1. Introduction

Brand equity―the differential effect of brand knowledge on consumer responses to a brand―is an essential concept in marketing literature [34]. Positive brand equity results in a variety of advantages (e.g., in terms of customer attitude, purchase intentions, word-of-mouth marketing, and profits in manufacturing and service sectors) that have been explored in prior marketing studies [19, 44, 51, 54, 62]. Since brand equity is a valuable asset, understanding how to develop, measure, and manage brand equity is extensively discussed in marketing research [17].

Brand equity may have a more substantial impact on services than on manufacturing firms. It can help consumers confirm a consistent quality level before they experience a service since the intangible nature of services makes it hard for consumers to assess its quality [41]. However, despite the importance of brand equity in the non-manufacturing sectors, there has been relatively scarce research on how brand equity impacts can differ across areas [14, 17, 41]. Primarily, brand equity is essential in government sectors since it can increase the public’s credence, trust, and loyalty to the government [9]. Public sectors develop their brand equity to disseminate their messages or policies to the public and thereby achieve their goals of increasing public awareness and participation [4]. However, for the public health system, few studies can be found in the literature on the brand equity effects of governments and public institutions and subsystems. In fact, a previous study on the EMS is Lee et al. [43], but it concerns the operational planning and scheduling of emergency medical systems under uncertainty. Therefore, there is a big difference from this study. Thus, the purpose of our research is to examine how public perceptions of a subsystem’s service quality affect the public health system’s brand equity development.

The public health system has encountered great challenges due to the rapid transmission of the Middle East respiratory syndrome coronavirus in 2015 as well as the coronavirus disease in 2019. The repercussions of such crises have drawn attention to public concerns over the emergency medical system while highlighting the importance of emergency medical services (EMSs) in the public health system. Despite the importance of the public health sector, there has been criticism that the industry has suffered from lower customer satisfaction due to a lack of understanding of customers’ needs from a marketing perspective [64]. Gromark and Melin [24] suggested that the public sector should understand brand values to build a holistic and balanced relationship between a service provider and customers to improve customer satisfaction. Sun et al. [64] applied internal marketing in the Korean public health sector, revealing a positive relationship between self-efficacy, internal customer satisfaction, service innovation, internal service quality, and competitive advantage.

Under these circumstances, EMS has garnered public attention as a subsystem of the public health system with regard to providing solutions for emergencies and crises [18]. EMS provides more opportunities than other health services to obtain health information and advocate for patients and interact with them as they move through the healthcare system [65]. Shah [59] found that EMS has emerged as an essential axis of the public health system due to its influence on medical and historical outcomes or social forces. It is crucial to understand EMS’s contributions to the public health system, observe its role, and identify its public perception. However, EMS has mainly been studied separately from the public health system in the literature. Previous research on EMS effectiveness tended to place greater weight on the suppliers’ viewpoint (government) than the beneficiaries’ (public) [e.g. 30, 57]. Research exploring EMS as a subsystem of the public health system is scarce [18]. Thus, it is pertinent to examine the impacts of EMS services' public perception on the public health system.

For these reasons, a user-centred approach is necessary to establish a system of governance and infrastructure in the public health system to justify and support the sustainability of policies. The public evaluation should be reflected in related policies as long as public health system is recognized as a public good. Through this process, policies can be improved and validated. However, the interactions among the individual functions of EMS; the public health system as the overall governance of a preventive, proactive, and responsive coordination system; and other forms of social capital have rarely been studied separately in earlier research. Furthermore, it is important to understand how the public evaluation of a sub-system of the public health system such as EMS affects the brand equity of the public health system, as the public does not perceive EMS as a separate system from the public health system [18, 57].

We classify EMS via a user-centred approach into four functions: 1) rescue/first-aid and transfer activities, 2) disaster prevention, preparation, and response activities, 3) educational activities in urgent situations, and 4) medical treatment in emergency rooms (ERs). The functions were based on the existing laws governing the EMS in South Korea, and questionnaires were developed to evaluate public satisfaction with each of the sub-functions. This study analyses the effects of these four EMS functions on the public health system’s brand equity using Keller’s customer-based brand equity (CBBE) model. A structural equation model was used to empirically test the relationships among the variables.

