A Conceptual Framework of Antecedents of Service Loyalty in Health Care: Patients’ Perspective

Abstract

As the health care sector in India is becoming more and more competitive, researchers and practitioners are getting increasingly interested in exploring how post-purchase behaviour of patients can be managed and high level of patient loyalty can be ensured. Patient loyalty has gained immense importance in health care service sector in India because of the drastic changes that have taken place in health care market in the last two decades. Today, the health care market is characterized by intense competition and specialization. Hospital management is increasingly recognizing the need to focus on patient loyalty as a means to achieve profitability and also to improve their competitive position. In this article, we theoretically explore the relationship of the antecedents of patient loyalty (service quality, perceived value, corporate image and perceived price fairness) and its outcomes (patients’ satisfaction and patient loyalty). The outcome of this research is a conceptualization of antecedents of patients’ loyalty in the context of health care supported by research propositions based on the existing literature. The article contributes to the existing literature a hypothesized model that permits the examination of consumer behavioural procedures with regard to service quality, perceived value, perceived price fairness, corporate image, patient satisfaction and patient loyalty. Exploring these processes through empirical studies in future will provide new insights, which will help hospital management retain existing customers and attract new customers.

Keywords

Service quality perceived value corporate image perceived price fairness patients’ satisfaction and patient loyalty

Introduction

Health care is emerging as a major service sector in India. At present, the overall Indian health care market is worth around US$100 billion and is expected to grow to US$ 280 billion by 2020 with a compound annual growth rate (CAGR) of 22.9 per cent (IBEF, 2018). Health care service affects the quality of life more than any other service sector (Cronin, Brady, & Hult, 2000) and is considered as a high-credence service characterized by a high degree of uncertainty and risk. Business organizations, including health care organizations, are generally interested in achieving long-term financial success (Al-Hawary, Alghanim, & Mohammed, 2011). Health care is an integral part of life and to achieve a healthy life, people always demand high-quality health service. This patient-centric approach and consumer satisfaction is becoming the fundamental requirement for health care providers (Desai, 2011). In this highly competitive environment of health service industry, creating and maintaining a sustainable consumer base is becoming increasingly difficult for hospitals. The long-term success of any service provider mainly depends on retaining and expanding customer loyalty. This is more evident in the health care industry, where different hospitals provide services of similar nature but are differentiated on the basis of quality of service. Moreover, patients are also becoming more conscious about the quality of health care services provided by hospitals (Carman, 2000; Zineldin, 2006). Nowadays, the business environment of health care service is becoming more competitive as the users have several choices and can switch to any other health care service provider. The marketing literature also puts more emphasis on customer loyalty, recognizing its importance as a key success factor for the service providers.

Loyal customers will stay with the same service provider despite the availability of other alternatives, often ready to spread positive word-of-mouth (WOM) communication and willing to pay a premium price without bothering much about the amount of sacrifice required to obtain services from their preferred service provider (Chang, Tseng, & Woodside, 2013; Zeithaml, Bitner, & Gremler, 2008). At times, loyal customers, who are like brand ambassadors, help the firm by providing many benefits. Hence, service providers who focus on customer loyalty can gain many benefits, including economic benefits such as cost reduction and increased revenue and profitability (Chang et al., 2013; Mittal & Lassar, 1998; Zeithaml et al., 2008). It has been verified that a 5 per cent increase in customer retention can lead to an increase in profitability between 25 per cent and 85 per cent, depending on the service sector (Reichheld, 1996). Management of health service institutions (HSIs) should understand the factors that influence patient loyalty in order to manage it effectively.

The primary aim of this research is to conceptually extend previous research about the relationship between antecedents of patient loyalty such as service quality, perceived value, corporate image and price fairness mediated through patient satisfaction in a distinct dimension. To be more precise, the objective of this article is to integrate all the strings of research conducted so far on service quality, perceived value, perceived price fairness, corporate image, patient satisfaction and patient loyalty to develop a conceptual model that can explain the interrelationships among these constructs. Thus, the article is intended to fill the conceptual gap in the existing literature pertaining to the domain of patient loyalty in the health care sector.

