; Al-Doghaither et al., 2003; Al-Doghaither, 2004; Alsharqi, 2006; Oxford Business Group, 2009).

If public and private hospital services are compared then generalizations are apparent. For instance, the health insurance expansion will link public and the private sectors hospital service quality to patient satisfaction. Al-Shekh (2003) compares the factors that influence Riyadh patients’ hospital experiences and perceptions. He suggests that perceptions must influence service marketing; i.e. enumerating patient satisfaction vis-à-vis their demographic data. Alsharqi (2006, p. 285) considers open-market competition to be inevitable under the new Saudi health system as privatization is expected to induce competition and healthcare service quality is expected to improve with a fair competition between the two sectors. He also raises some concerns: Will patient satisfaction with the healthcare facilities improve? What quality improvements will take place and what will be their effect on patient satisfaction and will patient satisfaction with their health status improve?

Comparing public and private hospitals using SERVQUAL As an operational method, SERVQUAL takes up the challenge to comprehend and quantify several factors that determine patient satisfaction with hospital service quality. SERVQUAL is praised as a widely cited research instrument’ primarily in the marketing literature (Parasuraman et al, 1985), some theoretical and operational concerns and criticism were also raised (Buttle, 1996). However, a decade after SERVQUAL’s introduction, it was concluded that it “remains the most complete attempt to conceptualize and measure service quality” (Nyeck et al., 2002, p. 101). We refer to some country-specific studies that examine inpatient service quality in Arabian and the Eastern Mediterranean public and private hospitals, with a view that these serve useful contexts for our analysis. These cover Saudi Arabia (Al-Shekh, 2003; Al-Doghaither, 2004); Egypt (Mostafa, 2005); United Arab Emirates (Naceur and Chaker, 2003); Bahrain (Luke, 2008); Turkey (Taner and Antony, 2006) and Yemen (Anbori et al., 2010). We outline the broader conclusions these studies draw out:

. Private hospital inpatient care was more satisfactory than public hospitals. Results suggest that compared to public hospitals, private hospital inpatients

Patients’ satisfaction in

Saudi hospitals

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were more satisfied with physicians, nurses and support staff. Satisfaction with doctors and a reasonable service-cost were among the major determinants in public hospitals (Taner and Antony, 2006).

. Qualitative data should be used to interpret patient perception and satisfaction trends, in particular, why public hospitals had relatively higher patient dissatisfaction rates.

. Patients usually prefer private hospitals hoping for a higher service quality. In comparison, public hospital staff are pressurized by the government and general public to improve service quality for competing with the private sector.

. Sometimes the major question is how well public and private sector healthcare providers understand the patients’ profile.

. Public and private hospitals must organize training programs on the significance of service quality and the role that inpatient satisfaction plays in the healthcare industry.

. Quantitative methods are valuable for establishing relationships between variables but weak in identifying the reasons for such relationships. Patients may have complex beliefs that cannot be easily confined in a questionnaire. Therefore, mix-methods can enhance research study findings (Mostafa, 2005; Alsharqi, 2006).

. A service quality “process” model that caters for continuous monitoring and subsequent improvement in hospitals could prove to be effective (Luke, 2008).

Methodology and scope We considered a mixed-method approach to be suitable for our study. It followed descriptive and analytical methods for collection and analysis of the data. We targeted all inpatients of Arab nationalities in Saudi Arabian government hospitals. The large number of respondents and limited fieldwork resources forced us to use a stratified random sample. Saudi Arabia was divided into five geographical areas and one province was selected from each: Riyadh, Jeddah, Eastern Region, Tabuk and Najran. Finally, one government and one private hospital were selected from each province.

Study population The yearly average of inpatients in all hospitals across Saudi Arabia is 2,792,106 (MoH, 2007). Out of these, almost 59 percent are in the MoH hospitals, 18 percent in the hospital affiliated to other government departments, and 23 percent in private hospitals. Of five hospitals representing each category, 1,000 patients were randomly selected (100 per hospital) who were given questionnaires. We included patients admitted to hospitals from 16 May to 15 June, 2009. Efforts were made to represent the population:

. A rapport was established with hospitals managers and quality assurance department staff for them to distribute and collect questionnaires.

