Quality & Quantity

, Volume 43, Issue 2, pp 277–289 | Cite as

An applied stochastic model of the quality–quantity trade-off in the public health care sector

  • Ahmet Kara
Research Note


It is a striking feature of the many of the developing country public service sectors that the sectors in question often overproduce the quantity of services but underproduce the quality. This feature, which is exemplified in this paper, is rooted in a wide spectrum of economic and sociological factors ranging from the economic and sociological profile of the service receiving people to the asymmetric density of service-receiving population across their regions. This feature, we conjecture, is a source of a considerable degree of suboptimality in some of the developing countries. If our conjecture is correct, correcting such suboptimalities is likely to yield significant welfare improvements that could help speed up the process of development in the underdeveloped regions of the world. To analyze the supoopimalites in question, we will first develop a concept (and a model) of optimal quality in the public service sector, which indicates the level of quality that maximizes expected public satisfaction subject to available resources. Resources are used in an efficient manner to produce the service in question. The concept and the model in the paper make a needed contribution to the quality discourse by presenting a way of determining the quality improvements (or adjustments) necessary to achieve optimum in the public service sector. The paper presents an application (a case study) of this new concept in the public healthcare sector in Turkey, and explores the differences between the actual and optimal quality in the sector in question. It turns out that there is a considerable difference between the actual and optimal levels of quality (as well as those of quantity) in the Turkish public healthcare sector in an overpopulated city (Istanbul), indicating a significant overproduction of quantity and underproduction of quality. Thus, to achieve the optimal levels, the sector should increase quality and reduce quantity by a considerable margin. The quantified differences (gaps) between actual and optimal levels point out a considerable room for welfare improvement. Optimum-seeking adjustments closing these gaps could be shown to lead to considerable satisfaction and welfare gains, the measurement of which is worthy of future research.