Literature Review and Model Development

Service Quality, Patient Satisfaction and Patient Loyalty

Service Quality

In the service literature, service quality is considered as an important research area and gets a higher level of attention from researchers and practitioners. Service quality is defined as a customer’s post-consumption evaluation of service that compares expectations with perceptions of performance (Carman, 1990; Cronin & Taylor, 1992; Parasuraman, 1988). According to Aagja and Garg (2010), hospital service quality is the discrepancy between customer perceptions and their expectations about hospitals offering such services.

Though many researchers have explored different dimensions of hospital service quality to detect their impact on service outcome variables such as satisfaction and loyalty (e.g., Babakus & Mangold 1992; Cronin & Taylor, 1992; Gremler & Brown, 1996; Sureshchandra, Rajendran, & Anantharaman, 2003; Otani & Kurz, 2004), the model proposed by Brook, McGlynn, and Shekelle (2000), Donabedian (1980) and Marley, Collier, and Meyer Goldstein (2004) is incorporated in the proposed model, because there is a tendency on the part of patients to depend on both functional and technical qualities of services. According to them, the quality of health care services can be broken down into two dimensions: technical quality (or outcome quality) and functional quality (or process quality). Technical quality is focused on the accuracy of procedures and medical diagnoses, while functional quality refers to the manner in which health care services are provided to the patients. In the health care setting, patients understandably tend to rely on functional attributes (e.g., facilities, cleanliness, quality of hospital food and hospital personnel’s attitudes) rather than technical attributes when evaluating the service quality, because they are unable to evaluate the technical quality due to lack of relevant expertise (Babakus & Boller, 1992). Though some health care studies disregard the importance of technical features, since it was believed that customers would not be able to discern the technical aspects of a service, Trumble, O’Brien, O’Brien, and Hartwig (2006) found that a patient is able to reach an inference through the evaluation of his/her care through the skills shown by the doctor and nurses when dealing with him/her. Further, the patient’s ability to understand disease description and treatment procedures is developed owing to today’s easily accessible scientific knowledge. The technical-feature perception complements and integrates with the process-quality dimensions of a successful medical service (Orava & Tuominen, 2002).

The model proposed through this study considered service quality as an antecedent of patients’ loyalty because patients’ assessment of service quality builds an interaction between patients and hospitals, which helps in developing the patients’ confidence in the overall health care service quality (Söderlund, 1998). Moreover, providing superior service quality is a prerequisite for the success of many organizations because it affects the customer-perceived value, customer satisfaction and customer loyalty (Laohasirichaikul, Chaipoopirutana, & Combs, 2010). Hence, the construct of service quality has been incorporated in the proposed model as an antecedent of both patient satisfaction and patient loyalty.

Patient Satisfaction

Customer satisfaction has been a subject of considerable interest for both marketing practitioners and academics since the 1970s (Churchill & Surprenant, 1982; Jones & Suh, 2000). Traditionally, in the service literature, satisfaction has been viewed as a function of the expectation– performance gap. In other words, customers having expectations about service attributes and performance on these attributes either confirm or disconfirm these expectations (Oliver, 1980). Customers’ satisfaction is an evaluation of perceived performance of the services received as against their expectations and may lead to satisfaction or dissatisfaction. Customers are said to be satisfied if perceived performance is greater than expectations, and if it is not, then the customers are said to be dissatisfied (Oliver, 1997; Zeithaml & Bitner, 2000). In the context of health care, satisfaction is defined as an attitude, that is to say, a person’s general orientation towards the total experience of health care.

