literature review service quality

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Impact of Service Quality on In-Patients’ Satisfaction, Perceived Value, and Customer Loyalty: A Mixed-Methods Study from a Developing Country

Nhi xuan nguyen.

1 Faculty of Business Administration, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam

Tuyet Anh Nguyen

2 Department of Business, Minerva University, San Francisco, CA, USA

Recent literature on healthcare quality demands more contextualized and patient-perspective research, as models from developed countries are not suitable for developing countries. Moreover, research on private healthcare services in Vietnam has long been underestimated by academia, but it has significant economic and commercial value. Hence, this study explores the dimensions of service quality in private healthcare and how they impact in-patient satisfaction, perceived value, and customer loyalty in Vietnam.

This mixed-method study had a sample size of five inpatients for the qualitative phase and 368 inpatients for the quantitative phase from hospitals in Vietnam. The qualitative analysis explores service quality dimensions in private healthcare and incorporates them with the literature to develop a conceptual model. The quantitative phase tests the relationship between each construct in the conceptual model via structural equation modeling.

The four dimensions of service quality were emotion, function, social influence, and trust. Most of these dimensions have a significant impact on customer perceived value and satisfaction. However, emotion does not significantly influence customer perceived value, and function does not considerably impact customer satisfaction. In addition, social influence is an underrepresented variable in the service quality literature, but it has the most substantial impact on customer perceived value and customer satisfaction. The quantitative results also confirm that customer satisfaction and customer perceived value significantly impact customer loyalty (word-of-mouth and revisit intention); however, customer perceived value does not significantly impact customer satisfaction.

The study suggests that private healthcare providers and the government in Vietnam should allocate resources to improve service quality. Practitioners should invest in social branding and e-services to reach out to their customers. Future research should focus on a cost-benefit analysis and compare the effectiveness of service quality dimensions on customer behavioral intention.

Private healthcare services are a crucial part of the global health system. Private healthcare providers have increasingly become involved in health systems, both in scale and scope, because of their potential. For instance, privately funded services stimulate equity in the society. Since clients from the middle and wealthy classes prefer to pay more for the private healthcare service to meet their requirements and higher service expectations, private healthcare providers satisfy those who can afford it and facilitate the public healthcare system to focus on those who cannot afford it. Additionally, private healthcare providers’ involvement in healthcare fosters accessibility to health services among people living in rural areas. 1 In addition, the private healthcare system shoulders the fiscal burden with governmental bodies when finance for maintenance, rehabilitation, and new investment in high-quality equipment. Recently, the private healthcare system has reiterated its role by joining the battle with a pandemic crisis. Amid the Covid-19 pandemic, many national healthcare systems worldwide have been overwhelmed. To alleviate the grave challenges and deal with pertinent implications, governments collaborate with private healthcare providers to enhance proactive and collaborative public-private partnerships. Hence, it is crucial to nurture a high-quality and sustainable private healthcare system in all nations.

Health care administrators and physicians have long strived to provide high-quality services. However, many studies have pointed out the healthcare literature lacks patient-centered design and localized research. Scholars have indicated that healthcare service providers should follow the patient-centered design to improve patient experiences and the value of care because it can help healthcare managers and policymakers make investments in the right element. However, a recent study pointed out that while employees consider the quality of a specific service element to be too low, patients do not always perceive it as a big problem. 2 Besides, prior research usually deploys quantitative methods, such as SEM-PLS, when studying service quality and behavioral intention. As service quality dimensions may differ according to surveyed contexts, quantitative analysis alone is not sufficient to make practical recommendations for healthcare service providers. 3 A recent systematic review recognizes that previous papers on measuring the quality of healthcare primarily utilized models from developed countries’ origin. This study suggests that research in developing countries should construct a model for measuring the quality of healthcare services, as models in developed nations might not be appropriate in developing contexts. With regard to research on patient experience of service quality in developing countries, there is little research in Vietnam. The majority is in Iran, Pakistan, Bangladesh, and India. 4 Hence, the context of our research is in Vietnam to bridge the literature gap.

In Vietnam, private health services have coexisted with public health services for over 20 years, but their scale and size are still small compared to their public counterparts. However, private healthcare services have the potential to bring about profitable business opportunities and economic growth. As stated by the Ministry of Health, when they implement a series of preferential policies to invest in medical examination and treatment, a considerable increase in private hospitals and hospitals with foreign investment occurs accordingly. Moreover, according to the Law on Corporate Income Tax since 2009, special tax incentives for businesses operating in the healthcare industry will remove many obstacles in private health activities. As the government has assisted private medical institutions with their supply side challenges, private healthcare providers’ current goal is to redirect patients from the public sector into their sector.

Vietnamese residents still prefer state-funded healthcare providers, leading to an overload in this sector, but a tragic scene in the other. One of the rationales is the higher price of private health services in Vietnam. However, researchers have stated that price is not a primary determinant when choosing private hospitals. 5 Instead, inpatients in emerging markets rely on convenience, turnaround time, specialties, reputation, and word-of-mouth in their decision-making process of private healthcare services. A previous study has also shown that the clinic’s delivery methods, such as customer-oriented care and amenities, might be more important than perceptions of physician’s technical skills and treatment methods. Therefore, service quality in health care might become a critical factor in inpatients’ choice of hospitals. It also indicated that technical quality across a range of private providers in Vietnam seems to be inferior to that of public institutions, although public healthcare services are also of a low standard. 6

There are two recent studies on service quality and customer loyalty in Vietnam. However, both studies have focused on public institutions. The first study recognizes that total quality management has a significant impact on in-patient’s perceived service quality and patient satisfaction, leading to patient loyalty in the public sector. In the limitation section, the authors question whether these relationships exist in the private healthcare context. 7 The other article, which researched the perceived crowding on patient satisfaction in public institutions, also acknowledges in its discussion that Vietnamese patients have different preferences for service quality between private and public healthcare. Public and private healthcare institutions also have different business models and business selling points; hence, the strategy for public institutions might not be transferable to private healthcare. 8 Thirdly, in terms of methodology, these two articles use SEM to measure patients’ perceptions of service quality, customer satisfaction, and customer loyalty. All these variables are subjective; therefore, quantitative methods may not reflect the perception or view of patients thoroughly. Therefore, there is a need for qualitative methods to comprehensively explore the demand for inpatients. From the practical contribution, the novelty of this research lies in contextualization, as understanding the context is likely to assist in making more practical and effective policies. From the theoretical contribution, this research will enrich the recent literature on the private sector, where profit-driven institutions aim to enhance their service quality to boost profits rather than lower costs and make it affordable in the public sector.