. Owing to the absence of other health service providers in Najran and Tabuk, one public and one private hospital each were selected in these areas as an exception. In the other regions; i.e. Jeddah, Riyadh and Eastern Province, one government and one private hospital were selected randomly.

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. Since MoH hospitals constitute most public hospitals, these were considered to represent all public hospitals.

Instruments Steps were taken to ensure our questionnaire’s suitability for meeting the study objectives and testing our hypotheses. SERVQUAL was employed to measure the gap between patient expectation and realization. This scale considers five service quality dimensions: tangibles; reliability; responsiveness; safety and empathy. Dimensions were scored using 27 statements. The questionnaire was translated into Arabic and was read by six Economics and Administration faculty members at the King Abdulaziz University; and modifications were made. The revised questionnaire had two sections: questions on hospital type, name and location; inpatient demographic profile, why he/she visited a particular hospital; visit frequency; and inpatient services-quality expectations prior to his/her visit; and actual service ratings during their stay. The difference between the two ratings was considered to be a quality indicator.

Data collection and analysis Locating 100 inpatients in each hospital was facilitated by the physicians. The researchers distributed and collected the completed questionnaires with the physician’s help. Data were entered and analyzed using SPSS v.17. The five quality dimensions (op cit) became independent variables.

Reliability The 27 statements making up the five dimensions were:

(1) tangibles (7);

(2) reliability (4);

(3) responsiveness (4);

(4) safety (4); and

(5) empathy (8).

These statements measured the gaps between service quality expectations and realizations. The scale’s reliability was tested using Cronbach’s Alpha (Table I).

Variants Realizations Expectations Statements Alpha Statements Alpha

Tangibles 7 0.906 7 0.906 Reliability 4 0.842 4 0.84 Responsiveness 4 0.908 4 0.923 Safety 4 0.919 4 0.929 Empathy 8 0.942 8 0.93 Total statements 27 0.968 27 0.969

Table I. Reliability dimensions –

Cronbach’s alpha

Patients’ satisfaction in

Saudi hospitals

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Results and discussion From 1,000 questionnaires distributed, 749 complete documents were analyzed (response rate ¼ 74.9 percent). Of the respondents, 61 percent were males and 33 percent (all respondents) were 30-39 years (Table II).

Service quality by hospital type Table III shows that general expectations towards service quality using the gap scale indicated negative results for all public (20.37) and private (20.23) hospitals, except the Riyadh private hospitals (þ0.16).

There was significant difference ( p , 0.05) in service quality according to hospital type. Private hospital service quality was higher than public hospital levels. The difference was minimal, the statistical significance and all actual performance averages in private hospitals were higher than public hospitals” (Table IV).

Service quality rankings differed between public and private hospitals (Table V), the best three dimensions in public hospitals were tangibles, empathy and safety. In

Gender Male Female Total

Age group n % n % n %

15-19 years 21 47.7 23 52.3 44 5.9 20-29 years 78 43.8 100 56.2 178 23.8 30-39 years 165 66.8 82 33.2 247 33 40-49 years 133 73.1 49 26.9 182 23.3 50-59 years 36 57.1 27 42.9 63 8.3 60 years and above 23 68.6 11 31.4 35 4.7 Total 457 61 292 39 749 100

Table II. Sample gender and age distribution

Expectations Realizations

Gaps between expectations

and realizations Hospital City n Mean SD Mean SD Mean SD

Public Tabuk 61 2.96 0.68 2.77 0.63 20.19 0.53 Najran 50 3.34 0.78 2.58 0.73 20.75 0.62 Riyadh 101 3.93 0.65 3.91 0.79 20.02 0.55 Jeddah 96 3.78 0.77 3.70 1.01 20.08 0.65 Dammam 92 3.97 0.59 2.98 1.03 20.99 1.05 Total 400 3.68 0.77 3.31 1.02 20.38 0.63

Private Tabuk 34 3.61 0.64 3.26 0.74 20.34 0.42 Najran 69 4.68 0.38 3.70 0.30 20.98 0.45 Riyadh 81 3.80 0.70 3.96 0.75 þ0.16 0.65 Jeddah 87 4.09 0.75 4.03 0.77 20.06 0.51 Dammam 78 3.66 0.59 3.57 0.81 20.09 0.70 Total 349 4.00 0.73 3.77 0.75 20.23 0.70

Total 749 3.83 0.77 3.52 0.93 0.31 0.77

Table III. Expectation and realization

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private hospitals they were safety, empathy and tangibles. Table V indicates that private hospital realization averages were higher than public hospitals. Moreover, the differences between expectations and realizations for all 27 statements were statistically significant.

