2016; 11(1):148-160150

Artículo

original

Public and Private healthcare provision:what do patients value?

Martina G. Gallarza1, Remedios Calero2, Ofelia Nerbón3

1Marketing Department, Faculty of Economics, University of Valencia, Valencia (Spain). 2Director, Hospitalof Hellín, Albacete (Spain). 3Dentist, Hospital of Denia, Alicante (Spain). Catholic University of Valencia,Valencia (Spain).

AbstractObjectives. The main objective of this study is to explore users’ perception and evaluation of the healthcare service ina threefold way: first, looking for differences between public and private healthcare (according to service provider);second, considering the existence of core and peripheral services (according to the nature of the service); and third,from a double perspective of supply (physicians and hospital managers) and demand (health care end-users).Methods. Within an exploratory approach, a qualitative analysis has been conducted where two research questionswere proposed. Their organised discussion in seven in-depth interviews served as a base for the following quantitativeanalysis.Results. Results tend to show that in health care provision, peripheral service must be considered as more and morevalued by patients, sometimes even more than core service (diagnostic and treatment).Conclusion. These results shed light to managers and administrators in order to design the best service for patientsaccording to their needs and preferences.Keywords. Healthcare service, peripheral services, end-users’ perceptions.

1511./ NV. 11 2016

INTRODUCTION

It is acknowledged by service researchers that one ofthe main characteristics of the health service is thedifficultyofevaluationby theconsumer1,2. Patientsveryrarely have the ability to judge whether the servicetheyhave received isappropriate.Becauseof this, pa-tients use elements that they can easily make tangi-ble to evaluate the service, rather than the main heal-thcare itself 3.

The patient does not question the quality and theprofessionalism of the medical staff, so one of themost important considerations for consumerswhen evaluating and choosing amongst alternati-ves is the convenience of access, location, timeta-bles, etc.4,5.

Subsequently, various tangible elements (access,restoration, comfort) are considered to be valuedcharacteristics, and can even be valued by thepatient more than the service itself (diagnostic andtreatment). These services can be considered in a“servuction model” as “peripheral” services6 asthey surround the core service, and are not consi-dered to be central. Thus, the health service is builtas a combination of a core service and peripheralservices, where the latter may overlap the former.

Taking into consideration the greater relevancethat health management models are gaining nowa-days7, 9, any research on perceptions of both privateand public health provision is relevant, but more indeed in Spain, the country where this field work isundertaken, and where the debate of the privatisa-tion is at a play, with some regions running private-public partnerships10,11.

Corresponding author

Remedios CaleroC/ Los Huertos, 3746500 Sagunto (Valencia). Spain(+34) 666921085remedios.calero@mail.ucv.es

2016; 11(1):148-160152

Within this framework, this study intends to ex-ploreusers’perceptionandevaluationof theheal-thcare service in a threefold way: first, looking fordifferencesbetweenpublicandprivatehealthcare(according to the service provider); second, con-sidering the existence of core and peripheral ser-vices (according to the nature of the service); andthird, from a double perspective of supply (physi-ciansandhospitalmanagers)anddemand(healthcare end-users).

The method followed to achieve this three-fold aim is a combination of qualitative (sevenin depth interviews conducted among threedifferent profiles of physicians and managers)and quantitative (a descriptive survey conduc-ted among 103 Spanish end users of bothpublic and private healthcare services). In thissense, the conclusions of this study shed lighton the comparison of users’ perceptions ofhealth services on public and private models ofhealthcare management according to the grea-ter relevance of peripheral healthcare services.

Conceptual framework

Public and private health care provisionAs it has been announced previously, this studydistinguishes between public and private healthcare provision. From years ago, there is a contro-versy around the way to provide this kind of ser-vice. Countries have adopted different ways ofprovision12,13: Denmark, Finland, Ireland, Norway,Sweden, United Kingdom, Greece, Italy, PortugalandSpainopt foraBeveridgeSystem(through ta-xes and public provision generally) while Austria,Belgium, France, Germany and Netherlands haveaBismarkhealthcareSystem(throughemployersandemployeescontributions, andpublicandpri-vateprovision).Beyondthesedifferencesbetweencountries, and due to the special idiosyncrasy ofthis kind of service, there has been this contro-versy between public and private healthcare withstrong advocates of every opinion14.