Literature Review

In 1985, scholars defined service quality as the comparison between customers’ expectations and their perceived service performance. 9 In the healthcare context, the main dimensions of service quality are (1) functional quality (or process quality), defined as the way healthcare providers deliver healthcare services to patients; and (2) technical quality (or outcome quality), related to the accuracy of medical procedures and diagnoses. 10 As most patients do not have enough knowledge to assess the technical side, our research concentrates on functional quality. Customer perceived value refers to customers’ assessment of the utility of products and services, which hinge upon their perceptions of what they give and what they receive in return. 11 Researchers normally operationalize customers’ perceptions of service quality in the healthcare context. 12 In other words, CPV in healthcare is patients’ assessment of service quality before deciding to use the healthcare service. Meanwhile, customer satisfaction pertains to customers’ comparison between expectations and the actual performance of services experienced by patients. 13 Therefore, researchers distinguish service quality, CPV, and customer satisfaction based on the patients’ evaluation stage. Service quality provides the criteria that patients use to evaluate hospital services. CPV appears when the patients use the criteria to assess service quality before usage based on external information such as friends’ recommendations or perceived cost and benefit. Customer satisfaction then occurs after usage when patients evaluate whether the quality of service achieves their perception of service quality.

To measure service quality, scholars have also developed the SERVQUAL model to help service providers identify and effectively improve their service delivery. The SERVQUAL model categories service quality into five dimensions: tangibility, reliability, responsiveness, assurance, and empathy. 14 This research paved the way for scholars to examine the impacts of service quality from customers’ perspectives. Subsequently, the modified SERVQUAL model in healthcare settings has become widely used to analyze patient’s perceptions of service quality. When researchers adopt this model in the healthcare context, they define service quality as medical services that simultaneously maximize inpatients’ welfare and balance the expected benefits and losses during the treatment process. The extent to which healthcare service quality meets inpatients’ demand depends on the service outcome, service process, and physical environment. 15 However, scholars have also pointed out the limitations of the SERVQUAL model in the healthcare context. Two significant problems are that this patient-centered approach fails to examine the patient’s evaluation of the outcome and the interaction between service users and service providers. 16 Secondly, there is little research on where scholars investigate the service quality dimensions from Vietnamese inpatients and in Vietnam’s healthcare system. These literature gaps lead the authors to carry out a qualitative review with inpatients, with the aim of determining the dimensions of service quality from the inpatients’ perspectives in the healthcare context of Vietnam.

After the qualitative phase, this study re-categorizes healthcare service quality into four dimensions: (1) emotion, (2) function, (3) trust, and (4) social influence. The researchers defined the scope of these dimensions based on previous studies. First, emotional value is the feeling or affective state generated by consumption experience. This study also stated that promoting positive or mitigating negative emotional states in emotional value plays a vital role in personal health. 17 Secondly, functional value refers to economic benefit and the functionality provided by a product or service. In healthcare, functional value illustrates how patients’ consumption of private healthcare services helps them achieve good health. Third, trust relates to the confidence of inpatients in medical staff’s professional ability and the reliability of medical service. 18 Finally, social influence is patients’ perceptions of service providers’ reputation through patients’ close networks, social media, and patients’ communication with medical experts. It also includes service providers’ contributions to society via offline or digital spaces, such as medical webinars or pro bono services. 19 , 20

Regarding CPV, although the perception of customer-related service quality is very subjective, existing empirical studies have pointed out that companies with high customer perceived value have more competitive advantages than their competitors and are more likely to retain customers. While previous empirical studies have shown that emotional value and social influence significantly affect CPV, these findings are in non-medical contexts. 21 , 22 Hence, to further understand the influence of service quality on CPV, the study posits the following hypotheses:

H1a: Function positively affects Customer perceived value.

H2a: Emotion positively affects Customer perceived value.

H3a: Social influence positively affects Customer perceived value.

H4a: Trust positively affects Customer perceived value.

In healthcare, in-patient satisfaction is a continuous evaluation based on the stimuli related to the stages before and after customers’ use of medical services. If healthcare providers can exceed the expectations of their inpatients in the long run, they can achieve sustainable success in the long run. 15 In recent healthcare research, most empirical studies have pointed out that service quality positively influences customer satisfaction. For instance, scholars investigating inpatients from eight private hospitals in Tehran, Iran, showed a causal link between service quality and overall satisfaction in private hospitals. 23 In online life insurance, social influence also strongly connects with customer satisfaction. 24 Therefore, authors formulate hypotheses as follows:

H1b: Function positively affects Customer satisfaction.

H2b: Emotion positively affects Customer satisfaction.

H3b: Social influence positively affects Customer satisfaction.

H4b: Trust positively affects Customer satisfaction.

Numerous studies on the relationship between CPV and customer satisfaction have shown that a higher CPV leads to higher customer satisfaction. Smith and Swinehart found that consumers’ perceptions of quality play a vital role in determining the satisfaction level in healthcare. 25 Other empirical studies in the medical context also support this finding, such as health insurance products in Malaysia and medical tourism services. 26 , 27 Thus, the following hypotheses are proposed in the Vietnamese private healthcare industry:

H5: Customer perceived value positively affects Customer satisfaction.

Customer loyalty occurs when the customer is willing to repeat purchases of products to build a stronger relationship with the provider. 28 According to Yim et al, customer loyalty makes the customer choose a supplier as their preference and resist all persuasion by its competitors. 29 Through the lens of private healthcare inpatients, this research focuses on two main aspects of customer loyalty. They are customers’ revisit intention (customer intention to visit to use the services of the private healthcare units again) and word-of-mouth behavior (people’s sharing experiences both orally and electronically).

Existing literature has explored the positive effects of CPV on customer loyalty. Caruana and Fenech conducted a postal survey among dental inpatients and found that CPV, directly and indirectly, affects customer loyalty. 30 Data collected from 515 hospitalized inpatients of 2 tertiary hospitals in India, 31 and the study on the association between CPV and in-patient loyalty in Turkish public university hospitals also reach the same conclusion. 32 Thus, researchers posit that:

H6a: Customer perceived value positively affects Revisit intention.

H6b: Customer perceived value positively affects the Word-of-mouth.

In addition to CPV, the literature has confirmed the relationship between customer satisfaction and customer loyalty in the healthcare context. For example, data from 40 private hospitals in Hyderabad, India, found that in-patient satisfaction is directly related to inpatients’ loyalty to the hospital. 33 Investigating six private hospitals in Pakistan, scholars also proposed that in-patient satisfaction is positively related to in-patient loyalty. 34 Thus, the following research hypotheses are put forward:

H7a: Customer satisfaction positively affects Revisit intention.

H7b: Customer satisfaction positively affects the Word-of-mouth.

Concerning the relationship between WoM and revisit intention, scholars believe that the former is an antecedent of the latter. Recently, an empirical analysis of the United Arab Emirates’ government healthcare system pointed out that WoM positively impacts inpatients’ continuous use of the healthcare services provided by a given hospital. 35 Similarly, the public healthcare industry in Turkey has also been proven to have a significant link between WoM and repurchase intentions. 36 Meanwhile, while research on nursing satisfaction indicated that revisit intention is also negatively affected by negative WoM; 37 therefore, the authors propose the following hypotheses:

H8: Word-of-mouth positively affects Revisit intention.