Two concepts of ‘satisfaction’ exist in the literature: first is the transaction-specific satisfaction (individual level), which means the customer’s evaluation of a specific purchase experience, and second is the overall (cumulative) satisfaction, which means an evaluation based on the overall experiences of purchasing a product or consuming a service (Johnson & Fornell, 1991). It is argued that overall satisfaction is most useful in evaluating the performance of a provider in rendering services and more effective in predicting customers’ post-purchase behaviours (Bolton, 1998; Kuo, Wu, & Deng, 2009; Wang, Lo, & Yang, 2004). Hence, it seems that satisfied patients are more likely to remain loyal to their providers, reuse of their services and recommend it to others. For hospitals, satisfied patients are important because they are more likely to continue using hospital services and adhere to prescribed treatment plans and still maintain their relationship with a hospital and recommend it to others (Hekkert, Cihangir, Kleefstra, & Vanden, 2009). The more satisfied the customers are, the greater the customer retention (Anderson & Sullivan, 1993; Fornell, 1992) and willingness to recommend (Zeithaml & Bitner, 1996). As the issue of patient satisfaction with health care providers continues to be an area of interest for health care researchers and practitioners, patient satisfaction is incorporated as a mediating variable in the proposed model.

Patient Loyalty

In the marketing literature, loyalty has been recognized as one of the most important constructs to be examined. Oliver (1999) defined the concept of loyalty as ‘a deeply held commitment to rebuy or patronize a preferred product/service consistently in the future, thereby causing repetitive same brand set purchasing, despite situational influences and marketing efforts having the potential to cause switching behaviour’. Customers frequently develop an attitude towards purchasing based on prior service experience and undergoing a cognitive decision-making process about whether to stay with or leave the service provider (Zeithaml & Bitner, 2000). This definition points out two principal aspects of service loyalty, namely behavioural aspects and attitudinal aspects, which have received much attention in previous studies (Bloemer, de Ruyter, & Peeters, 1998; Day, 1969; Dick & Basu, 1994; Oliver, 1999; Tucker, 1964). Behavioural loyalty refers to repeated purchase of a brand, whereas attitudinal loyalty refers to a degree of dispositional commitment and favourable attitude towards the service provider.

In the context of an HSI, loyalty can be defined as a patient’s ‘deep commitment to continually employ or prefer certain health care service providers even where alternatives are available’ (Chang et al., 2013; Moliner, 2009).Loyal customers provide measurable benefits to HSIs not only because they return to a preferred service provider when in need of health care services (Chang et al., 2013; Mittal & Lassar, 1998) but also because they serve as informal marketing agents. They promote their preferred HSI by recommending it to friends, relatives, neighbours, or other people in their social networks (Chang et al., 2013). The significance of customer loyalty cannot be overemphasized, because it relates closely to the continued survival as well as the future growth of health service providers. Hence, our model considers loyalty as an outcome variable.

Relationship between Service Quality, Patient Satisfaction and Patient Loyalty

The causal relationship between customer satisfaction and service quality has been explained in various ways by different authors and is a most debated topic in service marketing literature. Specifically, there are three major arguments regarding this relationship in the literature. First, service quality is described as an antecedent to customer satisfaction (Cronin & Taylor, 1992; Cronin et al., 2000; Eleuch, 2011; Lei & Jolibert 2012; Meesala & Paul, 2016; Murti, Deshpande, & Srivastava, 2013; Naidu, 2009; Padma, Rajendran, & Sai, 2009). Second, some other researchers argue that customer satisfaction is the cause of service quality and there are many pieces of evidence to support their argument (Bitner, 1991). The third argument centring service quality–satisfaction relationship holds that customer satisfaction and service quality are two independent constructs that can be used for the purpose of service evaluation. The two constructs of quality and satisfaction explain the same characteristics and we cannot consider one as the antecedent or predictor of another (Kuo, Chang, Cheng, & Lai, 2013). In general, although there is no general agreement on the conceptualization of the service quality–satisfaction relationship, service quality as an antecedent to customer satisfaction is considered as having a dominant position in service literature. Empirically, the effect of service quality on customer satisfaction has been examined by many researchers in various contexts (e.g., Andaleeb, 2001; George & Kumar, 2014; Lai et al., 2008; Rust & Oliver, 1994, Sumaedi, 2013). These studies show that service quality positively affects customer satisfaction. In the context of health care service also, researchers have found the positive impact of service quality on satisfaction (Carman, 1990; Chahal & Kumari, 2010; Choi, Cho, Lee, Lee, & Kim, 2004; Moliner, 2009).