Literature15, 17 identify as the main problems inpublic health care provision: excessive bureau-cracy, lack of flexibility, little human resourcescontrol, budget constraints,… Private healthcare provision is accused of: monopolisticpower, lack of equity, pursuit of profit18,19.

Due tohealthcare is consideredasabasicneces-sityandthereforenooneshouldbeexcludedfromitsbenefits12, it canbe justifiedpublicadministra-tion intervention in financing a public health sys-temandensure itsuniversalityandequity.Howe-ver, public fundingofhealthservicedoesnot leadinevitably to theprovisionof this service is carriedoutexclusivelybypublic institutions,existingmul-tiple formsofmanagement thatmaybeevenmoreefficient. Considering the extreme difficulty thatinvolves health distribution and production19,different forms of management are becoming re-levant, like public and private partnerships. Thatis the case of Spain, where in 1999 private initia-tive was introduced in health care management,in what was named “Alzira Model”, not being partof criticisms.

In this context, with multiple ways of health ser-vice provision inside and outside countries, thisstudy intends to explore users’ perception andevaluation of the healthcare looking for differen-ces between public and private healthcare.

Relevance of tangible elements in healthcareserviceOneof themain features thatmakesahealthcareservicedifferent fromothers is the fact thatamongall credence goods, they show the highest diffi-culty of evaluation20. Compared to education, in-surance or tourism, the consumer (in this case,the patient) needs more time to correctly assessthe received outcome, and sometimes may evenbe unable to judge it correctly, due to their lack ofmedical knowledge.

Subsequently, healthcare service outcome isdifficult to evaluate by patients21,22. The patientobviously knows that the symptoms havedisappeared, but he or she does not know ifthe employed procedure was the most efficientone due to a lack of specific technicalknowledge23,24.

Besides, in the healthcare service, thepatient assesses both the quality of the treat-ment and the physician-patient interface, andthe empathy felt. In intensive labour services,as the healthcare service is, the attention isfocused on the experience and on allsurrounding aspects (in the physical environ-ment) 25.

1531./ NV. 11 2016

The importance of the healthcare services offe-ring these tangible elements which the serviceuser perceives is derived from all the above. Thestudied literature concludes that intangibility, asa lack of physical attributes, is the most intrinsiccharacteristic of these services26, 29. Thus, as thehealthcare service is formed by a combination ofactions and processes, such as those mentioned,these services cannot be perceived by the patientexcept through tangible elements such as theequipment and the location28. This way, this givesrise to the question: “What impression is left ona future user who visits a relative in a hospitalwhichconsistsofacleanandwell-decoratedbuil-ding with an attentive and friendly staff?”27. Inother words, without sufficient knowledge, pa-tients tend to evaluate the healthcare servicethrough factors that they can make tangible suchas catering and comfort. This way, patients feelsatisfaction according to the amount of functio-nality, accessibility, comfort and wellness of thefacilities (such as the waiting rooms), contribu-ting greatly to the formation of a global satisfac-tion3.

Influence of tangible elements in patients´behaviourIn 2010, Porter31 distinguishes two purchasing cri-teria: “criteria of use” and “criteria based on sig-nals”. The criteria of use can include intangibleelementsandcomefrompurchasingmotivationsthat do not present an economic character in astrict sense. The criteria based on signals reflectvalue indicators that influencetheperceptionthatthecompanycanmeet thepatients’ criteriaofuse.For example: reputation, image, aspect and sizeof the facilities, etc. (in this way, the portrayal of amedical instrument can have a big impact on theperception of its quality, even when it influenceslittle to nothing in its performance).

For this reason, we observe a tendency inhealthcare management to develop a compe-titive advantage based on changing the clas-sic image of the hospital and the healthcareexperience towards actual and potentialpatients. This is the case of the RiversideMethodist Hospital in Ohio, which has soughtto adapt its service to patients’ demands withthe intention of reducing their feelings of

inferiority compared to the doctors, as well asthe anxiety and uncertainty that they mayexperience. With this effect, the peripheralelements of the healthcare service, such asfacilities or the frequency and duration ofvisits, are instrumental. This way, by impro-ving the patients’ perception, we manage toconvert an unpleasant experience in an enjo-yable and comfortable one26 (Bateson, 1995).

