Background: SERVQUAL is used for evaluating service quality by finding out the gaps between anticipation and observations of clients’ viewpoint.

Objectives: To ensure better insight on how service quality theory can help enhancing medical tourism in Qatar.

Methods: Cross sectional survey using SERVQUAL questionnaire involving a total of 350 HMC service users.

Results: HMC service users recorded a positive attitude as 57.4% replied that medical staff were friendly while 58.9% considered non-medical staff as friendly. Majority of HMC services users in Qatar rated the experience as good (30%), very good (28.3%) and excellent (21.1%).

Conclusion: HMC medical service users welcomed the idea of medical tourism and viewed HMC positively.

Keywords: Medical tourism; Management; SERVQUAL; Healthcare.

Medical tourism is a growing niche market within the tourism sector which has expanded significantly over the last two decades [1]. Medical tourism can generally be described as patients travelling out of their medical areas with the aim of general wellness, in order to obtain some critical or optional medical procedures [2,3]. The first category is inbound, which means foreign individuals visiting or coming into a particular country seeking medical help based on the origin of travel. The second one is outbound, which refers to natives of a country travelling to a different country outside their environment seeking medical help. The third category is known as intra-bound, which represents a developed form of domestic tourism whereby natives visit different regions or cities of their country [4].

Service quality is used as a means to determine how well the service level delivered matches the expectations of the client. Achieving quality service means ensuring clients expectations are met consistently [4]. SERVQUAL is one of the most popular models for evaluating service quality. This scale identifies service quality by finding out the gaps between anticipation and observations or insights in relation to the clients view point. It also involves the evaluation of the characteristics of service quality i.e. physical structure, trustworthiness, receptiveness, assertion, and understanding [5-7].

The aim of this research was to ensure better insight and to critically analyse how service quality theory can be used to help enhance medical tourism within the Arabic context.

A structured SERVQUAL questionnaire was used to collect primary data in this study from those who had experienced HMC services as a patient and or visitor. For the purpose of this research an HMC services’ user was any person, over 18, who was visiting HMC at the time of data collection either as a patient or visitor or both and therefore had had some interaction with the services provided by HMC and so was were able to comment on the quality of the services provided and received. The duration for this questionnaire was between 10-15 minutes. The questionnaire was produced in Arabic and English because the people being asked to participate were both Arabic nationals and English-speaking expats.

Sampling was done both randomly and voluntarily while the questionnaire was self-administered by the researcher or the customer service representative due to privacy issues, which meant no access to potential respondents’ details. Random sampling was done by handing some of the questionnaires in person to individuals within the hospital premises at random. Voluntary sampling was done by asking the participants about the willingness to take part in filling those questionnaires while waiting at for their appointment in different waiting areas at the hospital. To ensure confidentiality, the completed questionnaires were collected in daily batches from the feedback and suggestions boxes in those areas. It also meant that every patient or hospital visitor had an equal chance of being chosen as a participant.

Tool

The questionnaire that was administered to the HMC services users was based on the results of qualitative interview data and aligned to the SERVQUAL measurement tool. The questionnaire developed was tested with a pilot sample of 20 individuals to verify its ability to accurately reflect the meaning of the researcher within each question. The questionnaire was self-administered and made widely available and accessible from multiple channels including receptionist desks and in waiting areas.

Ethical considerations

This study was conducted in compliance with Cardiff Metropolitan University’s ethics policy and HMC research compliance committee. The ethical information was placed in the opening section of the questionnaire making it clear to all repondents that their participation was entirely voluntary, that they were free to withdraw at any point during the research, that they would not be able to be identified from the published results and that all raw data collected would be held securely and only be seen by the researcher, not by managers or anyone else employed by HMC.

The study involved a total of 350 HMC service users, people who either had been or were about to be patients of HMC plus to people who were visiting and or helping sick friends or family at HMC in Qatar: they were all HMC service users.

From the results shown in Figure 1 below, those who had experienced HMC as both patient and visitors were 196 followed by 118 who had experienced HMC as patients only. Only 35 respondents had experienced HMC as visitors only. Concerning the frequency of visiting HMC, 278 of the HMC service users had visited HMC more than twice, 43 had visited twice and 29 only once.