In fact, customer satisfaction has been considered to be an antecedent of loyalty in service context in previous studies (Koteswara, Kondasani, & Panda, 2017; Murti et al., 2013; Naidu, 2009; Shabbir, Kaufmann, & Shehzad, 2010), which suggested that customer loyalty should improve dramatically as a reaction to the improved level of customer satisfaction. In the service literature, it has been empirically verified that satisfaction is an essential and necessary condition to achieve customer loyalty. As explained earlier, the evidence support that service quality is assumed to be an antecedent of customer satisfaction. In various contexts of service literature, most of the studies confirm that there is a positive relationship between service quality and customer loyalty, and customer satisfaction is usually the mediator between them (Tung, 2013; Zineldin, 2006). Researchers have found that satisfaction acts as a mediating variable between service quality and purchase intentions (Cronin & Taylor, 1992; Cronin et al., 2000). Thus, in the context of health care, patients’ satisfaction serves as a mediating variable between service quality and customer loyalty. Deducing from these observations, the following hypotheses can be formulated for empirical testing:

H1: Service quality has a positive effect on patient satisfaction.

H2: Service quality has a positive effect on patient loyalty.

H3: Patient satisfaction mediates the relationship between service quality and patient loyalty.

Relationship between Patient Satisfaction and Patient Loyalty

Previous studies show that customer satisfaction is the most researched antecedent of customer loyalty and behavioural intentions (Anderson & Sullivan, 1993; Choi & Choi, 2014; Cronin et al., 2000; Donio, Massari, & Passiante, 2006; Oliver, 1999). Studies found a positive relationship between customer satisfaction and customer loyalty (Ramli & Sjahruddin, 2015; Stank, Goldsby, Vickery, & Savitskie, 2003; Tanford, 2016) and revealed that customer satisfaction also impacts the main predictor of customer loyalty. Caruana and Fenech (2005) opined that satisfaction can affect a customer’s attitude to such a degree where he/she not only feels motivated to rebuy but also offer recommendations to the service provider. Kandampully and Suhartanto (2000) conducted their study in the hotel industry and established the significant positive impact of customer satisfaction on customer loyalty. Customer satisfaction has been considered as a fundamental determinant of customer loyalty. Anderson and Sullivan (1993) found that satisfied customers have greater propensity to be retained and become resistant to alternative options, while Fornell (1992) stated that high satisfaction leads to increased loyalty in customers. Moreover, satisfaction enhances repeat purchase and positive WOM by customers (Ferguson, Paulin, & Leiriao, 2010; Gursoy, Chen, & Chi, 2014; Kapoor, 2009). Overall, it can be concluded that there are evidences to show that customer satisfaction has significant effect on both behavioural and attitudinal aspects of loyalty.

Given this, the following hypothesis is formulated:

H4: Patient satisfaction has a positive effect on patient loyalty.