From this point of view, the strategy ofincorporating a series of tangible elementswith which to adapt to the patients’ needsdetermine the hospital’s personality32. As it isknown, differentiation provides a significantbase to distinguish a provider’s service fromthat of another provider29. This differentiationstrategy becomes more necessary as a sector,particularly a service sector, becoming moreand more competitive27. As the competitiongrows, so does the necessity of differentiationbetween providers in a way that they offer aclear perception of differences between exis-ting offers to the patient35,37. Thus, differentia-tion is one of the sources of competitiveadvantages along with cost reduction31.

If we look also at the internal quality, suchas that which is related with the core service,and the external quality, such as that whichrefers to the form in which the service is offe-red38, we will see how in a service such ashealthcare, in which the internal quality isestimated with a reasonable minimum, thepatient is of higher importance to the externalquality, in other words, the way the service isoffered28.

In the terms of Levitt’s Model of ProductDimensions39, the strict medical attention is thegeneric product; the assistance of a professio-nal, the hygiene and minimum services are theexpected product; while the tangible elementsare those in charge of taking the product to itshigher dimension and potential, being thusperipheral services.

METHODS

Theaimofourempirical study is toshed lightoverthe role of peripheral elements in the healthcareservice. To do this, we will adopt a double view of

2016; 11(1):148-160154

supply and demand, with a double methodologi-cal approach that combines qualitative analysisand quantitative analysis.

Qualitative analysisBecause of the special healthcare idiosyncrasy,first an exploratory approach is needed beforeany quantitative analysis. For this purpose, wehave conducted seven in-depth interviews withhealth managers and professionals (physiciansfrom private and public hospitals and health ma-nagers) in order to gain insights for understan-ding the balance between core and peripheralhealth services, from the supply point of view. In-depth interviews are the most appropriate qua-litative technique for an exploratory aim such asthe one pursued in this study40,42.

As this is a qualitative analysis with an explo-ratory aim, no hypotheses are proposed, buttwo research questions instead: their organi-sed discussion in the seven in-depth inter-views allows the establishment of relevantconclusions for the management of the heal-thcare service, which serve as a base for thefollowing quantitative analysis.

RQ1 “The healthcare service presents a greatdifficulty for the user when it comes to evalua-ting it, since the patient lacks sufficient medi-cal knowledge in order to know whether or notthe received healthcare service is the adequateone”.

RQ2 “Peripheral services and various tangi-ble elements (such as access, restauration andcomfort) are valued by the patient equally thanthe core service (such as diagnostic and treat-ment)”.

Owing to the exploratory nature of this firstanalysis, the election of the samples was strati-fied and propositional43 while selecting groupsof interviewees with diversity among them butwho shared homogeneity in their occupationand/or formation, and were connoisseurs ofthe three models of healthcare management.Specifically, the following profiles were chosen:- Profile 1 (3 interviewees): Healthcare staff

with professional experience in the field ofpublic healthcare management as well asprivate: two professional doctors and oneprofessional nurse.

- Profile 2 (2 interviewees): Healthcare staffwho has practised or practises healthcareassistance and currently carries out his workfrom the management field in the Conselle-ria de Sanidad (health regional government).Owing to their experience, they offer a dou-ble vision, as professionals and healthcaremanagers.

- Profile 3 (2 interviewees): Healthcare mana-ger (manager of a public hospital and direc-tor in the Council of Health, charged with im-plementing and managing public-privatepartnerships in this Spanish region).

Quantitative analysisHere, we have conducted a quantitative analysisbased on an on-line survey (N=103) with the aimofdescribingend-users’perceptionofpublicandprivatehealthcareregardingtheirattitudestowardscore and peripheral healthcare services.