This literature illustrates the importance of service quality on CPV, customer satisfaction, and customer loyalty; however, specific research on private healthcare in Vietnam is limited. With the qualitative findings and the literature gap, Figure 1 visualizes the conceptual model and research hypotheses.

The conceptual model and research hypotheses.

Methodology

Research design: mixed-method approach.

According to McKim, the combination of qualitative and quantitative research will allow researchers to generate insightful patterns on customer behaviors from in-depth interviews and verify these observations with rigorous analysis. 38 This combination will deliver both information-rich data and data-driven results for practical decision-making in organizations and businesses. Hence, this study employs a mixed-method approach to investigate the impact of service quality on revisiting behavior and the tendency to recommend inpatients in Vietnam’s private healthcare industry.

Following this approach, researchers have designed the research into two phases. In Phase 1, the qualitative study conducted in-depth and open-ended interviews with inpatients. Between phases 1 and 2, the researcher used the collected data to develop four service quality dimensions and incorporated them with the literature to build a conceptual model for the quantitative phase. In Phase 2, the research employed Covariance-based Structural Equation Modeling (CB-SEM) to analyze the relationship between each construct in the model, with the aim of determining how service quality in private healthcare can impact the revisit intention and WoM of inpatients.

Phase 1: Qualitative Study

The qualitative phase explores the factors that influence service quality in the private healthcare context and how these factors might later impact revisit intention and WoM. To achieve this goal, the principal investigator conducted five in-depth interviews ( Table 1 ) with private hospital inpatients via face-to-face or telephone interviews within Ho Chi Minh City, Vietnam. He has Ph.D. qualifications, works as a lecturer for MBA students, and has previous publications in qualitative studies. As the qualitative step only acts as a pivot to explore how inpatients perceive service quality, the researcher employed the convenience sampling method from a close professional network. However, the researcher had no formal relationship with the participants. While the researcher recruited 7 participants, two participants refused to schedule the interview because they had other personal commitments. The interviewed group included one male and four females with ages ranging from 20 to over 35 years. They experienced various medical problems, such as neurology, gastroenterology, and lungs, and they all recovered from their medical problems through interview sessions ( Table 1 ). The diversity in participants’ medical treatment backgrounds helps researchers identify and acknowledge the demand of inpatients across private healthcare contexts. Moreover, the researcher interviewed inpatients after hospital discharge to respect the participants’ health and ensure that they had fully experienced the service and treatment process.

Demographic Characteristics of the Qualitative Samples

The purpose of using semi-structured questions is to cultivate targeted, rich and detailed information about the factors influencing individual decisions after using healthcare services. Each interview lasted 45 to 60 minutes via face-to-face or telephone interviews. Before the analysis, the research collected in-patient demographics and briefed them about the study’s goals. The in-patient answers and opinions were recorded via audio and later coded into themes for analysis. After collecting information from the inpatients, the researchers then investigated the antecedents of service quality in the specific context of healthcare services in Vietnam, seeking answers for the Board of Directors at private hospitals to make decisions in the future. For this study, the researchers developed a series of 5 core questions to facilitate conversation and maintain consistency in data collection. This interview guide can also help researchers achieve the optimum interview time by systematically, comprehensively, and relevantly collecting responses. However, the interviewers sometimes adopted the interview framework when the participants came up with new insights or unexpected topics from the theories but relevant to their purchasing and WoM behavior. This research utilized the member checking method to ensure the quality of the response. By interacting again with the interviewees, the study can compare their data interpretation again with participants, ensuring credibility and validation of the analysis. 39

This study employed content and thematic analyses to analyze the data. According to Braun and Clarke, in psychological and behavioral research, this method can “identifying, analyzing, and reporting patterns (themes) within the data” and use a “rigorous thematic approach to produce an insightful analysis that answers particular research questions.” 40 Firstly, the recorded data will be transcribed and translated into English from Vietnamese via a forward and back-translation approach to ensure clarity and consistency before and after translation. Two researchers who were fluent in both English and Vietnamese participated in this process. The researchers then coded the information and categorized them into groups of similar meaning patterns/themes. To ensure the quality of the analysis, the researcher organized a focus group meeting with medical experts. The practitioners comment on the findings concerning their medical practices and healthcare management, ensuring the credibility and applicability of the analysis.

Phase 2: Quantitative Study

The quantitative phase helps to explore the relationship between all constructs in the proposed model ( Figure 1 ). This phase starts with a consultation meeting between the authors and medical experts, and language experts. While the language experts translated the measurement scales from English to Vietnamese, the medical experts edited the translated scale and incorporated the qualitative data to build a questionnaire that fits the Vietnamese medical context. This medical-language expert session helped researchers develop a questionnaire with the consistency and clarity of dimensions and items. This questionnaire consists of two parts: (1) socio-demographic information (See Table 2 ) and (2) the scales for all measured constructs in the theoretical model. In part 2 of the questionnaire, the eight constructs were function, emotion, trust, social influence, CPV, customer satisfaction, WoM, and revisit intention. The questionnaire consists of 33 items, measured on a seven-point Likert-type scale ranging from “strongly disagree” (1) to “strongly agree” (7). Table 3 provides a description of the constructs and their scales.

Demographic Characteristics of the Quantitative Samples

Questionnaire Structure for Inpatients in the Quantitative Phase

Notes : *Adapted from: Budrevičiūtė A, Kalėdienė R, Bagdonienė L, Paukštaitienė R, Valius L. Perceptions of social, emotional, and functional values in patients with type 2 diabetes mellitus and their satisfaction with primary health care services. Primary Health Care Research & Development . 2019;20:e122. 17 © The Author(s) 2019. Creative Commons Attribution licence ( http://creativecommons.org/licenses/by/4.0/ ). **Reprinted from: Sweeney JC, Soutar GN. Consumer perceived value: The development of a multiple item scale. Journal of Retailing . 2001;77(2):203–220. 20 Copyright 2001, with permission from Elsevier. ***Reprinted from: Ndubisi NO. Mindfulness, reliability, pre-emptive conflict handling, customer orientation and outcomes in Malaysia’s healthcare sector. Journal of Business Research . 2012;65(4):537–546. 42 Copyright 2012, with permission from Elsevier. ****Adapted from: Nguyen N. Service quality, customer perceived value and repurchase intention in B2B professional service context – the case of general insurance sector in Vietnam [thesis]. Ho Chi Minh City: Vietnam National University; 2019. Available from: https://hcmiu.edu.vn/wp-content/uploads/2020/08/PhD-DISSERTATION-Nguyen-Xuan-Nhi-after-defense-compressed.pdf . Accessed October 8, 2021. 43

To test the model, the researchers developed a questionnaire to gather empirical data from a sample of 368 inpatients who used to stay at private hospitals in Ho Chi Minh City via snowball sampling from March to June 2020. Regarding the distribution of the questionnaire, the researchers utilized Google Survey and hardcopy to send and record the answers. A sample size of 368 qualified to testify the statistical significance, calculated as the number of free parameters in each model was multiplied by 10. 41 The sample had diverse backgrounds regarding gender, age, and education. Specifically, male respondents accounted for 51.1% of the responses while female respondents accounted for 48.9%. The age distribution has a high representation of Millennials and generation X (aged 26 to 60), which accounted for 80% of the respondents. Regarding education, most respondents had at least an associate or bachelor’s degree, and only 23.9% of respondents did not attend higher education. Regarding the occupation, 26.6% are civil servants, 26.1% are students, 14.9% are researchers and educators, 14.1% are unskilled labor, 12.5% work in entertainment, and 5.7% claim “others.” A summary of this distribution is provided in Table 2 .