The better dimensions of service quality in public hospital services were the tangibles. This dimension included staff appearance, followed by convenient and accessible location, modern equipment and technology. The better private hospital services were: convenient and easily accessible; and medical staff cordiality/friendliness. Employee humanitarian attitude, courtesy and communication skills when dealing with patients ranked last. The worst public-hospital services were medical specialization; dealing with hospitals; and employee cooperation with patients. The worst private services depended on individual interests of the inpatients. Hospital corridors, convenient elevators and a clean and comfortable dormitory followed next. On the whole, patients’ evaluations differed across the regions that the hospitals under study were located.

Hypotheses testing There were statistically significant differences between realizations and expectations for all five dimensions (Table VI):

(1) There were (negative) differences between realizations and expectations average for all seven statements in the first dimension; i.e. tangibles. Therefore, we rejected our first null hypothesis: there is no significant statistical difference between patient expectations and actual service level they get on the tangibles dimension.

(2) There were (negative) differences between realizations and expectations average for four statements in the second dimension; i.e. “reliability”. Therefore, we rejected our second null hypothesis: there are no statistically significant difference between the patient expectations and realizations on the reliability dimension.

(3) There were (negative) differences between realizations and expectations average for eight statements in the third dimension; i.e. “responsiveness”. Therefore, we rejected our third null hypothesis: there is no significant statistical difference between patient expectations and realizations on the “responsiveness” dimension.

(4) There were (negative) differences between realizations and expectations average for four statements in the fourth dimension; i.e. “safety”. We therefore rejected our fourth null hypothesis: there is no significant statistical difference between the patient expectations and realizations on the safety dimension.

Type of hospital n Mean SD SE t-value p-value

Public 400 20.38 0.83 0.041 2.622 0.009 Private 349 20.23 0.70 0.037

Table IV. T-test for service quality

and hospital type

Patients’ satisfaction in

Saudi hospitals

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Public hospitals

Private hospitals

n Statements Mean SE Mean SE p-value

1 Tangibles: hospital departments design makes it easier for the patients to access services

3.23 1.325 3.77 1.048 0.001

2 Internal organization helps achieve a rapid response to patient requests

3.37 1.308 3.67 1.022 0.008

3 Hospital facility, lounges, corridors and elevators are adequate and appropriate to the services

3.35 1.298 3.63 1.087 0.010

4 Hospital is equipped with the latest devices, technologies and medical equipment

3.49 1.176 3.74 1.087 0.003

5 Hospital staff are well 2 groomed and have a good appearance

3.70 1.081 3.95 0.977 0.001

6 Hospital’s location is convenient and easily accessible

3.60 1.195 4.04 0.982 0.001

7 Hospital rooms are clean, comfortable and attractive 3.33 1.245 3.63 1.231 0.001 Average 3.44 3.78

8 Reliability: hospital staff are committed to providing services at specified times

3.42 1.213 3.68 1.111 0.003

9 Hospital staff were keen to resolve patient problems and answer their questions

3.33 1.261 3.75 1.066 0.001

10 Hospital services are correct from the outset 3.05 1.365 3.73 1.086 0.001 11 All the necessary medical specialties are available in

the hospital 3.24 1.354 3.70 1.086 0.001

Average 3.26 3.72 12 Empathy: I can put my full confidence in all hospital

staff. 3.04 1.341 3.68 1.119 0.001

13 Hospital staff respond immediately to patient inquiries and complaints

3.18 1.363 3.72 1.107 0.001

14 Hospital staff respond promptly to all patient needs regardless of the degree of concern

3.10 1.372 3.65 1.176 0.001

15 The hospital medical files and records are accurate and error 2 free.

3.31 1.303 3.67 1.093 0.001

Average 3.16 3.68 16 Safety: I feel safe when dealing with hospital staff 3.31 1.337 3.92 1.028 0.001 17 The medical staff have sufficient knowledge to