The questionnaire posed a block of commonquestions evaluating the amount of satisfac-tion of a patient who used a public healthcareservice, a private one or both types of services;also, questions about the respondents’ socio-demographic profiles were included (seeAppendix A). The questionnaire was then sentvia email to a convenience sample of 200 resi-dents of the Valencian Region, obtaining a finalsample of 103 healthcare users.

RESULTS

The following results aim to offer, from a doublepointofviewofsupply (with theresultsof thequa-litative analysis) and demand (with those of thequantitativeanalysis), theperceptionofperiphe-ral elements against that of the central elementsin the healthcare service.

Perception from the perspective ofhealthcare supplyWith regards to the first research question, focu-sing on the difficulty of evaluation of the heal-thcare service, the majority of the intervieweesconfirm that this difficulty does exist. The inter-viewees confirm the patients’ lack of specificknowledge when it comes to judging the receivedhealthcare service, which is also qualified by one

1551./ NV. 11 2016

of the interviewees as “medical ignorance”. Also,it consists of a service in which the used termino-logy complicates the patients’ comprehension ofthehealthcareservice.However,someintervieweesseeanevolution in thepatient,whoadoptsamoreproactive attitude towards information research.According to one of the interviewees, “The pa-tient’sprofile isevolvingand this isgoodbecausesometimesyousavea lotof explanations, but theinformation is so biased, with no scientific base,that it could evenbecome imprudent. That scien-tific base is what the patient is lacking in. But it istrue that some years ago, patients did not evenhave aminimum base of information”.

The only case, in which an evaluation of thehealthcare service is observed, according tothe interviewees, is the one which concentrateson recidivist pathologies in which, thanks toexperience, the patient is capable of judgingthe received service.

In response to this evaluation difficulty, inthe second research question, we seek to knowif patients tend to evaluate the received servicethrough elements that they can make tangible,giving more or equal relevance to peripheralelements than to central elements in the heal-thcare service. This way, we find a unanimousanswer among the interviewees who continueto highlight the more distinguished role ofsurrounding services against a central service,which goes unquestioned by the patients. Theprofessionalism of doctors and nurses is assu-med and evaluated by the patients, but it doesnot affect their decision-making because theyconsider that this professionalism is at such alevel that it does not depend on the healthcarecentre where they perform their duties.

It is because of this that the elements that drivea patient to choose a healthcare centre or ano-ther are known as peripheral elements. Amongothers, the interviewees mention the following:catering, facilities, timetables, cleaning, etc.

In addition, the interviewees consider thatmore attention should be paid to peripheralservices. One interviewee claims that “theperipheral services must be looked after asmuch as the principal service, without losing asingle apex of scientific, healthcare or assis-tance quality”. Meanwhile, another interviewee

claims that “hospitals should look after image,be it aesthetic or catering, since they constitutea very important part of a hospital, and inmanycases it is not looked after. Moreover, it is loo-ked after more in private healthcare than inpublic healthcare.”

Lastly, it is noteworthy to mention the inter-viewees’ perception of a higher care forperipheral services in private healthcaremanagement than in public.

Perception from the perspective ofhealthcare demandWe will now show the perception of peripheralservices from the demand point of view, throughthe results of our survey. First, we asked patientshowtheyevaluatedifferentelements,be theycen-tral or peripheral, of the healthcare service, dis-tinguishing between public and private. In bothtypes of management, the idea manifested in thequalitative phase by the bidders of the high eva-luation given to medical and nursing professio-nalism, as well as to other central elements suchashygienicandmedical-surgicalelements, is con-firmed.

However, in the case of public healthcareservice (Figure 1), the highest rated elementsby patients are the central ones: hygiene of themedical and surgical team; privacy respect bymedical and nursing staff; and staff professio-nalism. This does not occur in private healthca-re services. In the latter, as shown in Figure 2,the patient gives a higher rating to peripheralelements (such the cleaning of facilities) thanto central elements (such as the medical staffprofessionalism). This confirms the higherrelevance that the peripheral services are rea-ching in the healthcare field, obtaining thisevaluation by patients. And, at the same time,how these peripheral services are more valuedin private than in public healthcare.

Figure 3 offers a comparison between thepublic healthcare system and the private one,where these radically different evaluations bythe patients are more evident. This way, theexposed idea by doctors and managers (in thequalitative phase) that there is a higher care ofperipheral services in private healthcaremanagement, is confirmed.