After data collection, the researchers imported these raw materials into Excel for preliminary screening and data cleaning. To ensure the reliability and validity of the multi-item scales, researchers used the SPSS 21 software to conduct the Scale reliability test (Cronbach’s Alpha) for internal consistency and Average variance extracted (AVE) and Composite Reliability (CR) for validity tests. Finally, The AMOS 22 software will perform Confirmatory factor analysis (CFA) and CB-SEM.

Qualitative Findings

Service quality’s dimension exploration.

After interviewing 5 participants, the preliminary qualitative phase generated content-rich data about the antecedents of service quality and customer-decision making factors in the specific context of healthcare services in Vietnam. The data analysis helped develop four dimensions of service quality: emotion, function, social influence, and trust. Each developed construct shares many similar themes among interviewees, providing some first insights about the customers’ expectations of the service quality of private healthcare in Vietnam and what factors determine their customer loyalty ( Figure 2 ). As the in-patient sample in this phase is relatively small, their answers only explore potential healthcare quality topics and recommendations for private healthcare rather than representing the demand and opinion of most Vietnamese citizens.

Qualitative results: the in-patients’ cognitive map.

First, inpatients commonly suffer pain or worries when they come to a private hospital; hence, providing better service is an effective way to share and relieve their pain. However, emotion is less content-wise than other constructs during the preliminary phase; hence, they do not have distinctive themes. However, recurring keywords were comfortable and supportive. These keywords can come from positive emotional contexts, such as “creating comfortable environments between inpatients and caregivers.” They can also derive from negative emotional contexts, including that the customer service team is not welcoming and approachable to initiate a refund process. According to the inpatients, post-treatment caring services or service feedback collection can also raise positive emotions and develop emotional bonds between inpatients and treatment centers.

Second, according to the customers, the function concentrates on the timeliness and sanitation of the facilities. The expected functions are the cleanliness of the room and equipment or how fast and convenient the medical test can be delivered to inpatients. In-patients also expect private hospitals to have more modern equipment and more complex or specialized tests than public medical institutions. In-patients also mention the need for specialized customer care services, which are rare and undeveloped in the public sphere. For example, one said: “Private hospitals have medical tests with an acceptable price that are not available at public ones”. These demands are recurring across interviews, showing examples of healthcare functions that private firms can utilize to develop a competitive advantage over public hospitals.

Third, the inpatients acknowledge the role of social branding and medical institutions’ contributions to society and the digital space. The participants highly praised the pro bono services of private institutions in the digital space, such as hosting medical webinars or providing free medical advice. These events help the patient perceive doctors’ expertise and promote virtual engagement between patients and doctors. The patient’s appreciation from communicating with medical experts during the treatment process resulted in satisfaction and long-term loyalties. Moreover, if the participant perceives that a private institution has high quality via digital and social activities, they will be more likely to recommend their friends and relatives. All respondents confirmed that their decisions to acquire services from private hospitals came from close friends and families who were happy with the services and treatment results. The reputation of a private hospital on social media and service review websites also influences the decision to use and re-use healthcare services. In short, the interviews show that social-digital activities can influence inpatients’ perceptions of quality before, during, and after the treatment process. They also highlight the importance of women in customer loyalty development and client acquisitions.

Finally, the elements of trust were mentioned many times by interviewees. Most inpatients prefer old and experienced doctors rather than young doctors, and even the youth might receive better education and training. All respondents agreed that the employees (doctors and nurses) were the primary source of trust in the private healthcare context in Vietnam. They associate reliable medical staff as attentive and knowledgeable people who are always available and provide easy-to-follow guidance from the examination stage to receive the results. Surprisingly, only a few respondents mentioned trust in gaining cutting-edge types of equipment. This preliminary analysis might indicate that the human element in treatment brings more trust to customers than the modern and potential effectiveness of technologies for Vietnamese inpatients.

According to the interview data, all five patients agreed on three priority improvements: (1) Training a team of highly knowledgeable medical experts with strong personal skills, namely empathy and communication; (2) shifting the administrative procedures to save time; and (3) building a solid social media presence and pro bono and e-service to justify their expertise. Each suggestion addresses multiple dimensions of service quality. For instance, personal skills and medical training programs will benefit the emotion and trust dimension, while social media presence and e-service contribute to the function and social influence dimensions. Although the scope of this research does not conduct a cost-benefit analysis for these suggestions, their applicability will be discussed again in the Discussion Section.

Quantitative Findings

Internal reliability and validity results.

Internal reliability was calculated using the Cronbach’s Alpha coefficient test at a benchmark of 0.7. For the validity test, the value of 0.5 for AVE and 0.7 for CR were the standard. 43 All measured constructs met the criteria for internal reliability and validity ( Table 4 ). Subsequently, Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were conducted. In this research, the EFA criterion is 0.5, which is reliable according to a previous study. 44 After removing three items that could not pass the 0.5 benchmarks, namely PERVA3, FUNTI2, and TRUST5, during EFA analysis, 33 items continued to the CFA analysis. Appendix 1 summarizes the results of the EFA analysis and its benchmarks, and Appendix 2 shows the results of the last factor rotation matrix. Through CFA analysis, the researchers observed that the values of CMIN/DF = 2.515, TLI (0.927), and CFI (0.936) > 0.9. The GFI index reached 0.839 (> 0.8), RMSEA index reached 0.064 (<0.08), and sig test value of model 0.000 (<0.05); 44 hence, the analytical data were compatible with the hypothesis model at 95% confidence. Finally, all square roots of AVEs are higher than their respective inter-construct correlations; hence, the scale achieves a discriminant value with the current data.

Constructs Reliability and Validity: Cronbach’s Alpha, Average Variance Extracted (AVE) and Composite Reliability (CR)

Structural Equation Models: A Multi-Group Analysis

After performing Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), the researchers performed a linear structural model (SEM) analysis to test the research hypotheses and measure the impact of factors on each other. Based on the results of the SEM analysis, the conformity assessment results of the model were satisfactory: CMIN/df = 2.667 (<3), TLI = 0.920 and CFI = 0.928 (> 0.9), GFI = 0.830> 0.8, RMSEA = 0.067 (<0.08), P-value test value relevance = 0.00 (<0.05). 44 Hence, at 95% confidence, the data are suitable for the SEM analysis model. The results are presented in Table 5 . Before concluding the investigation for the hypotheses, Bootstrapping, which deploys random sampling with replacement, is used to save money and resources. The analysis indicates that the average estimated coefficients bear little difference from conventional estimation methods. In addition, there is little chance for the estimated errors between the two approaches to occur; hence, the model’s estimated coefficients are a reliable source of safe results.

