“Sustainable business development of private hospitals in Vietnam: Determinants of patient satisfaction, patient loyalty and revisit intention”

ARTICLE INFO Phan Thanh Hai, Nguyen Thanh Cuong, Van Chien Nguyen and Mai Thi Thuong (2021). Sustainable business development of private hospitals in Vietnam: Determinants of patient satisfaction, patient loyalty and revisit intention. Problems and Perspectives in Management, 19(4), 63-76. doi:10.21511/ppm.19(4).2021.06 DOI http://dx.doi.org/10.21511/ppm.19(4).2021.06 RELEASED ON Wednesday, 13 October 2021 RECEIVED ON Monday, 23 August 2021 ACCEPTED ON Friday, 01 October 2021


INTRODUCTION
The healthcare sector in the market economy is witnessing competition among hospitals in attracting patients to use medical services at these hospitals. The patient-centered philosophy requires hospital managers and leaders to have appropriate strategies in attracting new customers, as well as ensuring patient satisfaction and loyalty, thereby ensuring business success. Previous studies have shown that loyal customers tended to pay more when using medical services, as well as having less resistance with the service delivery process (Evanschitzky et al., 2012). The cost to retain the patient was also significantly less than the cost to attract new patients. However, characteristic of the healthcare field is that most patients only visit the hospital when they have a desire to have their illness diagnosed and treated, and they mostly have no desire to return hospital if not for their illness (Liu et al., 2021). This has created great challenges in maintaining the loyalty of patients. Studies investigating factors related to patient satisfaction and loyalty have been  Zarei et al., 2015). These studies play an important role in deciding the right marketing strategy for each hospital. Several previous studies have shown the important role of factors such as hospital brand image and service quality in patient satisfaction and loyalty (Aliman & Mohamad, 2016;Ware et al., 1978). However, in each country and each sector, the degree of influence of these factors is different. Therefore, understanding the relationships between these factors is necessary to support the efforts of hospitals in improving the performance of their service delivery.
Vietnam is one of the countries with fast economic growth, leading to a rapid increase in people's demand for high-quality healthcare. It is estimated that the healthcare market in Vietnam reached 19.9 billion USD in 2020 and is expected to reach 22.7 billion USD in 2021 with an annual growth rate of 12.5% (Spire Research & Consulting Pte Ltd, 2020). However, the healthcare market in Vietnam is mainly dominated by public hospitals, while the private sector accounts for only a small proportion with an estimated total market of USD 8.7 billion by 2020 (Spire Research & Consulting Pte Ltd, 2020). According to the report of the Ministry of Health, in 2019, the total number of private hospitals increased from 102 hospitals (2010) to 231 hospitals with approximately 16,000 beds, accounting for 19.4% of the total number of hospitals in Vietnam (Vietnam Ministry of Health, 2019). Currently, private hospitals have advantages over public hospitals in making quick decisions and optimizing resources, as well as the ability to deploy extensive marketing activities and medical services which public hospitals do not have the financial and administrative capacities to perform (Nguyen & Wilson, 2017). However, some studies have revealed significant disparities in the service quality provided by public hospitals and private hospitals (Nguyen & Nguyen, 2014;Tran et al., 2005). In addition, the Vietnamese government is promoting the autonomy of public hospitals in terms of administrative and financial aspects (London, 2013). This could diminish the existing advantages of private hospitals and increase competitiveness among hospitals. Therefore, determining the factors affecting patient loyalty is a key for the survival and sustainable development of private hospitals. Currently, no studies have been conducted to evaluate the factors related to patient loyalty and revisit intention in Vietnam. Therefore, this study aims to identify some associated factors, namely hospital service quality and hospital brand image, with patient satisfaction, patient loyalty, and revisit intention at private hospitals in DaNang city, Vietnam.