2016; 11(1):148-160156

Food qualityFacilities comfort

Food quantityInformation provided by nursing staff

Service organizationFacilities cleaning

Nursing staff willingness to listenBedding cleaning

Medical staff willingness to listenInformation provided by medical staff

Nursing staff professionalismMedical staff professionalism

Privacy respect by nursing staffPrivacy respect by medical staff

Higiene of the medical/surgical team0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0 4,5

2,802,84

3,063,163,22

3,283,29

3,353,43

3,483,59

3,733,75

3,864,00

Food quality

Facilities comfort

Food quantity

Information provided by nursing staff

Service organization

Facilities cleaning

Nursing staff willingness to listen

Bedding cleaning

Medical staff willingness to listen

Information provided by medical staff

Nursing staff professionalism

Medical staff professionalism

Privacy respect by nursing staff

Privacy respect by medical staff

Higiene of the medical/surgical team

0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0 4,5

public healthcare service evaluation private healthcare service evaluation

Figure 1

EVALUATION OF PUBLIC HEALTHCARE SERVICE ELEMENTS

Figure 3

EVALUATION OF PUBLIC HEALTHCARE SERVICE ELEMENTS VS. PRIVATE HEALTHCARE SERVICE ELEMENTS

1571./ NV. 11 2016

DISCUSION

Theresultsof thisstudy,bothqualitativeandquan-titative, tend toshowthat inhealthcareprovision,theperipheralservicemustbeconsideredasmoreand more valued by patients, sometimes evenmore than the core service (diagnostic and treat-ment). Ifwe interpret thehealthcareserviceaccor-ding toLevitt’sModelofProductDimensions39,weunderstand that patients do not obtain satisfac-tion solely from their principal needs (basic be-nefits), but they receiveacombinationofperiphe-ral services which provide an added value. Thisway, the patient incorporates these peripheralservices into the core service and turns it into theexpected service. Other differentiating elementswhich are offered by the healthcare service pro-vider (such as timetables and facilities) allow usto elaborate on the increased and even potentialservice, which serve as the healthcare serviceoffer’s definitive configuration and make it into asource of competitiveness.

The peripheral services’ relevance, in light ofthe results of our study, is highlighted via adouble point of view of supply and demand. Onone hand, the lenders of the healthcare serviceinsist on the evaluation of these tangible ele-ments, due to the difficulty for patients to eva-luate the healthcare service itself, and the

more demanding nature of their behaviour. Onthe other hand, we observe how the peripheralelements are very highly rated, along with thehigh ratings of the service’s central elements.This is mostly noteworthy in the cases of priva-te healthcare services, confirming that thistype of management pays more attention toperipheral elements.

Limitations and Managerial implicationsThe firstone limitationwehave foundconcerns tohealth service idiosyncrasy. Health service is verydifficult todescribe, sowehavetried tocapture itsspecial nature through a number of variables, butit is more difficult and complex. A second limita-tioncorresponds to the fact thatwehavenot con-sideredthecoexistenceofothermanagementmo-dels, mainly public-private partnerships. Accor-ding to this, newconceptualproposals, especiallythose based on combined and multidisciplinarymodels would be welcome in order to avoid ha-ving to oppose the public versus private model.

Implications for healthcare management (bothprivate and public) are drawn in terms of betterconsideration of these elements from a manage-rial perspective. In consequence, these resultsshed light to managers and administrators inorder to design the best service for patientsaccording to their needs and preferences.

Figure 2

EVALUATION OF PRIVATE HEALTHCARE SERVICE ELEMENTSFood quality

Facilities comfort

Food quantity

Information provided by nursing staffService organization

Facilities cleaning

Nursing staff willingness to listen

Bedding cleaning

Medical staff willingness to listen

Information provided by medical staff

Nursing staff professionalism

Medical staff professionalismPrivacy respect by nursing staff

Privacy respect by medical staffHigiene of the medical/surgical team

0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0 4,5

3,713,76

3,873,883,913,943,953,97

4,034,034,094,144,194,20

4,00

2016; 11(1):148-160158

1. Shostack, L.G. Breaking free from product marketing. Journal ofmarketing. 1977; 41: 73-80.

2. Lovelock, C.H. Classifying services to gain strategic marketinginsights. Journal of Marketing. 1983; 47: 9-20.

3. Lovelock, C. and Wirtz, J. Services Marketing: People, Techno-logy, Strategy (6th ed.). Prentice Hall, Upper Saddle River, NJ.2007.