We provide important theoretical and practical contributions, unlike previous studies that focused on the brand equity of profit organizations, methods to improve the quality of EMS from a supplier’s perspective, or an analysis of the operational status of the EMS for disasters [33, 39, 56, 61]. First, we performed the scale development of four EMS functions. Second, we contribute to the brand equity literature as we lend empirical support for the relationship among brand identity, brand image, brand responses, and brand relationship to understand the establishment of brand equity in the public health system. Third, we examined the impact of public perception of the EMS, which is a subsystem of the public health system, on the brand meaning of the latter. The impact implies that role-sharing can be considered appropriate between the central and subsystem (local) governments. As both are stakeholders in public healthcare governance, this can improve the system’s overall coordination. Besides, we find a moderating effect of the level of coordination between the central and local government on the relationships between the four EMS functions and the public health system’s brand meaning. If the public perception of the governance structure is low, it would be difficult to support EMS as a subsystem of the public health system.

2. Literature Review and Hypothesis Development

2.1 Emergency Medical Service as a Subsystem of Public Health System

The World Health Organisation (WHO) defines the public health system as all organised measures (whether public or private) to prevent disease, promote health, and prolong life expectancy holistically. In South Korea, the public health system is defined in Article 2 of the Public Healthcare Act as ‘all activities, regardless of regions, classes, and sectors, performed by central and local governments and health and medical institutions, so that universal medical service is guaranteed and public health is promoted.’ In addition, Article 7, Section 1 in the same Act determines the range of public healthcare, including situations where there is a shortage of medical services due to low profitability such as for childhood and maternal diseases, people with disabilities or mental disorders, EMS for disasters and infectious diseases. Article 3 in the Disaster and Safety Management Act classifies infectious diseases as social disasters and prescribes the establishment of preventive measures against epidemics immediately after the outbreak of diseases such as those in Article 2 of the Prevention and Supervision of Infectious Diseases Act. Likewise, the social role of EMS is defined as a subsystem of public healthcare both at home and abroad.

As stated above, WHO emphasizes the necessity of immediate and overall coordination for infection prevention and a control strategy for infectious diseases that have the potential to cause public healthcare disasters. That is, WHO recommended that the strategy should be implemented systematically at a national level involving administrative control, environmental and engineering controls, and Personal Protective Equipment controls [73]. Additionally, Article 2, Section 5 of the South Korean Public Healthcare Act establishes an overall coordination system to prescribe that “the delivery system in public healthcare implies that central or local governments build a systematic role-sharing among the following public healthcare institutions such as National Medical Center, national university-affiliated general hospitals, and regional (private) and local hospitals to provide the following job tasks of public healthcare, defined at Article 7, Section 1 in the Public Healthcare Act.” However, despite the enactment of these laws, 185 human casualties occurred in South Korea in 2015 following the lack of an initial nationwide response and well-organized infection control due to the absence of a holistic national collaborative response system. The total casualties increased to 423 people worldwide, including cases in Saudi Arabia and the UAE [74]. With this new global and national trend, the value of emergency medical treatments by public and private response agencies and an overall holistic national collaborative response system have emerged as social capital that would improve public healthcare.

The role of EMS is defined in Article 2 of EMS Act, as “any medical treatments for emergency patients, including counselling, rescue, transfer and first aid, in a medical treatment process from the occurrence of emergency patients until the patients has recovered from a life-threatening risk or the serious mental or physical injuries have been removed.” In summary, an operational definition of EMS based on the above definition, Article 25 in the EMS Act, Article 1 in the Rescue and Relief Act, Article 4 in the same act, enforcement decree 12 in the Disaster and Safety Management Act, and Article 4 in the Prevention and Supervision of Infectious Diseases Act has been provided. This operational definition includes: 1) rescue/first-aid and transfer activities, 2) medical treatment in ERs after transfer to hospital, 3) disaster prevention, preparation, and reaction activities including for infectious diseases, and 4) educational activities in urgent situations such as fire, disasters, and occurrence of emergency diseases before arrival at the hospital. <Table 1> shows the subsystem and definitions of emergency medical services. In this paper, 1) first-aid activities, 2) disaster reaction activities, 3) educational activities, and 4) medical treatment in ERs were included.