Status of Research Hypotheses After Performing SEM Analysis

Note : ***0.000.

At 95% confidence, the results support 11 hypotheses and reject the three hypotheses ( Table 5 ). To summarize, emotion did not show a significant relationship with the CPV (H3a). In addition, neither function nor CPV significantly affected customer satisfaction (H2b and H5). Among the four service quality dimensions, the impact of social influence on CPV (0.276, P = 0.000) was the most significant, while that of function (0.138, P = 0.048) was the least. The results also show that social influence has the most significant effect on customer satisfaction (0.324, P = 0.000) while emotion (0.118, P = 0.008) had the most negligible effect on this construct. Regarding customer loyalty, both CPV and customer satisfaction exercises positively influenced WoM and revisit intention ( Table 5 ). Finally, the findings also show that WoM positively affects revisit intentions.

This study illustrates the impact of service quality, CPV, and customer satisfaction on customer loyalty. There are some insightful observations after the mixed-method analysis. In terms of contribution to empirical knowledge, this research confirms that the relationships, questioned by a recent study, that total quality management in the public healthcare context has the same effects on perceived value, customer satisfaction, and customer loyalty as in the private ones. 7 More specifically, patient satisfaction has a statistically significant impact on loyalty, specifically revisit intention (0.305; p = 0.000) and WoM (0.247; p = 0.000). Most of the service quality dimensions also had a statistically significant impact on the CPV and CS ( Table 5 ). Likewise, this research assists in closing the gap in research on perceived crowding in Vietnamese public institutions. In that article, the authors pointed out that patients of public institutions considered hospitals’ service quality higher when hospitals are crowded, but suspected patients of private institutions would be unsatisfied with crowded hospitals. 8 This paper successfully explores their suspicions through in-depth interviews.

However, one unconventional finding is that the CPV does not significantly impact customer satisfaction (0.205; P = 0.073) in the Vietnamese private healthcare context. This finding contradicts the results of a recent Vietnamese study and the literature when they tested this relationship in the healthcare context beyond Vietnam. 7 , 26 , 27 The researcher hypothesizes that the reasons might be due to two reasons. First, the sample size of the quantitative results might not be large or diverse enough to represent the entire population of Vietnam. Second, many respondents received treatment at the hospitals. Since their health is at risk, they might not feel satisfied yet because this feeling typically occurs only after the treatment process. Regardless, this finding raises new questions for future research to identify the answers and bridge the contrast of the findings.

Second, during the in-depth interview phase, trust, emotion, function, and social influence were illustrated as potential CPV and customer satisfaction predictors. The quantitative results confirm that trust and social influence have considerable impacts on both CPV and customer satisfaction (See Table 5 ). However, the function did not significantly influence customer satisfaction (0.048; P = 0.450). This result supports a recent systematic review, revealing that outcome measures concentrating on improving communication and interaction between patients and doctors brought more significant results than those concentrating on changing processes. 45 Therefore, although the qualitative phase emphasizes improving medical procedures and training conscientious medical staff, medical practitioners should prioritize training medical staff over procedures in a limited time and financial budget.

Moreover, quantitative data showed that emotional elements did not play an essential role in promoting CPV (0.087; P = 0.069). However, this dimension positively drives customer satisfaction, which eventually leads to positive WoM and revisit intentions. This observation might suggest that investing in a pre-treatment emotionally driven campaign might not be a practical option as customers do not perceive the service quality with these elements on the first purchase. Private healthcare services should nurture a sense of care and inclusion during the treatment process and provide post-treatment customer care. However, these suggestions should be considered with caution because this finding that emotion does not impact the CPV contrasts with previous studies in healthcare and non-healthcare contexts beyond the Vietnamese context. 17 , 21

Third, this study brings about variable novelty. In a recent paper about Vietnam, 7 the authors mentioned total quality management. However, they do not explain the dimensions of total quality management contextualized in the context of Vietnam. This research used an in-depth interview approach to propose four dimensions of service quality (emotion, function, trust, and social influence). The three first dimensions are similar to the suggestions of the SERVAL model; however, social influence is a novel variable that has gained little mention according to a recent systematic review. Social influence is derived from the Unified Theory of Acceptance and Use of Technology (UTUAT), a frequently used research on adoption behavior that has not been used to explore its’ impact on CPV and customer satisfaction in the healthcare context. 46 Previous research has illustrated the positive impact of social influences on customer satisfaction, customer loyalty, and customer lifetime value in non-medical industries, such as retail banking and online life insurance. 47 , 48 Moreover, previous research has studied the direct implications of social influence on customer loyalty; however, their indirect influence on customer satisfaction is limited. 24 Therefore, this research confirms the positive effects of social influence on customer satisfaction in the context of private healthcare.

Finally, the original SERVAL model and previous studies underestimated the value of digital service. 48 However, in our qualitative phase, interviewees mentioned e-service or its impacts on satisfaction and perceived value multiple times. Although not directly testify to the influence of e-service and patients’ feedback on digital space, existing literature has also found positive outcomes of digital engagement between patients and doctors. 48 , 49 Direct comments and feedback on the quality of healthcare services via social media promote transparency of service quality and motivate practitioners to improve their skills and services. 50 Interaction strategies with patients on social media can also provide emotional support, esteem support, social comparison, and faster booking. The benefits of social influence are in agreement with service quality criteria. 51 Therefore, investment in e-service or social media interaction may increase customers’ loyalty, perceived value, and satisfaction in the Vietnamese private healthcare system. Specially applied in the Covid-19 pandemic, healthcare services can reach out to an increasing number of customers.

The qualitative result also shows the crucial roles of recommendation between friends and family members on the participation and revisiting behaviors of potential inpatients. Moreover, among service quality dimensions, social influence had the most substantial impact on CPV (0.276, P = 0.082) and customer satisfaction (0.048, P = 0.064) in the quantitative result. Positive recommendations from inpatients also improve in-patient revisit intentions, as supported by previous research on healthcare. 37–52 This result might suggest that in the case of financial resource constraints, managers should prioritize social influence to enhance CPV and customer satisfaction, attracting them to purchase private healthcare treatment in the first place. For instance, private hospitals should concentrate on loyalty programs, such as discounts for family members or social media marketing.

Conclusion, Limitation, and Future Research

The application of mix-methods generates insightful and tailored content-rich data from customers and tests these relationships with large and statistically significant sample sizes. First, the qualitative phase develops a framework to improve service quality for private healthcare institutions in Vietnam, addressing the gaps proposed by previous scholars in Vietnam. Second, Structural Equation Modeling (SEM) tests these relationships, and the results show that the data largely support the model. This indicates that service quality positively influences CPV and customer satisfaction, which also significantly impacts customer loyalty.