4. Palmer, A. Principles of Services Marketing. McGraw-Hill. 2005.5. Kotler, P. and Lee, N. Marketing en el sector público. Todas las

claves para su mejora. Pearson Educación. Madrid. 2007.6. Eiglier, P. and Langeard, E. Servucción. El marketing de servi-

cios. McGraw-Hill. Madrid. 1989.7. Christensen, C.M., Bohmer, R. and Kenagy, J. Will disruptive in-

novations cure health care? In Harvard Business School, Har-vard Business Review on Managing Health Care (pp. 149-173).Harvard Business School Press, Boston. 2007.

8. Herzlinger, H.E. Let´s put consumers in charge of health care, InHarvard Business School, Harvard Business Review on Mana-ging Health Care (pp. 105-130). Harvard Business School Press,Boston. 2007.

9. Pricewaterhouse Coopers´ Health Research Institute. Build andbeyond: the (r) evolution of healthcare PPPs. 2010.

10. Sosa V., Brashers E., Foong S., Montagu D., Feachem R. Innova-ción Incremental: La experiencia de Valencia con asociacionesPúblico-Privadas integradas. Serie sobre Asociaciones Públi-co-Privadas para el sector salud, No. 3, San Francisco: El Grupode Salud Global, Ciencias de la Salud Global, Universidad deCalifornia, San Francisco y PwC. 2014.

11. Sánchez, F.I., Abellán, J.M. and Oliva, J. Gestión pública y gestiónprivada de servicios sanitarios públicos: más allá del ruido y lafuria, una comparación internacional. Elcano Royal Institute,Working Paper 4/2013.

12. Errasti, F. Principios de gestión sanitaria. Díaz de Santos. Ma-drid. 1997.

13. Frende, M.A., Martín, F. and Martínez Fierro, S. La reforma delsector sanitario español: una oportunidad para la cooperaciónempresarial. Comunicación presentada en el IX Congreso His-pano-Francés de la Asociación Europea de Dirección y Econo-mía de la Empresa. Logroño. 1999.

14. Oliva, J., Ruiz-Jiménez, J.L. and Segura, J. Qué hacemos por la sa-nidad pública. Ediciones Akal. Madrid. 2014.

15. Caviedes, R. Concesiones sanitarias: garantizando la sostenibi-lidad del sistema. Ed. Libertad y Desarrollo, Santiago de Chile.2009.

16. Colomer, J. La gestión sanitaria a través de la administraciónpública: burocracia y privilegios. Gestión Clínica y Sanitaria.2009; 4: 140-144.

17. Longo, F. La nueva Gestión Pública: crisis económica y reformade la Gestión Pública. En Colomer, J. & Del Llano, J. (ed.), UnaR

EFER

ENC

eS

1591./ NV. 11 2016

nueva forma de trabajar… mirando al futuro (pp. 31-35), Funda-ción Gaspar Casal, Madrid. 2011.

18. Auriol, E. and Picard, P.M. Privatizations in developing coun-tries and the government´s budget constraint. IDEI WorkingPaper nº 459, Toulouse. 2004.

19. Harford, T. El economista camuflado. Ediciones Temas de Hoy.Madrid. 2008.

20. Zeithaml, V., Berry, L.L. and Parasuraman, A. The nature and de-terminants of customer expectations of service. Journal of theAcademy of Marketing Science. 1996; 21: 1-12.

21. Vertinsky, I.B., Thompson, W.A. and Uyeno, D. Measuring consu-mer desire for participation in clinical decision making. HealthServices Research. 1974; 9 (2): 121-134.

22. Gabbott, M. and Hogg, G. Consumers and services. John Wileyand sons Ed. 1998.

23. Darby, M.R. and Karni, E. Free competition and the optimalamount of fraud. Journal of Law and Economics. 1973; 16 (1): 67-88.