Demographic data

Age: The respondents’ age was categorized into eight age brackets following the standard statistical age ranges used by Qatari government data collection. From the respondents age distribution, as illustrated in Figure 2, most of those involved in the study were young and middle-aged adults, although there were respondents from the elderly population. While this does not necessarily reflect the general profile of those seeking or using medical care in Qatar, it reflects the general population in Qatar by age group [8].

Gender: In terms of gender, slightly more females, totalling 184 (52.8%), were involved in the study while 166 males participated. One reason for this could be that it is females in Qatar who most frequently accompany and or visit their children or relations in hospital settings.

Nationality: Most of the HMC service users were nonQataris by origin at 228(65.1%) while those from Qatar were 122(34.9%), as illustrated in Figure 3 below.

Education: The education background of the HMC service users participating in this research was also evaluated given that level of education is a considerable factor influencing heath perception, health care services uptake and the ability to seek quality health care services. Most of the HMC service users taking part in this study, apart from just 19(5.4%), had a formal education. Those with graduate degree comprised 158(45.1%) while those with high school education were 125(35.7%). The highest academic qualification, post graduates, were 39(11.1%). The complete data about the education levels of the HMC service users is as presented in Figure 4 below.

Education levels are critical influencers of health consciousness and awareness of consumer rights [9] from the medical tourist’s perspective and that education enables or inhibits favourable medical tourism perceptions.

Occupation: In terms of occupation, 85 respondents (24.3%) who were the majority worked in public sector while 83(23.7%) respondents were working in the private sector. There was a higher- than-expected population of 54(15.4%) HMC service users who were housewives, which can be explained by the fact that most users were females. Altogether, the cultural and religious orientation of Qatar is such that the woman is normally expected to be the caretaker of the family. Of the respondents, 11(3.1%) were self-employed while 18(5.1%) were students, 45(12.9%) were professionals, and 32(9.1%) were retired. These results are illustrated further at Figure 5 below.

Hamad Medical Corporation (HMC)

Acquisition of knowledge about HMC: As illustrated in figure 6, most of the HMC service users i.e. 143(40.9%) knew of HMC through family members. 106(30.2%) had heard about the institution through local hospitals, 105 (30%) through friends and 94(26.7%) through health care referral. Only 49 (14%) knew about HMC through their website.

Main reasons why HMC was chosen as the medical service provider: The survey explored the main reasons for the HMC service users choosing HMC for treatment. The main factors include facilities (152, 43.4%), expertise of physicians (143, 40.9%) and quality of health care service (122, 34.9%). Figure 7 below illustrates the frequencies and the percentage of the total selections made.

Evaluation of HMC medical and non-medical staff: The HMC service users were asked to comment on the interpersonal skills of both the medical and non-medical front line staffs at HMC. In total, 201 HMC service users (57.4%) responded positively and said the medical staff were friendly while those who considered non-medical staff as friendly were 206(58.9%). Medical staff were considered as helpful by 194 respondents (55.4%) or welcoming by 168 respondents (48%) as compared to the statistic for non-medical staff which were 174 (49.7%) for helpful and 183(52.3%) for welcoming. Figures 8a and 8b below illustrate these results.

In both cases, more non-Qataris rated the medical and nonmedical staff higher than Qataris on the same metrics except for the trait of being accommodative in both cases of medical and nonmedical staff. This trend is also notable for the negative ratings of where the percentage of qataris who thought that medical and nonmedical staff were unhelpful, rude, and nonresponsive was higher than that of non-Qataris who thought the same. The fact that non-Qataris consider medical staff and nonmedical staff to be performing better than the Qataris raised three issues.

First, although the results relate specifically to HMC, this is an indication that Qataris feel that there is a gap in terms of service performance by both medical and nonmedical staff. Literature about the service delivery gap of the service quality extended model by [10], identifies inconsistencies in performance by staff on service delivery as a significant contributor to perceptions of poor service delivery. This could suggest that the Qataris in this study felt that there were inconsistencies in service performance by both medical and nonmedical staff at HMC despite their overall service performance being good. Alternatively, it could simply be because Qataris expect the availability of highquality medical services whenever they want them. Thus, they tend to be more critical of a provider like HMC who does not meet each of their needs such as provision of adequate car parking space.