2.2 Brand Equity

The three main streams in the literature on brand equity are Ahmad and Thyagaraj [2] 1) factors that affect brand equity, 2) impacts of brand equity, and 3) development of brand equity measurement. The first stream examined factors that influence brand equity. Customer satisfaction [66], brand credibility, brand commitment and loyalty intentions [45], word-of-mouth marketing [49], country-of-origin of brand [48], country of origin [53], service quality [27], product country image and marketing activities [7], advertising [13], corporate social responsibility and corporate reputation [60], service empathy and network quality [27], and recall management [40] affect brand equity. These studies suggest that consumer perceptions of a company’s product or service should affect branding performance (e.g. brand credibility, reputation, and brand equity). Despite several studies that identified the factors influencing brand equity, research to help understand brand equity in the public sector is scarce. Therefore, our study examines the impact of public perception of EMS on the public health system’s brand equity.

The second stream explored the impacts of brand equity. Consumer preference and purchase intentions [14], retailer’s dependence and commitment to the manufacturer [19], risk to the firm’s debt/equity holders [54], brand loyalty [51], customer acquisition, retention, and profit margin [62], consumers’ willingness to pay price premiums, and consumers’ attitude towards brand extensions, brand preference, and purchase intention [12] are some of the factors affected by brand equity.

Since our study develops scales to measure the public health system’s brand equity, we mainly focus on the third stream. Aaker [1] used brand loyalty, brand awareness, perceived quality, brand associations, and brand assets to measure brand equity. Keller [34] added brand knowledge, combining brand awareness and brand image to measure brand equity. Yoo and Donthu [75] developed a multidimensional consumer- based brand equity scale―perceived quality, brand loyalty, and Brand awareness/associations. Vázquez et al. [68] developed a consumer-based brand equity scale that included product functional utility, symbolic product utility, brand name functional utility, and brand name symbolic utility. Netemeyer et al. [52] developed scales to measure the brand equity of 16 different brands from six product categories in the US. They used perceived brand quality, perceived brand value for the cost, brand uniqueness, brand awareness, brand familiarity, brand popularity, organisational association, and brand image consistency. Pappu et al. [53] added brand personality and organisational association to measure brand associations of cars in Australia. Wang et al. [71] developed a brand equity index that includes brand awareness, brand associations, service quality, and customer loyalty in the context of Taiwan’s healthcare industry. Baalbaki and Guzmán [6] introduced two new dimensions (sustainability and social influence) to measure smartphones’ brand equity in the US.

However, there is still a need to construct brand equity measurements for different industries [6, 68]. These brand equity measurements should prove useful in different industries, as they are psychometrically robust and parsimonious enough to be manageable [2, 70], potentially allowing practitioners to measure the customers’ perceptions of brands. We found only a few studies measuring brand equity in the health system. Berry and Seltman [10] conducted a case study of the Mayo Clinic to investigate the interrelationship between brand communication with customers, brand awareness, brand meaning, and brand equity. Kim et al. [37] identified five dimensions―trust, customer satisfaction, relationship commitment, brand loyalty, and brand awareness―of building brand equity in hospitals.

2.3 Customer-Based Brand Equity in Public Health Service

A typical measure of brand equity uses Keller’s CBBE [35] model. Keller elucidated how for-profit and nonprofit organisations could construct their brand equity both in the manufacturing and service sectors. The CBBE framework follows a four-stage sequential process consisting of brand identity, brand meaning, brand response, and brand relationship. Brand identity is the first stage of CBBE and is concerned with whether the brand is known and recognised by customers, and whether the brand performs its functions properly [37]. There are two reasons why brand identity is essential: first, customers tend to respond more actively to a brand they feel a personal connection with [29]; second, brand meaning affects how brand identity is established [37]. Becker-Olsen and Hill [8] found that when brands from nonprofit organisations are consistently exposed to the public and perform their functions properly, customers associate themselves with those particular brands, which becomes their brand identity. In this context, we studied four EMS functions: rescue/first-aid and transfer activities, disaster prevention, preparation, and response activities, educational activities in urgent situations, and educational activities in urgent situations, and 4) medical treatment in ERs.

A lasting and consistent brand identity gives a special meaning that involves an intrinsic image or belief regarding the brand. These images and beliefs are multi-faceted [38] and differ by nature of the organisation [69]. Most importantly, it should fit the intrinsic brand identity image that customers recognise [8]. Customers or the public assign characteristics to a brand, such as ruggedness, sophistication, competence, excitement, and sincerity, through exposure to it [11]. These characteristics embody the brand identity association [36]. Such systematic brand management is essential for EMS. Therefore, as mentioned above, EMS is managed within or together with public health system. The EMS is perceived by the public as a part of public health system, and the image of EMS will affect the overall image of the public health system. At this point, the perspective of this study, which regards EMS as a lens in recognizing the public image of public health system, is a unique perspective of this study and corresponds to its contribution.