answer patient questions 3.38 1.302 4.00 1.007 0.001

18 Hospital staff are always ready to cooperate with me 3.34 1.274 3.85 1.009 0.001 19 Patients told about the time limit for delivering and

completing the service 3.29 1.346 3.70 1.070 0.001

Average 3.33 3.87 20 Responsiveness: hospital staff are characterized by

humanity, decency and civility 3.32 1.350 3.82 1.043 0.001

21 Hospital staff follow up sick cases constantly 3.39 1.309 4.01 0.879 0.001 22 Staff handle hospital information confidentially 3.60 1.224 3.92 0.942 0.002 23 Hospital workers are helpful and sympathize with

the patients 3.40 1.294 3.93 0.932 0.001

24 Inpatients’ interests are always at the forefront 3.34 1.319 3.61 1.139 0.013 25 The medical team is friendly and is fun 3.25 1.430 3.74 1.111 0.001 26 Work and time allotted for hospital are suitable for

patients 3.25 1.291 3.77 0.972 0.001

27 Hospital staff are familiar with and aware of patients needs

3.25 1.325 3.73 0.977 0.001

Average 3.35 3.82

Table V. Public vs private hospitals

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(5) There were (negative) differences between realizations and expectations average for four statements in the fifth dimension; i.e. “empathy”. Therefore, we rejected the fifth null hypothesis: there is no significant statistical difference between the patient expectations and realizations on “empathy” dimension.

Demographic impact factors and gaps between realizations and perceptions The satisfaction levels had statistically significant differences by sex. Males were more satisfied than female patients. However, there were no significant statistical differences between age groups. The educational level had a significant impact on satisfaction, while there were statistically significant differences among patient occupations; the patients who were private sector employees and businessmen had higher satisfaction-levels compared to students and government employees.

Hospital type’s impact on service quality There were statistically significant differences between service quality according to hospital type (public/private). Service quality provided by private was higher than public hospitals. Patients’ quality rankings varied between public and private hospitals. In the public hospitals the best three dimensions were tangibles, empathy and safety; whilst in the private hospitals these were safety, empathy and tangibles.

Area impact on service quality Tables VII and VIII show large statistically significant differences in service quality across different regions in public hospitals (0.02 in Riyadh to 0.99 in Dammam) and across private hospitals (0.16 in Riyadh to 0.98 in Najran). Service quality was highest in Riyadh public and private hospitals, followed by Jeddah, Tabuk, Najran, and Dammam for public hospitals; and Jeddah, Dammam, Tabuk and Najran, respectively in the private hospitals.

Jeddah hospitals were considered to be the best in Saudi Arabia for tangibility and reliability while Riyadh hospitals were viewed as best for responsiveness, safety and empathy. Tabuk hospitals were considered to be the worst for all five quality dimensions.

Interpretations Employing the SERVQUAL scale was useful for measuring Saudi inpatient satisfaction. It was considered to be a reliable instrument in our study because the Cronbach’s alpha for five quality dimensions was strong. Cronbach’s alpha for each dimension scale was strong too. The empathy dimension had the highest value in comparison with other dimensions. Similarly, Cronbach’s alpha for the safety dimension was strong. The third one was the responsiveness dimension for which the

Quality dimensions Average difference SD SE t-values p-value

Tangibles 20.242 0.08 0.03 8.259 0.001 Reliability 20.301 0.84 0.03 9.741 0.001 Responsiveness 20.343 1.04 0.04 9.033 0.001 Safety 20.316 1.06 0.04 8.166 0.001 Empathy 20.328 0.91 0.03 9.902 0.001

Table VI. Realizations and

expectations for each quality dimension

Patients’ satisfaction in

Saudi hospitals

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Cronbach’s alpha was 0.908 for expectations and 0.923 for the realizations, and the fourth was tangible dimension (0.906 each for both expectations and realizations. For the last; i.e. the reliability dimension, Cronbach’s alpha was 0.842 for expectations and 0.84 for realizations.

There were significant differences in the service quality according to hospital type (public or private). Private hospitals service quality was higher than public and these differences were statistically significant. Service quality dimension rankings from the patients’ opinions differed among public and private hospitals. The best three dimensions in the public hospitals were tangibles, empathy and security, respectively; whilst in private hospitals the best three dimensions were security, empathy and tangibles. The reliability dimension was fourth, followed by responsiveness in all public and private hospitals.