Second, the comparatively better evaluation of nonmedical and medical staff service performance by non-Qataris could be an outcome of comparatively poor medical and nonmedical staff service performance in their home countries or countries of origin since in Qatar they are assured of access to superior quality medical service, whether they pay for it in full or partially while residing in Qatar. If this is the case, this could be an indication that HMC is likely to attract medical tourists from where these non-Qataris originate because of the perceived superiority in medical and nonmedical service delivery. Although the findings reported here are based on the views of the HMC service users, this argument is supported in literature that patients move from their home countries to pursue advanced cross-border care [11]. Thus, the views of the expats about the superiority of medical services in Qatar could form a basis from which to build perceptions of the quality of medical care in Qatar.

Third, these results raise concerns about the support of the host communities towards medical service provision if their perceptions of service performance by medical and nonmedical staff are unfavourable. This is because the medical services and staff provided by HMC were seen more positively by nonQataris that the Qataris. It may be that such Qataris are more likely to be critical/suspicious of the efforts of the medical and nonmedical staffs in delivering medical tourism at HMC than they are likely to be supportive because they are accustomed to high quality medical services and anything that falls short of their high expectations is met with sharp criticism.

In addition, the Qatari HMC service users who have negative perceptions towards the level and quality of medical and nonmedical staff are likely to engage in negative word-of-mouth about medical and nonmedical staffs at HMC. Considering the results presented earlier in this section on the crucial role played by WOM and electronic WOM in notifying people about HMC, their negative perceptions about the performance of medical and nonmedical staffs at HMC is a critical concern. This is because it could influence the perceptions of other potential users/customers who have not yet experienced the medical and nonmedical services of HMC.

Evaluating the services provided at HMC: As illustrated in Figure 9 below, most of the HMC service users recorded a positive attitude towards and description of HMC. The majority of the HMC service users strongly agreed, agreed, or slightly agreed with the argument that HMC maintains high standards of hygiene and cleanliness, observes confidentiality and professionalism, offers high quality treatment and uses valid and effective technology in their treatment.

Rating physical and experiential servicescape at HMC: When evaluating their physical surroundings, privacy, entertainment, Wi-Fi, noise, lighting and heating, most of the respondents rated the services as satisfactory, good, very good and excellent. However, there were a high number of HMC service users who considered shared patient rooms, Wi-Fi and entertainment as poor (Figure 10 below).

These results compliment those reported earlier in this section which indicated that facilities in general are amongst the most influential factors when the respondents to this study chose HMC as their hospital. Moreover, these findings are also consistent with literature about the importance of the physical environment including room designs, lighting, and level of noise in promoting constructive or destructive developmental, psycho-social, medical and welfare consequences among patients, families and employees [12-16]. Such literature also underscores the significance of ensuring privacy of facilities such as single-patient rooms in the medical tourism environment.

Laundry services at HMC: Similarly, the laundry services such as bed comfort or linen changing were mainly positively rated as satisfactory, good, very good or excellent as illustrated in Figure 11 below.

These results support the results presented about HMC maintaining high standards of hygiene. However, the results in this section are more specific in the sense that they show the exact constituents of hygiene that the respondents considered essential in the maintenance of hygiene by HMC. One current facilities issue may be that HMC might not have as many luxurious suites as it has standard rooms considering that its current purpose to serve the Qatari public per se.

Catering services at HMC: The respondents were also asked to rate and comment about the catering services at HMC since it was one of the criteria raised during medical tourism provision. Staff presentation and interaction with patients, quantity of food, quality of food and variety of menus were rated positively by most of the respondents. Figure 12 below illustrates the results about the rating of catering services at HMC by the HMC services users.

Approximately 90.6% (317) of the respondents thought that food service staff presentation and interaction with patients was between satisfactory and excellent. Again, this brings out the paradox between the results showing low ratings of service performance by nonmedical staff as shown at section 2.3 above and the high rating of some nonmedical staff like food service staff in this. It would appear that the staff that the respondents understood to be nonmedical in section 2.3 above did not necessarily encompass all nonmedical staff.