Perceived Value, Patient Satisfaction and Patient Loyalty

Perceived Value

Practitioners and academics have identified that perceived value is a fundamental concept in marketing (Yang & Peterson, 2004). There is no single agreed definition of perceived value; most authors have explained it as customers’ perception based on their evaluation of the comparison between the benefits they obtain from a service provider and the sacrifice they have to make to gain the benefits. Perceived value is a trade-off between perceived benefits and perceived costs. Zeithaml (1988) defines perceived value as ‘customer’s overall assessment of the utility of a product or service based on perceptions of what is received and what is given’. Perceived value is the worth that a product or service has in the mind of customers. In fact, customers are unaware of the true cost of a product or service; instead they have an internal feeling for how much certain products are worth to them. Perceived benefit is defined as what customers can obtain from a service provider and is often operationalised in terms of service quality (Jen, Tu, & Lu, 2011).

In health care, perceived value is the patient’s perception of the difference or discrepancies between total benefits and total sacrifice (Moliner, 2009). The results of process and outcome quality of hospital services can be considered as benefits. Monetary and non-monetary or psychological sacrifice of patients denotes the perceived cost for getting service. Therefore, if the total sacrifice was higher than total benefit, then the perceived value of the health care service would be low, while minimal sacrifice combined with high benefits would equate to high satisfaction (Moliner, 2009). To achieve high level of satisfaction and loyalty, a service provider must provide high customer value. Perceived value is not only influential at the pre-purchase phase, but it also influences satisfaction, intention to recommend and repurchase behaviour of consumers, and therefore perceived value is incorporated as an antecedent in the proposed model.

Relationship between Perceived Value, Patient Satisfaction and Patient Loyalty

Recent studies have stressed the importance of perceived value as a prerequisite for the patient loyalty (Bolton & Drew, 1991). Moreover, it has been identified as an antecedent for customer satisfaction. When the perceived value is low, the chance of switching the service provider may be high with a resulting decline in loyalty, which ultimately affects profitability. Therefore, researchers have identified that perceived value is a major predictor of both customer satisfaction and customer loyalty (Moliner, 2009). In the case of service quality, perceived value is also an input for customer satisfaction, and the relationship between perceived value and patient satisfaction has been confirmed in previous studies (Sumaedi et al., 2014; Trasorras, Weinstein, & Abratt, 2009; Tung, 2013).

Some researchers have suggested that perceived value has been verified as a better predictor of customer loyalty in various contexts. Numerous studies have verified this empirical relationship in the health care sector too (Moliner, Sánchez, Rodríguez, & Callarisa, 2007; Suki, Lian, & Suki, 2011; Xu, Peak, & Prybutok, 2015). A patient’s judgment of value influences his/her post-purchase behaviour in the form of reuse and recommendation. Recent studies have stressed the importance of perceived value as an essential element of patient’s loyalty and patient satisfaction as a mediating construct between perceived value and loyalty (Caruana & Fenech, 2005; Chang & Wang, 2011; Kim, Kim, Kim, Kim, & Kang, 2008; SahinDölarslan, 2014). Based on the literature review, the following hypotheses are formulated:

H5: Perceived value has a positive effect on patient satisfaction.

H6: Perceived value has a positive effect on patient loyalty.

H7: Patient satisfaction mediates the relationship between perceived value and patient loyalty.

Corporate Image, Patient Satisfaction and Patient Loyalty

Corporate Image

Corporate image is concerned with knowledge, feelings and beliefs about an organization that exists in the mind of customers (Hatch & Schultz, 1997). An image can be defined as ‘a signal that can be used by a customer to evaluate a product or a service especially when a customer does not have a competency to do it or the characteristics of the service can be categorized as credence service’ (Hu, Kandampully, & Juwaheer, 2009). Image plays a vital role in a customer’s decision-making regarding the selection of a particular service provider. An image can be expressed as a mental evaluation of a service experience and level of satisfaction from service provider’s activities and performances (Moore, 1981). In the context of health care, Kotler and Clarke (cited in Woodside, 1987) stated that any hospital’s corporate image is the sum of beliefs, ideas and impressions that a patient holds towards it. The patients often form an image of a hospital from their own medical experiences (Kim et al., 2008).