Definitions
Hospital brand image is defined as an intangible asset of the hospital, formed from the quality that patients perceive and the value of the hospital, in other words, the impression of patients and customers about the hospital (Yagci et al., 2009). Hospital brand is a factor that helps to ensure the sustainable development of the hospital, as well as the uniqueness of the hospital in the perception of patients (Roberts & Dowling, 2002). A positive hospital image helps to position the hospital brand in the market, demonstrating patient trust in the hospital (Kim et al., 2008a). However, the hospital brand image always changes depending on the patient's perception and experience. Therefore, a good hospital brand image promotes the patient choice of hospital services.
Service quality is widely recognized as one of the key factors affecting the business performance and outcomes of service organizations (Liu & Tsai, 2010;Mei-Liang & Kuang-Jung, 2013). Service quality refers to the customer or patient assessment of the actual service compared to their expectations (Bitner et al., 1991;Parasuraman et al., 1988;Zeithaml, 1988). In fact, before using a service, patients will have expectations about what they will get when they use that service, then they compare this expectation with the actual service they receive (Wu, 2011). Service has quality when it ensures to meet the patient's expectations (Lytle & Mokwa, 1992).
Patient satisfaction refers to the patient attitude during the whole process of using healthcare services, including before, during, and after utilization (Kim et al., 2008b). Patient satisfaction is also related to whether the service meets the patient's expectations. It is an important metric in monitoring and evaluating hospital performance, which is used by healthcare facility leaders in their decision-making processes. Patient satisfaction is related to the doctor-patient relationship and affects the treatment process and the re-visit of the patients (Hekkert et al., 2009).
Loyalty is defined as a deeply held commitment to rebuy or patronize a preferred product/service consistently in the future, thereby causing repetitive same-brand or same brand-set purchasing, despite situational influences and marketing efforts having the potential to cause switching behavior (Oliver, 1999). Due to the distinguishing characteristics of the healthcare industry from other service industries as mentioned above, theories regarding customer loyalty to other services may not be applicable in the healthcare field (Liu et al., 2021;Sheth & Park, 1974). In this study, the information that will be collected from patients will help determine their perception of patient loyalty, thereby building tools and scales to measure patient loyalty. In addition, the study results also help to provide evidence on the mechanisms of patient loyalty formation, which will assist hospitals in developing effective marketing strategies and business models.
Revisit intention is considered as an aspect of loyalty and several previous studies in the healthcare sector have shown a strong association between behavioral intentions and the actual behavior of this concept. Evaluation of revisit intention is also a metric used to determine patient loyalty (

Effect of satisfaction on loyalty and patient revisit intention
In previous studies, customer satisfaction was considered an important predictor of loyalty with organizations. Many studies in the healthcare sector also show the same thing. Kim et al. (2008b) showed that patient satisfaction also had a positive impact on their intention to revisit. At the same time, patients often express their satisfaction through the evaluation of the hospital service (Bendall-Lyon & Powers, 2004); hence, patients having satisfaction with the service were more likely to reuse that service.

AIM
This study was conducted to measure patient evaluation of the relationship between hospital service quality, hospital brand image, patient satisfaction, patient loyalty, and revisit intention at private hospitals in DaNang city, Vietnam.

HYPOTHESES AND RESEARCH MODEL
Based on the content of the literature review, the study proposes ten research hypotheses as follows: H1: Service quality at private hospitals has a positive impact on patient satisfaction.
H2: Service quality at private hospitals has a positive impact on patient revisit intention.
H3: Hospital brand image has a positive impact on patient loyalty.
H4: Hospital brand image has a positive impact on patient satisfaction.
H5: Patient satisfaction has a positive impact on patient loyalty.
H6: Patient loyalty has a positive impact on patient revisit intention.
H7a: Service quality at private hospitals has a positive relationship with facilities.
H7b: Service quality at private hospitals has a positive relationship with human resources.
H7c: Service quality at private hospitals has a positive relationship with the reasonableness and transparency of service prices.
H7d: Service quality at private hospitals has a positive relationship with the medical examination and treatment process.
Synthesized from many previously published studies, the model used for this study is proposed in Figure 1.

Sampling and scale of research
A typical survey was conducted in DaNang, a tourist city in Vietnam. The city's health system includes 86 medical facilities, with 7 private hospitals and 1,223 beds. The data collection period was from January to March 2020. Criteria for selecting survey participants included individuals who were undergoing inpatient or outpatient treatment at private hospitals and all of them agreed to participate at the time of the survey. Regarding the study sample size, the minimum sample size for exploratory factor analysis (EFA) should be 5 times higher than the total number of observed variables in the questionnaire (Hair et al., 2006). Therefore, the questionnaire in this study has 35 observations so the sample size must be larger than 175 (

Statistical analysis
Cronbach's alpha test is used to measure the reliability of observations in each research scale. The scale is acceptable when the Cronbach's alpha coefficient of the scale is greater than 0.6 and the corrected item-total correlation is greater than 0.3 (Peterson, 1994). EFA was then performed on all items on the scale. In the EFA analysis, KMO

Infrastructure (INF)
The hospital campus and environment are guaranteed to be green, clean, and beautiful