Access to services at HMC: The admission process, securing appointments and waiting times had the most negative scores, although overall access to all services variables assessed recorded a positive attitude. Reception and discharge process were the variables rated most positively, as illustrated in the Figure 13 below.

The negative scores of admission process, securing appointments and waiting times signal the need to ensure synergy between the nonmedical and medical services’ delivery. This is because while the face of these three processes is in the nonmedical administrative staff domain the actual cause of the problem may lie within that of the medical staff. For example, even if the administrative staff are able to process appointments sooner and reduce waiting times, their efficiency depends on the availability and schedule of the medical personnel.

Overall experience of services at HMC: Most users of HMC medical services in Qatar rated the experience as good 105(30%), very good 99(28.3%) and excellent 74(21.1%). In total, 50 users of HMC medical services in Qatar (14.2%) rated the experience, as satisfactory and the combined rating for fair, poor and not applicable was 22(6.3%). These results are illustrated in Figure 14 below.

The results portrayed above show that the vast majority of current patients and visitors were happy with the service provided by HMC although they may have had some specific issues as highlighted in the previous sections. In terms of medical tourism development in Qatar this suggests that medical tourists would be likely to be happy with the service provision at HMC. However, HMC alone would not be adequate to cater for largescale medical tourism. Thus, Qatar would need to ensure that service provision in other medical tourism facilities matches or even exceeds that which is available at HMC

Meaning and concept of medical tourism

One part of the survey had intended to establish the respondents view of HMC and the services it provides from the user perspective. The other part, discussed in this section, sought to probe establish their views on medical tourism.

Understanding of the concept of medical tourism

As Figure 15 shows, 133(38%) HMC service users considered medical tourism to be traveling to another country to receive medical treatments and participate in leisure activities (i.e. medical leisure such as spas, rehabilitation, relaxation). Another 102(29.1%) considered medical tourism to be getting medical treatment and visiting new places. 69(19.7%) believed that medical tourism was simply about seeking medical treatment in another country while 45(12.9%) had no knowledge of what medical tourism meant. The data illustrates that most HMC service users had some knowledge of medical tourism, though most associated it with leisure rather than seeking essential medical treatment.

These results already indicate the possibility of two types of medical tourism. The first kind is health tourism whereby medical tourists travel to Qatar to get treatment for illnesses that they may have. The second is the elective wellness type of medical tourism where the medical tourist travels mainly for leisure purposes although she/he may also be seeking to undergo an elective procedure that does not necessarily have a medical imperative. An example of such elective procedures would be cosmetic or spa experiences. Pure medical health tourism seems more suitable for neighbouring countries while the elective wellness form best suits the more international medical tourists. This is because medical tourists from neighbouring countries are likely to pursue medical services and treatment than they would luxury in Qatar, which they are already able to access with ease.

Preferred companions if participating in medical tourism

It was considered important to know who people would choose to be accompanied by if participating in medical tourism in order to be able to identify the type of partnership packages required in the implementation of medical tourism in Qatar. Interestingly, 167(47.7%) respondents considered a family member other than spouse as their choice of companion while 133(38%) chose their spouse as their preferred person to accompany them. As illustrated in Figure 16 below, 25(7.1%) indicated that they would consider a friend or no one to accompany them.

This confirms that Qatar would need to consider developing medical tourism packages that include family members and spouses as well as the medical tourist. This could translate to consideration for family accommodation facilities, for example, instead of private rooms only. This may necessitate the development of close working links with nearby hotels and accommodation facilities. This would especially be important for medical tourists originating from the neighbouring countries that have similar cultural and social orientations.

Medical procedures appropriate for medical tourism

The HMC service users were asked to identify the medical procedures and services they considered to be most appropriate for medical tourism. Medical tourism has been linked to consumers moving out of their countries of origin because the treatment required is either absent, too expensive or offered at low quality in the home country and cardiology, diagnostics or techniques for performing diagnosis, rehabilitation and orthopaedic are the most frequently identified procedures sought by medical tourists. Noting that rehabilitation was cited by numerous respondents and that HMC is in the has already built a new rehabilitation unit, this could constitute Qatar’s medical tourism niche.