Quality–quantity trade-off Optimal quality Public service sector 


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  1. Andaleeb S.S. (2001). Service quality perceptions and patient satisfaction: a study of hospitals in the developing country. Soci. Sci. Med. 52: 1359–1370 CrossRefGoogle Scholar
  2. Babakus E. and Boller W.G. (1992). An empirical assessment of the SERVQUAL scale. J. B. res. 24: 253–268 CrossRefGoogle Scholar
  3. Bartel, A.P., Harrison, A.E.: Ownership versus Environment: why are Public Sector Firms Inefficient. National Bureau of Economic Research, Working Paper (1999)Google Scholar
  4. Bloemer J., Ruyter deK. and Wetzels M. (1999). Linking perceived service quality and service loyalty: a multi-dimensional perspective. Eur. J. Mark. 33(11/12): 1082–1106 CrossRefGoogle Scholar
  5. Brady K.M. and Cronin J.J. (2001). Some new thoughts on conceptualizing perceived service quality: a hierarchical approach. J. Mark. 65: 34–49 CrossRefGoogle Scholar
  6. Carman M.J. (1990). Consumer perceptions of service quality: an assessment of the SERVQUAL dimentions. J. Retailing 66: 33–55 Google Scholar
  7. Caruana A., Money H.A. and Berthon R.P. (2000). Service quality and satisfaction—the moderating role of value. Eur. J. Mark. 34(11/12): 1338–1352 CrossRefGoogle Scholar
  8. (1997). Public expenditure: Effective Management and Control. Harcourt Brace, Dryden Press, New York Google Scholar
  9. Taylor A.S. and Cronin J.J. (1992). Measuring service quality: a reexamination and extension. J. Mark. 56: 56–68 CrossRefGoogle Scholar
  10. Taylor A.S. and Cronin J.J. (1994). SERVPERF versus SERVQUAL: Reconciling performance –based and perception – minus – expectations measurement of service quality. J. Mark. 58: 125–131 CrossRefGoogle Scholar
  11. Crosby P.B. (1980). Quality is Free. New American Library, New York Google Scholar
  12. Dabholkar A.P., Shepherd C.D. and Thorpe I.D. (2000). A comprehensive framework for service quality: an investigation of critical conceptual and measurement issues through a longitudinal study. J. Retailing 76(2): 139–173 CrossRefGoogle Scholar
  13. Deming, W.E.: Improvement of quality and productivity through action by management. Nat. Pro. Rev. 1(1), 12–22 (1981–1982)Google Scholar
  14. Domberger S. and Jensen P. (1997). Contracting out by the public sector: theory, evidence, prospects. Oxf. Rev. Econ. Policy 13(4): 67–78 CrossRefGoogle Scholar
  15. Downes T.A. and Figlio D.N. (1999). Do tax and expenditure limits provide a free lunch? Evidence on the link between limits and public sector quality. Nat. Tax J. 52(1): 113–128 Google Scholar
  16. Duncombe W., Miner J. and Ruggiero J. (1997). Empirical evaluation of bureaucratic models of inefficiency. Public Choice 93(1–2): 1–18 CrossRefGoogle Scholar
  17. Evans J.R. and Dean J.W. (2003). Total Qualty: Management, Organization and Strategy. Thompson and South-Western, Ohio Google Scholar
  18. Fayek N.Y., Nel D. and Bovaird T. (1996). Health care quality in NHS hospitals. Int. J. Health Care Qual. Assur. 9(1): 15–28 CrossRefGoogle Scholar
  19. Haskel, J., Sanchis, A.: A Bargaining Model of Farrell Inefficiency. CEPR Discussion Papers, Working Paper (1998)Google Scholar
  20. Juran, J.M.: The quality triology. Qual. Prog. 19–24 (1986)Google Scholar
  21. Juran J.M. and Gryna F.M. (1993). Quality Planning and Analysis. McGraw Hill, New York Google Scholar
  22. Kanji G.K. and Yui H. (1997). Total quality culture. Total Qual. Manage. 8(6): 417–428 CrossRefGoogle Scholar
  23. Kanji G.K., Tambi A.M.B. and Wallace W. (1999). A Comparative study of quality practices in higher education institutions in the US and Malaysia. Total Qual. Manage. 10(3): 357–371 CrossRefGoogle Scholar
  24. Kanji G.K. and Sa P.M.E. (2003). Sustaining healthcare excellence through performance measurement. Total Qual. Manage. Bus. Excell. 14(3): 269–289 CrossRefGoogle Scholar
  25. Kara A. (2005). A concept of optimal quality and an application. Total Qual. Manage. Bus. Excell. 16(2): 243–255 CrossRefGoogle Scholar
  26. Kara A., Tarım M. and Zaim S. (2003). A low performance-low quality trap in the nonprofit healthcare sector in Turkey and a solution. Total Qual. Manage. Bus. Excell. 14(10): 1131–1141 CrossRefGoogle Scholar
  27. Kara, A., Tarım, M., Zaim, S.: A dynamic model and empirical examination of performance and customer satisfaction in a non-profit health-care sector in Turkey. In: Tarim, M., Zaim, S. (eds.), Proceedings of International Management Development Association Conference pp. 519–526 (2002a)Google Scholar
  28. Kara, A., Tarım, M., Zaim, S.: Expectation and performance-based determinants of service quality: a special case at a non-profit hospital in Turkey. In: Proceedings of International Management Development Association Conference pp. 556–562 (2002b)Google Scholar
  29. Kara A., Lonial S., Tarım M. and Zaim S. (2005). A paradox of service quality in Turkey. Eur. Bus. Rev. 17(1): 5–20 CrossRefGoogle Scholar
  30. Kara A. (2000). Dynamic Modeling Exercises. Fatih University, Mimeo Google Scholar
  31. Karlaftis M. and MacCarthy P. (1999). The effect of privatization on public transit costs. J. Regul. Econ. 16(1): 27–43 CrossRefGoogle Scholar
  32. Kaya, S.: Developing a Quality Management Program for the Ministry of Health Hospitals in Turkey. Takemi Program in International Health. Harvard School of Public Health, Research Paper (2000)Google Scholar
  33. Li X.L. and Collier A.D. (2000). The role of technology and quality on hospital financial performance: an exploratory analysis. Int. J. Serv. Ind. Manage. 11(3): 202–224 CrossRefGoogle Scholar
  34. Lim P.C. and Tang N.K.H. (2000). The development of a model for total quality healthcare. Manag. Serv. Qual. 10(2): 103–111 CrossRefGoogle Scholar
  35. Nicholson, W.: Microeconomic Theory. Dryden Press (1998)Google Scholar
  36. Parasuraman A., Zeithaml V.A. and Berry L.L. (1985). A conceptual model of service quality and its implications for future research. J. Market. 49: 41–50 CrossRefGoogle Scholar
  37. Parasuraman A., Zeithaml V.A. and Berry L.L. (1988). SERVQUAL: A multiple item scale for measuring customer perceptions of service quality. J. Retailing 64: 12–40 Google Scholar
  38. Parasuraman A., Zeithaml V.A. and Berry L.L. (1991). Refinement and reassessment of the SERVQUAL scale. J. Retailing 67: 420–450 Google Scholar
  39. Rao A., Carr L.P., Dambolena I., Kopp R.J., Martin J., Rafii F. and Schlesinger P.F. (1996). Total Quality Management. Wiley, New York Google Scholar
  40. Savas B.S., Karahan Ö., Saka R.Ö. Health care systems in transition: Turkey. In: Thompson, S., Mossialos, E. (eds.) Health Care Systems in Transition, Vol. 4(4), European Observatory on Health Care Systems, Copenhagen (2002)Google Scholar
  41. Shi M.S. (1994). The inefficiency of the public sector and trade theorems: a simple general equilibrium analysis. Acad. Econ. Pap. 22(2): 211–35 Google Scholar
  42. Sivadas E. and Baker-Prewitt J.L. (2000). An examination of the relationship between service quality, customer satisfaction and store loyalty. Int. J. Retail Distrib. Manage. 28(2): 73–82 CrossRefGoogle Scholar
  43. Scrivens E. (1995). International trends in accreditation. Int. J. Health Plann. Manage. 10: 165–181 CrossRefGoogle Scholar
  44. Tanzi, V.: The Role of the State and the Quality of the Public Sector. IMF Working Papers (2000)Google Scholar
  45. Taylor A.S. and Cronin J.J. (1994). Modeling patient satisfaction and service quality. J. Health Care Mark. 14(1): 34–45 Google Scholar
  46. Teas R.K. (1994). Expectations as a comparison standard in measuring service quality: an assessment of a reassessment. J. Mark. 58: 132–139 CrossRefGoogle Scholar
  47. West D.M. (2004). Government and the transformation of service delivery and citizens attitudes. Public Adm. Rev. 64(1): 15–27 CrossRefGoogle Scholar
  48. World Bank.: Honduras: toward Better Health care for All. World Bank County Study, Washington (1998)Google Scholar
  49. Yavas U., Bilgin Z. and Shemwell D.J. (1997). Service quality in the banking sector in an emerging economy: A consumer survey. Int. J. Bank Market. 15(6): 217–223 CrossRefGoogle Scholar
  50. Yavas U. and Shemwell D.J. (2001). Modified importance-performance analysis: an application to hospitals. Int. J. Health Care Qual. Assur. 14(3): 104–110 CrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media B.V. 2007

Authors and Affiliations

  1. 1.Department of EconomicsFatih UniversityIstanbulTurkey

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