24. Kaplan, R.M. and Babad, Y.M. Balancing influence between ac-tors in healthcare decision making. BMC Health Services Re-search. 2011; 11: 1-14.

25. Uhl, K.P. and Upah, G.D. The marketing of services: why and howis it different? Working Paper 584, University of Illinois, Illinois.1979.

26. Bateson, J. Management Services Marketing. The Dryden Press.Harcourt Brace College Publishers. 1995.

27. Lovelock, C.H. Services Marketing. Prentice Hall InternationalEditions. 1996.

28. Zeithaml, V., Bitner M.J. and Gremler, D. Services marketing. In-tegrating customer focus across the firm (6th ed.). McGraw-HillInternational Edition. New York. 2013.

29. Kotler, P. and Keller, K.L. Dirección de marketing. Pearson Edu-cación. Madrid. 2006.

30. Civera, M. Análisis de la relación entre calidad y satisfacciónen el ámbito hospitalario en función del modelo de gestiónestablecido (Tesis Doctoral, Universitat Jaume I, 2008).

31. Porter, M.E. Ventaja competitiva. Ed. Pirámide. Madrid. 2010.32. Stevens, D. Brand building for hospitals, In Boyer, C., Dunlop, D.,

Stevens, D., Stremcha, J., Teach, D. et al. (ed.), The thought lea-ders project: hospital marketing (pp. 12-20), Bierbaum Pu-blishing, Minneapolis. 2011.

33. Chamberlin, E.H. Product heterogeneity and public policy. TheAmerican Economic Review. 1950; 40 (2): 85-92.

34. Lambin, J.J. Marketing estratégico. ESIC Editorial. Madrid. 2003.35. Gilligan, C. and Lowe, R. Marketing and health care organiza-

tions. Radcliffe Medical Press. New York. 1995.36. Costa, G. Posicionamiento de los servicios de salud en la

mente del consumidor. Revista portuguesa de marketing.2009; 21: 33-42.

37. Medina, P. El carácter estratégico de la proyección externa dela marca hospitalaria: el caso de Mayo Clinic. Universidad ySalud. 2011; 13 (1): 79-86.

38. Alcaide, J.C. Fidelización de clientes. ESIC Editorial. Madrid.2010.

39. Levitt, T. Marketing success through differentiation ofanything. Harvard Business Review. 1980; january-february:83-91.

40. García Ferrer, G. Investigación comercial. ESIC Editorial. Ma-drid. 2002.

41. Legard, R., Keegan, J. and Ward, K. In depth interviews, In Rit-chie J and Lewis J. (eds.), Qualitative Research Practice (pp.138-169), SAGE Publications, London. 2003.

42. Mercado, F.J. and Torres, T.M. Análisis cualitativo en salud. Teo-ría, método y práctica. Ed. Plaza y Valdés. México D.F. 2000.

43. Ritchie, J., Lewis, J. and Elam, G. Designing and selecting sam-ples, In Ritchie J and Lewis J. (eds.), Qualitative Research Prac-tice (pp. 77-108), SAGE Publications, London. 2003.

2016; 11(1):148-160160

App

end

ixA Questionnaire

1. In the last two years, what type of healthcare servicedid you use?

� Public� Private� Both

I: Public Healthcare – If you do not have receivedpublic healthcare, please continue on II

2. During the last two years, have you received healthcareassistance in public primary care?. Detail number oftimes

� Number of times in the place of residence� Number of times in a different city where you live� Number of times in another part of Spain

3. During the last two years, have you received healthcareassistance in public hospital?. Detail number of times

� Number of times in the place of residence� Number of times in a different city where you live� Number of times in another part of Spain

4. Which was the average time of waiting from the firstcontact to the moment that received public primaryhealthcare?

� Less than 24 hours� 1-2 days� 3-4 days� 5-7 days� 8-15 days� 16-20 days� 21-30 days� 31-60 days� More than 60 days