Reasons for choosing medical tourism

The HMC service users were asked what their reasons would be if they were to participate in medical tourism. As illustrated in Figure 18, high quality care the most important followed by having a vacation and getting treatment. Time constraints in one’s own country affordable cost and exposure to new opportunities were also mentioned by many respondents. Interestingly, exposure to new opportunities was not limited to medical tourism opportunities. Instead, it includes access to new networking interactions, business opportunities and cultural and tourism experiences [17].

The ranking of high-quality care as the most cited, likely reason for choosing medical tourism if the HMC services’ users were to choose shows that the huge government investments in healthcare in Qatar are worthwhile. The issue of time constraints being a potential influencer for choosing HMC insinuates speed of access to HMC services.

Potential influencers in the decision to participate in medical tourism

The HMC service users were asked to indicate who they believed would influence them if they ever decided to participate in medical tourism. The two most important influencers were self and advice from a doctor with 187 respondents (53.4%) for each influencer. Other influencing forces included friends and relatives, websites, advertisement, medical tourism guide and medical tourism agency, as illustrated in Figure 19 below.

Although friends and relatives are considered important in spreading the word about HMC, the results in Figure 19 above show that the respondents would still make the final decisions about medical tourism by themselves or when advised by doctors. In other words, this shows that some influential factors are only influential to the extent of informing the service user as a decision-maker, but such factors do not have the same influence on the final decision made.

Developing medical tourism in Qatar

A total of 282 HMC service users (80.6%) had never participated in an elective procedure outside Qatar therefore, most HMC service users had no lived medical tourism experiences. However, they were asked what in their opinion would be the features that they felt could make Qatar an attractive destination for medical tourists. The rationale for the prompt was to establish the most important features of medical tourism and tourism in general in Qatar.

Qatar’s attraction features for medical tourists

From a list of the most frequently cited reasons for choosing a particular medical tourism destination derived from previous literature the HMC service users were allowed to choose more than one factor. Among the top factors considered to be critical in attracting medical tourists and those accompanying them to Qatar safety and security topped the list with 61 Qatari respondents (76%) and 158 non-Qatari respondents (70%) choosing it. This was followed by hospitality, which was chosen by 56 Qataris (45%) and 124 non-Qataris (55%). Advanced medical facilities came third with 45(36) Qataris and 70(31%) nonQataris, followed by culture with 38(30%) Qataris and 79(35%) non-Qataris. Other considerations in the Qatari/ non-Qatari order were urban development with 31(25%)/ 81(36%), nature with 25 (20%)/ 45(20%), and other factors, which were the least favoured with only 3(2%)/ 5(2%) selecting it. These findings are illustrated in Figure 20 below. The difference between Qataris and non-Qataris’ perceptions is illustrated so that the views of ‘insiders’ and ‘outsiders’ can be distinguished in order to demonstrate any potential variations between foreigners and locals, which may impact upon the implementation of medical tourism.

The importance given to safety and security is in line with literature concerning political instability or stability as a crucial component of the behavioural and demographic influencers of medical tourism consumption where it is listed as one of the most significant perceived risks which influences the choice of a medical tourism destination [18,19].

The potential for Qatar to become a popular destination for medical tourism

The majority of respondents, 217(62%), believed that Qatar has a real possibility of becoming a popular destination for medical tourism although 104(29.7%) were not sure about it. Only 29(8.3%) respondents disagreed that Qatar had the potential to become a popular medical destination for medical tourism. The reasons behind the potential for Qatar to become a popular medical tourism destination are illustrated in Figure 21 below.

The most commonly cited reason for this potential was the current HMC advanced health and medical system according to 59 HMC service users (16.85%), high quality of medical care according to 12 HMC service users (3.43%), quality of facilities mentioned by 8 HMC service users (2.29%) and for hospitality and cultural development, which 8 HMC service users (2.29%) mentioned. Of the 29 HMC service users who disputed the idea of Qatar ever becoming a popular medical tourism destination long-waiting times for appointment at HMC topped the list, were cited by 3 HMC service users (0.86%). These results, the views of those who actually use medical services in Qatar, challenge the interview findings of the second phase which indicated that managers were sceptical about the people of Qatar accepting medical tourism.

