Testing Hirschman’s exit, voice, and loyalty model: citizen and provider responses to decline in public health services

Abstract

Dissatisfied users of public services may choose to voice or exit. But when does voice emerge? To answer this question, we deploy Hirschman’s exit, voice, and loyalty (EVL) model. We set out an ‘available alternatives’ hypothesis—increasing the number of exit options reduces voice—in contrast to an ‘effective voice’ hypothesis where voice is lower when there is no choice. We expect the exit-voice relationship to be moderated by loyalty; and providers that respond to user voice improve satisfaction and reduce exit. We evaluate these hypotheses in a survey experiment on publicly funded doctors’ services in the UK. We find no effects of the number of exit options on voice, nor evidence for loyalty as a moderator. A response by the provider results in higher satisfaction and lower intention to exit, strengthened by loyalty. Providers can promote satisfaction and discourage users moving to alternative providers by responding to voice.