RESULTS
Information on patients participating in the survey is presented in Table 2. The majority of patients surveyed were between the ages of 18 and 30

Procedures (PRO)
The medical examination and treatment process is clearly posted, public, easy to understand, and is guided enthusiastically by medical staff PRO1 Developed by the authors The hospital has a good process for responding to patient and family comments PRO2 Al-Damen (2017) Medical staff guide how to take the drug, what issues to monitor, and pay attention to while taking the drug PRO3 Developed by the authors The hospital adheres to the appointment schedule and time of examination, medication distribution, and counseling to meet the expectations of patients and their families PRO4 Bentum-Micah et al.
The hospital performs services and processes such as registration, payment, medical examination, testing, screening, admission, and discharge during examination and treatment correctly from the beginning

Results of Cronbach's alpha and EFA testing
In Table 3, the Cronbach's alpha coefficient of all independent and dependent variables is > 0.6, suggesting that all variables in the scale have high reliability and could be included in the CFA and SEM analysis.

CFA result
In Table 4, the reliability of factors in the model is suitable via C.R values is > 0.7, the AVE values are > 0.5, meaning that the components in the scale are reliable and have convergent validity. Correlation coefficients among factors are < 0.85, suggesting that components in the scale have discriminative validity. The model had 542 degrees of freedom, and the CFA model had the Chi-squared = 772.715 with p = 0.000; Chi-Square/df = 1.426 (< 2); TLI = 0.962 > 0.9; CFI = 0.966 > 0.9; RMSEA = 0.04 < 0.08; Thus, with the indicators obtained from the results of CFA, the proposed model is consistent with the actual data collected (Figure 2).

SEM model
The This result showed that the model was suitable for the data collected ( Figure 3).
The SEM model was implemented to evaluate the direct influence of independent variables such as hospital service quality and hospital brand image with dependent variables such as patient satisfaction and patient loyalty, patient revisit intention. Next, this model evaluated the direct influence of service quality on factors such as facilities, medical personnel, service prices, and medical examination and treatment processes. The results in Table 5 show that except for the relationship between satisfaction patient and hospital brand image is not statistically significant (p > 0. 05   The evaluation results also show that hospital service quality has a direct positive correlation with facilities (H7a: p < 0.001), health workers (H7b: p < 0.001), transparent and reasonable service prices (H7c: p < 0.001), and medical examination and treatment process (H7d: p < 0.001).

DISCUSSION
With the increasing health care needs of people in Vietnam, the involvement of the private hospitals in this industry plays an important role, supporting public health facilities in ensuring protect the health of the people. The development of medical examination and treatment services at private hospitals will help people have more choices about the best healthcare services that are suitable depending on the conditions of individuals and families. This study was conducted to examine the relation-  tor that contributes to service quality. For patients, the hospital brand image may be important in deciding to use a service, but it is not an important factor determining their satisfaction. Satisfaction is determined by service quality including equipment, facilities, human resources, transparent and clear service prices, and medical examination and treatment process, which does not come from the brand image.
Several suggestions can be drawn from the study results. Firstly, the hospital brand image acts as a factor that directly affects patient loyalty, leading to the promotion of the patient intention to re-examine. Therefore, in the operational strategy of private hospitals, brand image management should be concentrated and prioritized, especially in building a positive and valuable brand image for patients. Possible measures include online advertising, building good customer relations, or training in branding for key medical staff. In addition, the hospital can deploy special and modern medical services, thereby helping to position the value of the hospital. Second, hospital service quality has an important impact on patient satisfaction and revisit intention, indicating that service quality is a factor that needs attention and improvement in private hospitals. Hospital leaders need to develop customer-oriented health service delivery strategies to help customers have high-quality medical service experiences. These strategies need to be implemented synchronously, systematically, and comprehensively from equipment, facilities, human resources, transparent and clear service prices, and medical examination and treatment processes. These improvements will ensure the sustainability of patient satisfaction and patient loyalty, thereby helping to increase revenue and profit for the hospital.

CONCLUSION AND LIMITATIONS
This study was conducted with the aim to measure the relationship between hospital service quality, hospital brand image, patient satisfaction, patient loyalty and revisit intention of private hospitals in Vietnam. On that basis, the aim is to provide policy implications to create the foundation for marketing and customer care programs of private hospitals in Vietnam towards sustainable business development.
The results of the study show that there are 9/10 accepted hypotheses. This study provides practical evidence on the role of hospital service quality and hospital brand image in important outcomes such as patient satisfaction and patient loyalty. Service quality has a direct effect on patient satisfaction and re-