Ease of accessing Qatar

A large number of HMC medical services users, 84(24%), strongly disagreed, disagreed, slightly disagreed, or slightly agreed with the statement that the entry process to Qatar was an easy one, as illustrated in Figure 22 below. This is a significant number of respondents considering it translates to about one in every four respondents at best slightly agreeing that the immigration process including visa granting is easy.

The quality of healthcare in Qatar

More than half of the HMC service users agreed and strongly agreed that the health care institutions in Qatar provide quality care and that these institutions could be considered for medical tourism destinations (see Figures 23 and 24 below).

Impacts of medical tourism

Other than having an impact on the health status of those seeking such services, medical tourism may have profound impact on a country’s healthcare system. In total, 304 HMC service users (86.9%) thought medical tourism would be appreciated and accepted by Qatari society with 330 HMC service users (94.3%) thinking that its impact would be positive. Figure 25 below illustrates the results described in this section.

The main reasons quoted were helping to improve the country’s economy and increasing the number of foreign tourists visiting the country. These results complemented those suggested by the QNV, the impact of medical tourism would be positive on Qatar.

Only 20 HMC service users (5.7%) comprising both Qataris and non-Qataris believed that medical tourism would have a negative impact on Qataris citing issues related to safety concerns, own rights of receiving the services in their mother country and increasing foreigner flow in the country. While this is a genuine concern, it is possible that the reason why the percentage of HMC service users citing the potential increase of foreigner flow into Qatar and safety as potential negative impact was so low was because there are already many expatriates working in Qatar and this has not caused any notable safety issues.

The aim of this research was to ensure better insight into the complexity of medical tourism and the complexity of medical tourism in term of being defined as a distinct niche market in the Qatari context and to critically analyze how service quality theory can be used to help enhance medical tourism within the Arabic context. A framework was developed to identify the critical service quality factors in that context using HMC as a vehicle in Qatar which signaled the need to rethink the SERVQUAL model within this context. This aim was achieved through an objective developed to critically examine the HMC service users (proxy medical tourists) experiences of medical tourism in relation to service quality.

The perceptions and experiences of the users of HMC medical services in Qatar were critical in this study because they gave experiential-based insights into how medical tourists might want to be treated, the kinds of procedures that they would be most likely to be interested in and their experiences of medical services and tourism, all of which could affect perceived service quality.

The respondents to the questionnaires were users of medical services in Qatar as opposed to medical tourists per se. Contextualizing or interpreting these findings as though they came from medical tourists may mean that their accurate application when medical tourism is eventually implemented in Qatar requires further verification. However, and as previously discussed, many of the respondents did in fact have many of the attributes of medical tourists in that they were seeking medical care in a country outside their own. Thus, they were well placed to offer insights about how they felt medical tourism could be like in Qatar and what they thought Qatar needed to do to become a top medical tourism destination. Indeed, the proxy population in this study provided a rich range of diverse views about the potential for medical tourism in Qatar in the absence of information about the actual medical tourists in the country.

Education, occupation, and nationality were found to be influential factors of the overall experience of services at HMC. Family members and local institutions topped the list of how the HMC service users learnt about while facilities, expertise of physician, and quality of healthcare were the main reasons for choosing HMC. There were more non-Qataris with favorable evaluations of the medical and nonmedical staff and services than Qataris. The physical and experiential services cape at HMC also received positive assessment as did the laundry and catering services. While access to services at HMC was assessed in positive light overall, admission processes, securing appointments and waiting time had the most negative scores

It was also found that most HMC service users had a good understanding of medical tourism and considered it to be more about leisure more than medical services. Family members and spouses would most likely be their companions if they were to engage in medical tourism. Cardiology, performing diagnosis, rehabilitation, and orthopedic services were ranked as the most appropriate medical procedures for medical tourism in Qatar.

Acknowledgements: The author would like to acknowledge Saad Al Tamimi (HMC) for his support in reviewing the manuscript draft and guidance on the submission process.

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