Based on the review results of previous studies introduced above, the operational definitions of the main concepts of this research model are summarized in <Table 2>.

Next, the research hypotheses were then formulated as follows:

The following four sub-hypotheses were posited for each function.

Brand response can be considered a cognitive and emotional response developed by brand meaning [36]. Cho et al. [15] argued that certain images, such as those that convey mystery, sensuality, and intimacy, influence a customer’s response to fashion brands―that is, customers may generate favourable or unfavourable responses depending on the brand image. For the public health system, its intrinsic and unique image guides public response in distinct ways [47]. For example, a patient’s trust in the public health system is critical because it delivers services as part of the social infrastructure and requires cooperation or collective action [23]. The services provided by the public health system are intangible in nature and difficult to measure, thereby making trust necessary to reduce transaction costs and perceived risks. Thus, we hypothesise the following:

Customers develop a unique relationship with a brand through the accumulation of cognitive and emotional responses to the brand. This relationship constitutes brand loyalty, and the brand relationship strengthens as customers’ loyalty increases [35]. Service organisations need to build customers’ loyalty, which is the ultimate goal of all marketing activities. Thus, we hypothesise the following:

2.4 Role of Public Health Service Governance in Establishing Image

Governance refers to an autonomous and horizontally complex organisation with interdependent players, such as the state, market, and civil society [32], and shares commonalities with policy networks [55]. Thus, the concept of governance is useful in resolving almost all areas of difficulty involving multiple stakeholders in modern society. Governance has been studied mainly in public administration focusing on the organising factors in networks [e.g., 28, 32, 63].

A governance structure that includes interactions among stakeholders is also vital to overall health system performance [5]. Many experts and non-governmental organisations have severely criticised the global governance regime in healthcare, attributing failures to deal with emergency disaster situations to a lack of disaster response capacity of individual national governments and the inability of a joint response by the concerned international community [18]. Gulland [25] pointed out that many state officials recognise that crises in the public health system may go far beyond the public healthcare problem itself. However, effective governance is also possible when public participation is voluntary and thus, is not merely a governmental matter [63]. This requires a positive response from the public and depends on the credibility of the various institutional actors [23]. In a sense, even if the public has a positive perception regarding individual players, it is unlikely to show strong support for policy performers if its overall perception of governance is poor. This belief also applies to the cooperative relationship between the public health system and EMSs. The public reflects the functions of the EMS more actively in the brand meaning of the public health system when they have a positive brand meaning, rather than a negative one, based on their perception of the level of governance between central and local governments concerning EMSs and disaster response. For instance, we measured the public perception of how the central government collaborates with the local government to communicate, reach a consensus, or perform joint business for regional emergency and disaster response activities. We hypothesise the following:

Four additional sub-hypotheses were constructed for each EMS function.

Based on the aforementioned hypotheses, our research model is illustrated in <Figure 1>.

3. Method

3.1 Development of the Instrument

We developed the survey questionnaires for four functions of EMS as no papers have measured them. We adopted the approach by Secchi et al. [58] to develop the constructs' operational definitions and survey items. First, we conducted a comprehensive literature review and explored existing operational definitions to build the constructs. Next, we determined the conceptual dimensions for each construct. We refined their operational definitions and selected related items from scales used in previous studies in public health policy and marketing. We created additional items that might fit the construct definitions. When items were not available, we developed new items from public health laws, team members’ work experience, and interviews with other healthcare professionals on EMS’s role in South Korea. We did not perform Q-sort to measure reliability and validity of the initial survey items; however, we performed the interviews to check face validity. We reviewed them with two healthcare professionals in a local hospital and a marketing faculty member at a university in South Korea to ensure the validity of the constructs and the basic adequacy of the sample items addressing each construct. Separate interviews were conducted via conference calls and face-to-face meetings between the university and the local hospital. Through the interviews, construct definitions and items were refined, and the gaps were resolved.

We reworded the survey items used in existing literature [42] to measure the governance coordination between central and local governments. Additionally, we used the CBBE process in the previous papers [8, 34] to measure the brand equity of the public health system. CBBE is divided into four stages: 1) brand identity (Step 1) is concerned with the role of organizations; 2) brand meaning (Step 2) shows the images and beliefs regarding organizations; 3) brand response (Step 3) is built by the public’s trust, belief in the system’s sincerity, and feelings; and 4) brand relationship (Step 4) is built by cumulative interactions between the brand and the public.