Through strategic marketing activities, the corporate image of a hospital can be used to help it improve its competitive position (Javalgi, Whipple, McManamon, & Edick, 1992). A hospital with a good image is more likely to stand out in the marketplace because it provides loyal customers as well as new users. Moreover, the more favourable image in the mind of customers can be understood as a sign of better, higher quality and improved worth of service provider. Even though previous studies have presented the role and the effect of corporate image, it is still unclear whether there is a direct relationship between image and consumer behaviour (Bloemer et al., 1998). Understanding the role and the effect of corporate image in the customer’s retention decision is a key issue that has received little attention in the service marketing research. From the marketing point of view, corporate image can be considered as an asset which differentiates a service provider from its competitors, helps to attain market share and profit by attracting new customers and retaining current customers. Therefore, corporate image is considered as an antecedent of patient loyalty in the suggested model.

Relationship between Corporate Image, Patient Satisfaction and Patient Loyalty

In the marketing literature, there is a general assumption that a favourable brand image has a positive impact on customer satisfaction. Ishaqa (2012) suggested that brand image correlates with customer satisfaction. Brand image has been recognized as an important antecedent of customer satisfaction. Hence, a positive hospital brand image will tend to generate high patient satisfaction in the hospital (Davis, Chun, da Silva, & Roper, 2003). In addition, it is apparent from preceding studies that brand image has direct and/or indirect positive effects on loyalty or behavioural intention. Yarmen et al. (2016) discovered that brand image has a direct effect on loyalty. A brand image can be certainly viewed as a predictor of customer loyalty. Thus, a positive hospital brand image appears to stimulate patient loyalty. A number of empirical researches have been performed to examine the impact of the image on loyalty (Faullant, Matzler, & Füller, 2008; Johnson, Gustafsson, Anreassen, Lervik, & Cha, 2001; Kandampully & Suhartanato, 2000; Sumaedi et al., 2014). Davies and Chun (2002) found that brand image has an indirect influence on loyalty via customer satisfaction. Therefore, patients’ satisfaction can play a mediating role in the relationship between corporate image and patient loyalty. Any increase in the image of an HSI will result in the increase of patient loyalty. Given this, the following hypotheses are formulated:

H8: Image has a positive effect on patient satisfaction.

H9: Image has a positive effect on patient loyalty.

H10: Patient satisfaction mediates the relationship between image and patient loyalty.

Perceived Price Fairness, Patient Satisfaction and Patient Loyalty

Perceived Price Fairness

According to Zeithaml (1988), price is something that must be sacrificed to obtain certain kinds of products or services from consumers’ cognitive conception. In addition, a sense of price fairness should be generated. If customers view a firm’s practices as unfair, negative consumer responses are likely to occur (Wirtz & Kimes, 2007). Consumers evaluate the fairness of a quoted price by making appropriate comparisons with other references, and also taking into account situational circumstances (Beldona & Namasivayam, 2006). The price of the service can significantly influence perceptions of quality and satisfaction (Zeithaml & Bitner, 2000). Many authors have indicated that price is a vital factor for customers when selecting products or services. When customers believe that a product’s price is fair, the purchase behaviour tends to be repeated. If customers feel that a certain product or service doesn’t deserve its price, they will not repeat purchase behaviour. The perceived ‘reasonableness of price’ has a positive correlation to customer satisfaction.

The role of perceived price fairness as a predictor of satisfaction and loyalty has not been fully investigated in previous empirical studies (Bei & Chiao, 2001), especially in the health care sector. The marketing literature emphasizes price as an important factor of consumer satisfaction, because whenever consumers evaluate the value of an acquired product or service, they usually think of the price (Anderson, Fornell, & Lehmann, 1994; Anderson & Sullivan, 1993; Cronin et al., 2000; Fornell, 1992; Zeithaml, 1988). Hence, price fairness has been incorporated as an antecedent of patient loyalty in the proposed model.