5. Based on your experience, how do you value this timeof waiting?

� Very brief� Brief� Medium� Long� Very long� Don’t know, don’t answer

1611./ NV. 11 2016

6. Which was the average time of waiting from the firstcontact to the moment that received public specialtyhealthcare?

� Less than 24 hours� 1-2 days� 3-4 days� 5-7 days� 8-15 days� 16-20 days� 21-30 days� 31-60 days� More than 60 days

7. Based on your experience, how do you value this timeof waiting?

� Very brief� Brief� Medium� Long� Very long� Don’t know, don’t answer

8. Later, you can see some aspects of public healthcare.Indicate the degree of satisfaction.Possibilities: Very down, Down, Medium, High, Very high

� Medical staff professionalism� Nursing staff professionalism� Hygiene of the medical/surgical team� Privacy respect by medical staff� Privacy respect by nursing staff� Information provided by medical staff� Information provided by nursing staff� Medical staff willingness to listen� Nursing staff willingness to listen� Bedding cleaning� Facilities cleaning� Service organization� Food quantity� Facilities comfort� Food quality

9. Here, you have a list of affirmations about sensationsthat you could have experienced on having receivedthe healthcare service.Possibilities: Nothing, little, indifferent, In agreement,Very much

� I felt disoriented� I felt nervous� I felt inconvenient

� I felt that I was losing the time� I felt guided� I felt calmed� I learned new information about my health

II: Private Healthcare – If you do not have receivedprivate healthcare, please continue on III

10. During the last two years, have you received healthcareassistance in private primary care?Detail number of times

� Number of times in the place of residence� Number of times in a different city where you live� Number of times in another part of Spain

11. During the last two years, have you received healthcareassistance in private hospital?Detail number of times

� Number of times in the place of residence� Number of times in a different city where you live� Number of times in another part of Spain

12. Which was the average time of waiting from the firstcontact to the moment that received private primaryhealthcare?

� Less than 24 hours� 1-2 days� 3-4 days� 5-7 days� 8-15 days� 16-20 days� 21-30 days� 31-60 days� More than 60 days

13. Based on your experience, how do you value this timeof waiting?

� Very brief� Brief� Medium� Long� Very long� Don’t know, don’t answer

2016; 11(1):148-160162

14. Which was the average time of waiting fromthe first contact to the moment that receivedprivate specialty healthcare?

� Less than 24 hours� 1-2 days� 3-4 days� 5-7 days� 8-15 days� 16-20 days� 21-30 days� 31-60 days� More than 60 days

15. Based on your experience, how do you valuethis time of waiting?

� Very brief� Brief� Medium� Long� Very long� Don’t know, don’t answer

16. Later, you can see some aspects of privatehealthcare. Indicate the degree ofsatisfaction.Possibilities: Very down, Down, Medium, High,Very high

� Medical staff professionalism� Nursing staff professionalism� Hygiene of the medical/surgical team� Privacy respect by medical staff� Privacy respect by nursing staff� Information provided by medical staff� Information provided by nursing staff� Medical staff willingness to listen� Nursing staff willingness to listen� Bedding cleaning� Facilities cleaning� Service organization� Food quantity� Facilities comfort� Food quality

17. Here, you have a list of affirmations aboutsensations that you could have experiencedon having received the healthcare service.Possibilities: Nothing, little, indifferent, Inagreement, Very much

� I felt disoriented� I felt nervous� I felt inconvenient� I felt that I was losing the time� I felt guided� I felt calmed� I learned new information about my

health

III: Both Public and Private Healthcare

18. Where did you find the information tochoose the hospital?

� Family� Friends� Newspaper, magazines� Internet� Family doctor

19. Later, you can see a series of reasons thatcan influence you to choose healthcareprovider.Possibilities: Nothing, little, indifferent, Inagreement, Very much

� I trust in the public service� Health problems were solved� Low cost of utilization service� Medical treatments are frequent� It is the only available service in my

area

Profile of the polled oneSex: male /female .......................................................................Year of birth ....................................................................................Work situation ...............................................................................Marital status .................................................................................Number of children....................................................................Income................................................................................................Is your income depending on healthcare sector? ..................................................................................................................

Suggestions to improve the healthcare service..................................................................................................................................................................................................................................