The best service quality dimension in public hospitals was tangibles. This dimension included hospital staff appearance, convenient and easily accessible locations, followed by modern equipment and technology. The best service quality in private hospitals was convenient and easily accessible locations followed by medical staff cordiality and friendliness when dealing with patients. Employee humanitarian attitude, courtesy and communication skills dealing with the patients ranked last. The lowest service quality level in public hospitals was medical specialization. Safety came next, followed by employee cooperation dealing with patients. The lowest service quality in private hospitals depended on patients’ individual interest. Hospital corridors, convenient elevators, clean and comfortable patient dormitory were next. The patients’ perception of the five dimensions of quality differed across the regions under study.

Recommendations We recommend macro-health planning and policymaking changes for Saudi Arabia’s hospitals. On the broader policymaking level, our findings could help to set and revisit

City n Average SD SE F-value p-value

Tabuk 34 20.34 0.42 0.07 31.738 0.001 Najran 69 20.98 0.45 0.05 Riyadh 81 þ0.16 0.65 0.07 Jeddah 87 20.06 0.51 0.05 Dammam 78 20.09 0.70 0.07 Total 349 20.23 0.70 0.04

Table VIII. Private hospital service quality

City n Average SD SE F-test p-value

Tabuk 61 20.19 0.53 0.07 31.250 0.001 Najran 50 20.75 0.62 0.09 Riyadh 101 20.02 0.55 0.05 Jeddah 96 20.08 0.65 0.07 Dammam 92 20.99 1.05 0.09 Total 400 20.38 0.63 0.04

Table VII. Health service quality in public hospitals

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the priorities for improving Saudi Arabian health services using key quality indicators. Our data clearly hints at misappropriated health-services resources in the regions. We recommend policymakers initiate evidence-based healthcare budgeting for different regions. Our findings also invite future researchers in health economics and policy analysis to project this misappropriation in its broader details. For instance, even when the government policies were in favor, private sector healthcare managers grossly neglect rural areas, which have a higher population, such as Tabuk and Dammam. This situation places the 1999 national health insurance plan at risk, which had been issued by Royal Order.

At the institutional level, periodically evaluating and continuously monitoring service quality dimensions must be incorporated in all Saudi Arabian hospitals. This approach could improve public and private hospital services. Also, our quality dimension ranking scale could be used to design hospital services: from initial purposes and objectives to operational planning, mainstream strategic management and competitive marketing. Expectations and realizations gaps that we highlighted mean that private hospital managers are required to standardize and upgrade services they offer. We consider these dimensions to be influential and recommend that are taken up in future research studies.

Limitations The study was constrained by geographical feasibility, time and other resources. Ideally, all 20 regions (as defined by the MoH) should have been included but we were confined to five Saudi Arabia regions. Also, owing to resource limitations, the study did not include other key variables that are related to service quality, like leadership and organizational design. The survey difficulties were aggravated by a lack of cooperation from private hospital managers, notably their reluctance to distribute the questionnaires to inpatients.

Conclusions This study identifies some important dimensions of healthcare service quality in Saudi Arabian hospitals and points to directions and questions for future researchers. It also provides some guidance to healthcare quality assurance policy and practice.

References

Al-Doghaither, A.H. (2004), “Inpatient satisfaction with physician services at King Khalid University Hospital, Riyadh, Saudi Arabia”, Eastern Mediterranean Health Journal, Vol. 10 No. 3, pp. 358-64.

Al-Doghaither, A.H., Abdelrehman, B.M., Saeed, A.A.W. and Magzoub, M.E.M.A. (2003), “Factors influencing patient choice of hospitals in Riyadh, Saudi Arabia”, Perspectives in Public Health: The Journal of the Royal Society for the Promotion of Health, Vol. 123 No. 2, pp. 105-9.

Alsharqi, O. (2006), “An analysis of access to and the quality of the new health system in Saudi Arabia: mixed methodology study”, PhD thesis, Monash University, Melbourne.

Al-Shekh, A.A. (2003), Perceptions of Hospital Experiences in Riyadh City, Saudi Arabia: A Comparison of Service Quality in Public and Private Hospitals, University of Wales, Swansea.

Patients’ satisfaction in

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