Expanding the TQM Customer Satisfaction Model: The Role of Leadership and External Factors in Pakistan’s Public and Private Hospitals

Abstract

Healthcare systems in developing countries have faced longstanding issues in achieving patient expectations because of limited resource allocation, weak governance, and infrastructure gaps. Total Quality Management (TQM) has been examined as a systematic, integrated approach to enhance the delivery of healthcare services and improve customer satisfaction (CS). However, previous empirical work including the recent contribution by Tessema et al. (2025) has tended to focus on private hospitals, adopt convenience sampling, and did not include and integrate the external contextual factors into model development leading to limited generalizability. This study addresses the external contextual factors that Hong et al. (2022) identified and examines the TQM–CS relationship in both the public and private hospitals in Pakistan, a developing country which is characterized by a fragmented healthcare system comprising resource constrained hospitals in the public sector, and relatively nimble private providers. The study collects data from a stratified population of doctors, nurses, paramedics, supervisors, and managers, and builds and tests an extended model with SQ (service quality) as a mediator, and leadership support, economic conditions, and technology advancement recommended as part of the TQM–CS model the moderators. Structural equation modelling (SEM) was applied to provide support for the complex relationships involved. TQM had the greatest indirect effect on CS through SQ, and leadership support and technology readiness strengthened this positive pathway. Economic conditions reduced TQM implementation mainly in public hospitals. This study contributes to theory and practice by situating the TQM–CS relationship in the context of South Asian healthcare.

Keywords: Customer Satisfaction, Total Quality Management, Service Quality, Leadership Support, Public and Private Hospitals.