Last, the operational definitions of the constructs developed for this study are based on a consensus between healthcare practitioners and academic professionals.

3.2 Survey Procedure and Sampling

We conducted the survey at two universities (one national and one private) in South Korea using a paper-based collection method, which allowed us to control for bias arising from different formats and settings of the questionnaires [20]. We then surveyed university students who had experience with the EMS provided by the public health system in South Korea to understand how they perceived the public health system. The participating university students were appropriate for our research, as understanding the purpose of our study did not require any work experience or expertise in public health.

All the subjects were informed about the research and agreed to participate in the survey. Of the approximately 180 questionnaires that were distributed, 150 were used for our analysis after excluding those with missing data. The demographic characteristics of the survey respondents are summarized in <Table 3>.

We adopted several approaches to address sources of bias that might affect the results of the survey. First, we adopted the approach by Secchi et al. [58] to address and resolve common method variance (CMV). The survey instrument was developed based on feedback from several academic experts and practicians regarding wording problems and clarity [16, 46]. To prevent social desirability bias, which might affect the responses of the survey, the respondents were assured of confidentiality. They were provided with the contact information of the university’s Institutional Review Board [58]. Further, if CMV occurs, it implies that items from different constructs are highly intercorrelated and load together [50]. We performed statistical methods such as factor analysis to identify whether CMV was present, which revealed that the items were not artificially correlated with each other. Therefore, CMV was not a significant problem.

Another threat to validity is bias due to differences between respondents and non-respondents [3]. However, when we performed the paper-based survey in a classroom, the bias did not affect our survey results.

4. Results

4.1 Reliability and Validation of Survey Questionnaires

After developing the questionnaires to measure the four functions of EMS and brand identity, brand image, brand response, and brand relationship of the public health system, we checked the questionnaires’ reliability and validity. First, we conducted exploratory factor analysis. Initially, we had a total of 13 items under ‘Four functions of EMS’. Our criteria for factor extraction were as follows: eigenvalue ≥ 1, factor loading ≥ 0.5, and communality ≥ 0.5 [26]. Each of the 13 items had independent explanatory power, as shown in <Table 4>. All four factors were then given suitable labels: ‘first-aid activities’ (factor 1), ‘disaster preparation and response activities’ (factor 2), ‘educational activities’ (factor 3), and ‘medical treatment in ERs’ (factor 4).

Second, we conducted confirmatory factor analysis to check the validity of our measurement tool. Throughout this procedure, convergent and discriminant validity was tested by computing factor loading, construct reliability (CR), and average variance extracted (AVE). Cronbach’s α ≥ 0.7, factor loading ≥ 0.5, CR ≥ 0.7, and AVE ≥ 0.5 are desirable [26]. As reported in <Table 5>, some AVEs are slightly below 0.5, while all other statistics are within the acceptable ranges. Thus, convergent validity holds for our variables because AVE is a more conservative index than CR. Fornell and Larcker [22] argued that researchers might use CR and factor loading instead to test convergent validity when AVE falls short of the base value. This was on the grounds that AVE leads to a more conservative result, although it is a working index for convergent validity as well as CR. In addition, the overall model fit was acceptable because χ² = 769.560, df = 461, χ²/df = 1.669, Comparative Fit Index (CFI) = .923, Tucker-Lewis index (TLI) = .911, and Root Mean Square Error of Approximation (RMSEA) = .067 [26].

4.2 Hypothesis Testing

A structural equation modelling path analysis was conducted to test the hypotheses. <Table 6> summarizes the results of hypothesis testing for the main effect. The functions of EMS significantly affect the brand meaning of the public health system. For instance, first-aid activities (M = 5.17, SD = 1.05) positively influenced the brand meaning (M = 4.30, SD = .96) of the public health system (H1-1) (.305; p < .01). When the public has a positive perception of first-aid activities (e.g. patient delivery, professional first-aid activities, and first-aid training) in EMS, they build a positive brand image involving functional performance, perceived integrity and consistency, and a clear image of the public health system. Education activities (M = 2.95, SD = 1.31) positively affected the brand meaning of the public health system (H1-3) (.245; p < .05). Positive public perceptions of medical education activities (e.g. education activities for severe diseases, natural disasters, and first aid equipment) result in a positive brand image of the public health system. Medical treatments in ERs (M = 4.12, SD = 1.25) positively affected brand meaning of the public health system (H1-4) (.374; p < .01). Similarly, a positive public perception of medical treatment in ERs (e.g. quick response to patients, systematic emergency operating system, and triage and emergency assessment) results in a positive brand image of the public health system. However, disaster response activities (M = 3.11, SD = 1.37) did not affect the brand meaning of the public health system (H1-2) (.165; p > .05). The perceptions of these activities (e.g. the emergency system for epidemics, quick response to epidemics, and emergency operating systems in major accidents) did not affect the public health system’s brand image.