On the theoretical implication, this research makes novel contributions to the existing literature on service quality and customer loyalty in the healthcare context. First, it explores the impact of service quality on CPV, customer satisfaction, and customer loyalty in the context of Vietnam’s private healthcare sector, which has long been under-researched but has significant economic and commercial value. Unlike previous literature, this study interviewed hospital inpatients to obtain service quality indicators and then combined them with CPV and customer satisfaction results to build the conceptual model. In the qualitative phase, the research also provides the first step in understanding the roles of online feedback websites and e-services on the constructs of social influence and how these services may impact WoM, and revisit intention in the private healthcare context.

On the managerial implication, the research suggests that improving service quality can help private hospitals attract and retain more inpatients. Practical suggestions from customer viewpoints may also provide a stepping stone for more effective investment in the private health business. For instance, private hospitals can improve customer loyalty by developing attentive medical staff and considering e-service or online pro bono services as trust and social influence significantly impact CPV and CS. Private hospital managers should pay attention to social media and post-treatment services to attract new customers via WoM and increase the chance of being revisited by inpatients. Future research can use pre-post tests and cost-benefit analyses to test the effectiveness of different recommendations from this study to provide more practical advice to private healthcare businesses in Vietnam.

This study had some limitations. First, researchers carried out this research before the COVID-19 pandemic. Thus it cannot include the effects of the current crisis on the research results. Therefore, future research can repeat the analysis to explore how and why the pandemic has affected the promotion of private healthcare. Second, the constructs of this research are limited to functional value, emotional value, social value, and trust. However, future research may use other constructs such as ten constructs (reliability, responsiveness, competence, access, courtesy, communication, credibility, security, understanding/knowing the customer, tangibles) proposed by Parasuraman to obtain a comprehensive perspective.38 Third, our research findings indicate that the effects of CPV on customer satisfaction are not significant, which contradicts many results in the literature. Hence, it is suggested that scholars conduct more qualitative research with this scale or increase the sample size to bring about a consistent result. Finally, the sample in the study only includes residents in Ho Chi Minh City, Vietnam, and there are no people over 60 years old. The data might weigh the Millennials and Generation Z’s opinions higher than the older generations, such as the Baby Boomer and Gen X generations. The age distribution might still be valid for the study because the Millennials and Generation Z are the most likely and financially capable of becoming private healthcare customers. However, this sample cannot statistically represent the opinions of all Vietnamese citizens regarding the relationship between service quality and customer loyalty. Therefore, it fails to reflect the pattern of the whole nation. Future research needs a more comprehensive and inclusive sample.

Acknowledgments

The authors would like to acknowledge and thank all the participants in this study. We also express our gratitude to the medical and language experts who provided us with advice on questionnaire development and language editing.

Funding Statement

There was no funding for this research project.

List of Abbreviations

CPV, Customer perceived value; WoM, Word-of-mouth.

Data Sharing Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Ethics Approval and Consent to Participate

The study was conducted in accordance with the Declaration of Helsinki and the Vietnamese regulations. Under Circular No.4/TT-BYT, the scope of IRB covers only Biomed studies (defined in the Circular at Article 15, Section a: (1) clinical trials of drugs, (2) equipment, and (3) other products that have not yet been licensed for circulation in Vietnam). An ethics committee review was not required because the study was conducted for service evaluation. The institutional review board of Nguyen Tat Thanh University waived the IBR for this research because the recorded information could not readily identify the subject. Any disclosure of responses outside the research could not reasonably place the subject at risk. All participants provided written consent to participate in the study through acceptance of the invitation. Participants under 16 years of age provided written informed consent from their parents or guardians.

Consent for Publication

This manuscript does not contain any identifiable data.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

The authors declare that they have no conflicts of interest for this work. The views expressed are those of the authors and do not represent the views of any organization or agency to which they are affiliated.

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CHAPTER -II LITERATURE REVIEW OF SERVICE QUALITY DIMENSIONS

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• Published: 05 October 2023

Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review

• Rondi Anderson 1 ,
• Sojib Bin Zaman 2 ,
• Abdun Naqib Jimmy 3 ,
• Jonathan M Read 4 &
• Mark Limmer 1  

BMC Pregnancy and Childbirth volume  23 , Article number:  712 ( 2023 ) Cite this article

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There is an urgent global call for health systems to strengthen access to quality sexual, reproductive, maternal, newborn and adolescent health, particularly for the most vulnerable. Professional midwives with enabling environments are identified as an important solution. However, a multitude of barriers prevent midwives from fully realizing their potential. Effective interventions to address known barriers and enable midwives and quality sexual, reproductive, maternal, newborn and adolescent health are less well known. This review intends to evaluate the literature on (1) introducing midwives in low- and middle-income countries, and (2) on mentoring as a facilitator to enable midwives and those in midwifery roles to improve sexual, reproductive, maternal, newborn and adolescent health service quality within health systems.

An integrative systematic literature review was conducted, guided by the Population, Intervention, Comparison, Outcome framework. Articles were reviewed for quality and relevance using the Gough weight-of-evidence framework and themes were identified. A master table categorized articles by Gough score, methodology, country of focus, topic areas, themes, classification of midwives, and mentorship model. The World Health Organization health systems building block framework was applied for data extraction and analysis.

Fifty-three articles were included: 13 were rated as high, 36 as medium, and four as low according to the Gough criteria. Studies that focused on midwives primarily highlighted human resources, governance, and service delivery while those focused on mentoring were more likely to highlight quality services, lifesaving commodities, and health information systems. Midwives whose pre-service education met global standards were found to have more efficacy. The most effective mentoring packages were comprehensive, integrated into existing systems, and involved managers.

Conclusions

Effectively changing sexual, reproductive, maternal, newborn and adolescent health systems is complex. Globally standard midwives and a comprehensive mentoring package show effectiveness in improving service quality and utilization.

Trial registration

The protocol is registered in PROSPERO (CRD42022367657).

Peer Review reports

There is an urgent global call for increased availability of quality sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) [ 1 ]. Literature finds that professional midwives with enabling environments are an effective solution [ 2 , 3 , 4 ]. The global standard for a midwife is delineated by the International Confederation Midwives (ICM). Although most countries are working toward attaining this standard, wide variation in the definition of midwife within countries remains.

Professional midwives have been found to improve quality in both high- and low-resource settings. However, barriers to practice are also noted [ 5 ]. Resistance to quality improvement within health systems is one barrier that can require complex system change to address [ 6 ]. In spite of clear World Health Organization (WHO) guidance on SRMNAH, there is a perpetuation of low quality–at times harmful–care in low- and middle- income countries (LMICs) [ 5 , 6 , 7 ]. The broad sweep of LMICs was chosen to reflect the ubiquitous nature of the problem, however contextual differences between and within countries are acknowledged and warrant further study [ 7 ]. The WHO 2021 publication from the Network for Improving Quality of Care for Maternal, Newborn and Child Health (or, the Quality of Care Network) outlines five functions for quality improvement, for LMICs [ 1 ]. The first one—onsite support—has been found to be effective in addressing resistance and influencing system change. The provision of onsite support can be key in supporting enabling environments for desired changes, thus it may be needed for midwives to reach their full potential.