Relationship between Perceived Price Fairness, Patient Satisfaction and Patient Loyalty

Empirical findings have shown that perceived price fairness has a positive influence on customer satisfaction (Chua, Lee, Goh, & Han, 2015; Haddad, Hallak, & Assaker, 2015; Kaura, Prasad, & Sharma, 2015; Kimes & Wirtz, 2002). Service literature also reveals that price fairness is important in framing post-purchase behaviour. It has been verified that when a customer perceives the fairness of price decided by the service provider, the customer attitude becomes positive, which leads to positive behavioural outcomes. Loyalty is one of the favourablebehavioural outcomes and it has been firmly established in the literature that price fairness significantly affects customer loyalty (Bolton et al., 2003; Fombrun & Shanley, 1996; Martin et al., 2009; Xia et al., 2004).

The indirect impact of perceived price fairness on patient loyalty through patient satisfaction has also been verified in the literature (Liu & Lee, 2016; Lymperopoulos & Chaniotakis, 2008; Martín-Consuegra, Molina, & Esteban, 2003; Matzler, Mühlbacher, Altmann, & Leihs, 2004). In the context of health care, we can assume that the same relationships exist. Given this, the following hypotheses are formulated:

H11: Perceived price fairness has a positive effect on patient satisfaction.

H12: Perceived price fairness has a positive effect on patient loyalty.

H13: Patient satisfaction mediates the relationship between perceived price fairness and patient loyalty.

Conceptual Model

Based on the discussion made in this article and the stated objectives, a conceptual model (as shown in Figure 1) is proposed to exhibit the predictors of patient loyalty— service quality, perceived value, corporate image and perceived price fairness—as antecedents and patient satisfaction as a mediating construct.

Implications and Conclusions

The outcome of this paper is a conceptualization (provided in Figure 1) supported by research propositions based on the available literature. The review of literature also underpins the importance of retaining existing customers, because retention provides many benefits to the service providers. This article contributes to the existing literature a hypothesized model that permits the examination of consumer behavioural procedures with regard to service quality, perceived value, perceived price fairness, corporate image, patient satisfaction and patient loyalty. Exploring these processes through empirical studies in future will help in gaining new insights, which will help hospital managers to retain existing customers and to attract new customers. To put it succinctly, the model presented in this article can be used to promote empirical research which, in turn, will augment health care marketing literature. Examining the antecedents of patients’ loyalty will contribute to the theory of consumer behaviour by broadening the scope of research on consumers’ purchasing behaviour.

Figure 1.

Source: The authors.

Until very recently, few studies in the developing nations have been conducted to understand the types of relationship that exist between antecedents of patients’ loyalty such as service quality, perceived value, corporate image and perceived price fairness mediated through patient satisfaction. Although a lot of research has been conducted in the developed countries, the findings of these cannot be generalized to create a framework for the Indian context. It has been contended that constructs of service quality and other antecedents that are developed in one culture might not be applicable in another culture. Therefore, it is felt imperative to go deeper into the subject matter, thereby identifying the dimensions and relationship that exist between the antecedents—patient satisfaction and patient loyalty—and health care services in the context of a developing country, investigating the direct effect of service quality, perceived value, corporate image and perceived price fairness on patient loyalty as well as the indirect effect of all antecedent constructs mediated by customer satisfaction.

Patient loyalty has gained immense importance in the health care service sector in India because of the drastic changes that have taken place in the health care market in the last two decades. Today, the health care marketplace is characterized by intense competition and specialization. The market share of private hospitals, specifically in the cities, has increased multifold during this period. This has forced private hospitals to compete with each other to gain as much market shares as possible. In the context of health care service, loyalty is considered to be a success factor. Hence, it is important to examine the factors that influence patients’ loyalty. In this context, the present article makes theoretical contribution by proposing a patient loyalty model, which is expected to help the service providers to manage the aspect of patient loyalty effectively.

Declaration of Conflicting Interests

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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