Brand meaning positively affected the brand response (M = 4.15, SD = .98) of the public health system (H2) (.826; p < .01). When the public has positive perceptions of the public health system’s brand image, they build a positive brand response, including leadership, trust, sincerity, and emotion toward the public health system. Brand response positively affected the brand relationship (M = 4.12, SD = 1.14) of the public health system (H3) (.636; p < .01). When the public has positive perceptions of the public health system’s brand response, they build a positive brand relationship that includes positive word-of-mouth communication, affection, and loyalty. The results for Hypotheses 1, 2, and 3 are illustrated in <Figure 2>.

After testing the hypotheses in the basic model, a multi-group comparison analysis was conducted to verify Hypothesis 4 that tested the moderating effect of the perceived level of governance (between the central and local governments) on the relationship between the four functions of EMS and the brand meaning of the public health system. The sample was sorted into two groups labelled ‘High’ (the group whose perception level of governance is higher than the sample mean) and ‘Low’ (the group whose perception level of governance is lower than the sample mean), using the mean-split method on the perception of level of governance (M = 4.00, SD = 1.04) in the public health system between the central and local governments. First, a hierarchical robustness test was conducted before analyzing the path difference between the two groups. In general, a base model with no constraints was used as a starting point, and then the robustness of factor loading between the groups and structural weights was checked [21, 26]. <Table 7> shows the robustness test results between the two groups divided by the perception level of governance and suitability to conduct comparative path analysis.

<Table 8> shows the differences in the effects of brand identity on the perception of governance in EMS. Hypotheses 1, 2, and 3 were concerned with EMS’s impact on loyalty to the public health system. However, the public is a beneficiary of the public health system and participates in its governance. Thus, even if public perception is positive regarding an individual EMS function, it is unlikely to imply strong support for the entire EMS system if the overall perception of EMS governance is poor. As expected, EMS functions (rescue/first-aid and transfer activities, educational activities in urgent situations, and medical treatment in the ERs) had a significant impact on the brand meaning of the public health system in the ‘High’ group, while there were a few functions (i.e. medical treatment in ERs) that affected its brand meaning in the ‘Low’ group. Thus, Hypothesis 4 was partially supported. Meanwhile, the impact of both the ‘brand meaning to brand response’ (High = .853; Low = .527) and ‘brand response to brand relationship’ (High = .543; Low = .453) paths was significant.

Finally, <Figure 3> illustrates the impact of the perception of governance between the four functions of EMS and the brand meaning of the public health system.

5. Conclusion

5.1 Discussion and Implications

We adopted customer-based brand equity (CBBE) to develop the measurement for four functions of EMS and brand meaning, brand response, brand relationship of the public health system. We examined how four functions of EMS builds brand identity and influence brand meaning of the public health service. We found how the perception of governance levels (low vs. high) between local and central government affects the relationship between four functions of EMS and brand meaning of the public health service. Then, our findings provide evidence that the public health system must be considered a part of the governance structure, as validated by research hypothesis 4. When the public perceives a high level of coordination between the central and local government, it accepts a user-centred approach where EMS is viewed as a subsystem of the public health system. Its performance is highly correlated with that of the public health system as a whole.

Further, our findings show that the public health system is not limited to an administrative system, but is a social service managed by the public’s evaluation of public services. Our application of Keller’s CBBE suggested that EMS plays a role to positively affect the entire governance of the public health system. For instance, EMS, especially first-aid activities, educational activities, and medical treatment in ERs, plays a significant role in brand equity for the public health system.