Facility mentorship, a type of onsite support, is an increasingly popular approach for enabling quality SRMNAH in LMICs [ 8 , 9 ]. It comprises both clinical and facility-wide interventions aimed to capacitate and create enabling environments for quality care [ 10 , 11 ]. Through advocacy, modeling, and problem solving for the needed changes, quality improvements can be achieved.

Mentorship and midwifery have been found to be synergistic as midwives need enabling environments to achieve optimum results, and midwives’ expertise increases the success of mentorship [ 2 , 10 , 12 , 13 ]. This review intends to evaluate the bodies of literature on (1) introducing midwives and (2) facility mentoring to better understand facilitators and barriers to implementation of quality, evidence-based SRMNAH care. It aims to provide insight into effective methods of integrating midwives and their related services into health systems [ 14 ]. It is hoped that further refinement of our knowledge on this topic will support program efficacy and improve quality of care for the most vulnerable women. The research question was: what is the impact of deploying midwives, and of mentoring midwives, other cadres midwifery roles, managers, and support staff, on providing SRMNAH care in LMICs?

An integrative systematic literature review was performed with a narrative synthesis approach [ 15 ]. The details of the methodology have been published previously [ 16 ]. An initial scoping found abundant literature on midwives in high-resource countries and limited literature focused on LMICs. Very few articles from LMICs had a specific focus on the introduction of ICM-standard midwives, or on mentoring to support newly introduced midwives. For the purposes of this review, the term ‘midwife’ included all skilled health workers providing SRMNAH services and was not limited to midwives meeting ICM standards. Facility mentoring was defined as regular visits to health facilities to support providers, staff, faculty, and or managers. Mentors could engage in observation, guidance, feedback, and/or data collection, all with the intention of improving the quality and availability of SRMNAH services. Supplies and equipment as well as infrastructure support were not considered mentoring. An integrative systematic review was chosen as it encouraged the inclusion of diverse articles, thus allowing for a more robust comprehensive review [ 15 , 17 ].

Inclusion and exclusion criteria

The review was guided by the Population, Intervention, Comparison, Outcome (PICO) framework [ 18 ]. Inclusion and exclusion criteria are listed in Table 1 . The review included literature from the last 13 years (Jan 2010 to May 2023) that addressed systems strengthening in LMICs through the introduction of midwives, enabling environments for midwives, mentoring, and achieving quality of care. Reviews from the past thirteen years are thought to capture current contexts and issues [ 19 ]. Only articles published in English were included.

Information sources

The review was conducted in February of 2023. The literature was searched through Medline, EMBASE, and CINAHL. In addition to the database search, internet searches of published reports and gray literature, and hand searching of relevant reference lists were performed using a snowball approach. References were managed using an EndNote citation manager.

Search strategy

The review was carried out using a priori planned searches. It was inclusive of all literature that addressed the introduction of midwives and/or the use of mentoring to improve SRMNAH in LMICs, including qualitative experiences of those involved. Predetermined key concepts were searched with specific subject headings and the related Medical Subject Headings (MeSH) or thesaurus terms, as shown in Table 2 . The search was ConceptTerms1 AND ConceptTerms2 AND ConceptTerms3. Additionally, we conducted a systematic search of relevant gray literature sources using these search terms and key concepts to include gray literature in this review. After identifying relevant gray literature documents, such as government reports, conference proceedings, and institutional repositories, that align with this research topic, we critically assess their quality and relevance to our research question, applying the PICO inclusion and exclusion criteria. Finally, we synthesized the key findings from the selected gray literature sources alongside findings from peer-reviewed literature.

Study selection

The process of screening and reviewing abstracts and full-text articles based on eligibility criteria is presented in Fig. 1 [ 20 ]. After the initial titles were screened, the authors (RA, SBZ, ANJ) screened all abstracts against the inclusion and exclusion criteria. The full texts of all abstracts were then reviewed by the authors (RA, SBZ, ANJ).

PRISMA flowchart of the literature review

Quality assessment

All selected articles were reviewed for quality and relevance. A combined, modified mixed-methods synthesis tool was used with the Gough (2007) weight-of-evidence framework [ 21 ]. The Gough tool guides quality evaluation using four themes: coherence and integrity, appropriateness for answering the question, relevance and focus, and overall assessment (Table 3 ). Using the tool, each theme was given a rating of high, medium, or low. These ratings then combine to form an overall rank. Author RA and SBZ independently reviewed and ranked the articles based on the above criteria, and results from the individual rankings were discussed. In case of discrepancies in rankings, the final decision was taken by the principal author (RA). All articles were included with recognition given their potential strengths and weaknesses.

Data analysis and presentation

As this was an integrative review, there were multiple types of research used. The articles were sorted by research types using five broad categories: 1) project intervention, 2) retrospective country analysis, 3) qualitative process description, 4) literature review, and 5) modeling study. This helped reduce risk of bias by at once evaluating a wide range of studies and distinguishing findings by their research approach.

A health systems building block framework was used to guide data extraction and analysis by the three authors (RA, SBZ and ANJ). Data from the articles were iteratively compared to identify common sub-themes relevant to the research question [ 17 ]. The sub-themes were coded and aggregated to identify emerging themes under the existing health system building blocks: national policies and administration, care quality, health-seeking behaviors, experiences and underlying motivators of staff, health outcomes, access to essential medicine, and information systems were identified (Table 4 ). Although the themes are distinct, they could also be described as steps in a process, tied to and dependent on each other. They are also aspects of the health systems building blocks.

Following theme identification, articles were categorized according to the building blocks. A master table and supplementary tables were created to classify each article according to its Gough score, country of focus, themes, building blocks and methodology. The table also categorized articles according to whether they were inclusive of midwives and or mentoring, if care providers met an international standard for midwives, and how mentoring was defined. To minimize risk of bias in the synthesis of findings, articles involving interventions (methodology type 1) were disaggregated to identify interventions most likely to be transferable. Disaggregation was based on their approaches to measuring outcomes and direction of change. Four outcomes measurement approaches were determined: 1) self-reported or before/after tested knowledge or skills; 2) observed quality improvement at clinical sites; 3) information system health outcome tracking; and 4) facility data on service utilization.

The results analysis is divided into three sections. We provide an overview of key characteristics, rankings and methodological approaches. We then present an analysis of the two main themes (a) midwives and/or both midwives and mentors and (b) mentoring, which emerged from the studies. Finally, we offer a comprehensive synthesis of the specific findings related to midwifery and mentorship according to the health system building blocks approach observed across the included studies.