Our findings show the public perception of EMS, a subsystem of the public health system, partially affects the public health system’s brand meaning. We find that ‘disaster response activities’ as a function of EMS are not directly linked to the establishment of the brand meaning of the public health system, while the other three functions are positively related. This does not mean that the importance of disaster response activities can be ignored. Rather, it is necessary to find the reasons for their insignificant effect on the public health system’s brand image. First, the activities related to ‘rescue/first-aid’, ‘educational activities’, and ‘medical treatment in ERs’ are demonstrated more frequently and found at a closer distance than ‘disaster prevention, preparation, and response activities’. This may affect the public’s psychological distance, and the activities involved in evaluation since different attitudes and behaviours towards certain subjects or events often depend on temporal and spatial distance [67]. Second, disasters may be attributed to inevitable accidents but the public cannot be protected against them by the public health system’s internal capabilities through contingency planning. Such situations are affected by the content of communication between the public and the media. For example, when an unavoidable accident occurs (e.g. oil spill), negative information on the organisations responsible for the accident leads the public to attribute the cause of the accident to internal institutional factors (e.g. mistakes by the organisations; [31]).

Our study holds three theoretical implications regarding the emerging importance of EMS. First, we extended the literature of public sector marketing with a set of developed measurement scales of four EMS functions (first-aid activities, disaster response activities, educational activities, and medical treatment in ERs) that build the brand identity of the public health system. Second, we extended the importance of brand equity to the public organizations. Our study found the empirical support for brand identity, brand image, brand responses, and brand relationship to understand the establishment of brand equity in the public health system. Lastly, we identified the impact of the public perception of EMS, a subsystem of the public health system, on building brand equity of the overall system. An organisation needs to recognise that customers’ perception of its subsystem’s service quality affects its parent organisation’s brand equity, which can signal perceived service quality before customers experience its service [41].

We provide three practical implications. First, customers in the public health system can evaluate both EMS and the public health system as a whole, but they do not view it separately. It is thus not desirable to manage EMS and the public health system separately. Administrators in the public health system should make more significant efforts in first aid, education, and medical treatment in ERs to build strong public health system loyalty. This might help administrators establish a future vision and more pro-popular policies for the public health system. Second, our findings indicate that consumer satisfaction with EMS can affect the public health system’s brand equity. It is interesting to note that the various EMS functions in this process independently influence the brand meaning formation of the public health system. Therefore, administrators should consider the details of what to do and how to improve satisfaction with EMS’s various functions. To improve the overall level of satisfaction with EMS, it is necessary to investigate what needs to be done and how it could be implemented in the future. Third, EMS’s impact on the brand image of the public health system is moderated by the public perception of the level of governance. Administrators should pay close attention to managing an effective governance structure between the central and local governments to generate a favorable brand image and public loyalty towards the public health system. For instance, the central government should be openly willing to receive local governments’ opinions and reach an agreement if there is a conflict between the two parties over policies or laws for emergency response systems. The central government must also ensure systematic cooperation with the local governments by supporting educational activities in ERs or monitoring the local governments’ needs.

5.2 Limitation and Future Research

The limitations of our study are as follows. First, as our work was conducted in South Korea, the brand equity measurement needs to be extended to other countries to be valid. Second, EMS is an integral part of the public health system, but it is not the same as the public health system. In major developed countries, government agencies provide funding to private and public hospitals to maintain an adequate EMS quality. Although some private hospitals also offer EMS in Korea, EMS’s policy direction and the corresponding budget support are led by the Ministry of Health and Welfare. This is the case in the US as well. However, there are some differences by state for example, in Maryland in the US, state governments have been leading the way in EMS by providing greater publicity than Korea regarding the role of EMS. Although EMS is not the only component of the public health system, we have empirically confirmed that the perceived level of public satisfaction with EMS can be an adequate indicator of their perception of the national public health system.

<Appendix 1> The Survey Scale Item

** 공공의료란, 공공성이 요구되는 의료로, 공공성은 사회적 가치관에 따라 달라질 수 있으며, 공익실현을 위해 정 부의 개입이 필요한 영역이라 할 수 있습니다. 주요 역할로는, 공중보건, 질병예방, 보건교육, 국가적 재난․재해 대비 및 대응, 응급의료 등의 다양한 업무가 있습니다.

※ 관련 기관으로서는 지역 119소방과 병원의 응급실, 보건소, 지자체이다.

** 국가적 재난․재해․응급상황 대처는 중증환자, 신종 전염병, 대규모 사상자 발생 등의 각종 비상사태에 대비, 대응하는 활동을 말합니다.

** 중증환자란, 뇌졸중․심뇌혈관․중증 외상을 가진 환자를 말합니다.