Fifty-three articles were included in this review (Fig. 1 ) [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ]. Tables 5 and 6 at the end of the article display all article data. Among them, 13 were ranked as high, 36 medium, and four low (Table 5 ). In addition, 18 focused on the introduction of midwives, 29 on mentoring, and six combined midwife introductions with mentoring. Ten articles described midwives meeting a global ICM standard while the others described a range of categories of staff who were called midwives or were providing maternity care. These included nurses, midwives not meeting ICM standards, midwives with unspecified education, general maternity staff (i.e., not midwives), and skilled birth attendants with unspecified education (Table 7 , also at end). Across both midwifery and mentoring articles, theme categories yielded overlap, with all articles aligning with multiple themes.

Among the articles focused on midwives and/or both midwives and mentors, seven assessed interventions, seven were retrospective country analyses, five were qualitative process descriptions, four were literature reviews, and one was a modeling study (Table 5 ). Key barriers were found across articles that limit midwives’ ability to provide quality care [ 2 , 12 , 39 , 66 , 74 ]. These included policies and work environments that relegated midwives to support roles and constrained their scope and opportunities for growth. For instance, midwives were found to have limited opportunities to attend normal births, and restrictions from managers on providing aspects of evidence-based care, including managing life threatening emergencies. In her integrative review of midwifery programs in LMICs, Schuldt (2019) noted that only one third of midwives were practicing to their full scope [ 12 ]. Despite the challenges, all midwives were providing aspects of midwifery care and many midwives were successfully expanding their roles and improving care quality [ 36 , 59 , 64 , 73 ]. Evidence-based policy and guidelines, supportive management, mentoring, and continuous professional development all enabled midwives’ performance. Practicing to their full competencies was more likely when midwives met a global standard and when facility mentoring was provided [ 59 , 60 , 64 , 73 ].

Of the articles that addressed mentoring (including mentoring of midwives), thirty evaluated mentoring interventions and five were literature reviews. Most mentors were project-based, providing support to government health facilities; some were government employees [ 23 , 36 , 40 , 44 , 45 , 61 , 62 ]. Except for one project that used international mentors, all mentors were national nurses, midwives, or doctors and all mentorship was conducted onsite [ 64 , 65 ]. Mentors largely received pre-mentoring training of up to a week, while some described only existing professional expertise. Three studies described a five week training [ 23 , 31 , 32 , 33 , 48 ]. Frequency of mentor visits and mentorship approaches varied across projects. Most mentors conducted from bi-weekly to bi-monthly visits ranging from a total of six facility visits to bi-weekly visits for over 18 months [ 27 , 43 , 48 , 52 ]. In two projects, mentors were deployed full time [ 69 , 74 ]. Most mentoring visits lasted one day and visit frequency was positively correlated with quality improvement [ 45 ]. While most mentoring focused on service delivery, three articles described mentoring as part of midwifery education to improve quality of classroom teaching and clinical teaching at practice sites [ 60 , 64 , 65 , 66 ]. Components of mentoring visits included group teaching, case studies, bedside teaching, assessing and advocating for supplies and equipment, establishing and reinforcing data systems, and providing problem solving support [ 23 , 30 , 36 , 40 , 44 , 45 , 47 , 61 , 62 ]. Checklists for mentors to guide their mentoring were mentioned in ten studies [ 49 , 50 , 51 , 58 , 69 ]. The mentoring programs that found improvements in outcomes mentored at least twice per month for at least a 3-month duration [ 49 , 51 ].

The six studies that described introducing midwives in education and practice with mentoring support found additional benefits of mentoring when introducing a new midwifery profession [ 32 , 33 , 34 , 35 , 36 , 37 ]. This was largely because of improved enabling environments. The benefits of combining mentoring with the deployment/strengthening of midwives include improved quality of care and improved service utilization. One study found statistically significant improvements in use of ANC cards and partographs over what was found with introducing midwives alone [ 60 ].

Across all 31 articles that described interventions, none achieved 100% of identified quality improvement goals. Nine articles highlighted gaps in achieving desired goals [ 37 , 38 , 41 , 43 , 46 , 47 , 69 , 70 , 71 ]. Outcomes measurement approaches with direction of change are delineated in Table 7 . Participant self-reported or researcher tested improvements in knowledge or skill, and researcher observed quality improvements were the most common approaches. Twenty-seven and 20 articles respectively showed improvements in outcomes using these approaches. Eleven articles reported improved outcomes using health facility data, eight reported increased service utilization, nine highlighted gaps in achieving desired goals, and one reported no improvement. Most intervention articles included baseline and endline observations and some were retrospective evaluations looking at sustainability. Notably, due to larger numbers of mentorship articles examining interventions, more rigorous outcomes measurement information is available on mentoring than on introducing midwives.

Across all articles, the most common building block themes were governance and leadership, and service delivery, with 31 and 28 articles aligning respectively (Table 6 ). Eleven or fewer articles aligned with access to essential medicine and supplies, data/ health information systems, finance, and health workforce. Studies examined 23 countries: Afghanistan, Bangladesh, Benin, Botswana, Burkina Faso, Cambodia, Ethiopia, India, Indonesia, Jordan, Kenya, Laos, Morocco, Malawi, Nepal, Pakistan, Peru, Rwanda, South Africa, Sri Lanka, Tanzania, Uganda and Zambia (Table 8 ) [ 33 , 37 , 39 , 40 , 41 , 43 , 44 , 47 , 52 , 58 , 62 , 64 , 65 , 69 , 70 , 71 , 73 , 74 , 75 ]. The following sections discuss the findings in further detail according to the health system building blocks, with midwifery and mentorship specific findings presented separately within each section.

Leadership and governance

The 33 articles that touched on leadership and governance discussed strengths and gaps. They aligned neatly with both the leadership and governance building block and the theme national policies and administration drawn from the review. Thirteen articles looked at the introduction of midwifery, and 18 looked at mentorship interventions. Another two looked at mentorship supporting midwives. Eight were rated high, 22 medium, and three low. The types of articles that addressed leadership and governance included intervention/ program interventions (17), retrospective country analysis (05), qualitative process review (05) and six literature reviews. Most articles on mentoring focused on local-level service delivery governance, including of managerial staff, and systems for overseeing implementation. Midwifery articles more commonly looked at national policies and guidelines. The articles broadly point to evidence-based leadership and governance that reflects ground realities being essential for midwives to practice to their full competencies. Workplace settings that are unsupportive to midwifery, a ground reality, significantly detracted from full scope midwifery and service quality, while supportive workplace settings fostered full scope practice and quality sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) services. Supportive workplace settings typically involved manager engagement through various modes.

Strong leadership and clear global recommendations have helped shape national policies on midwifery and SRMNAH quality improvement [ 1 , 9 , 14 , 24 , 42 , 76 , 77 ] [ 1 , 54 , 61 ]. Global and national standards for midwives have brought stakeholders together and are an impetus to support midwifery in spite of competing interests [ 59 ]. Political will and multi-stakeholder collaboration were found essential for a quality midwifery profession [ 61 ]. Good governance of logistics and infrastructure were also identified as essential, though gaps were highlighted in adequate space for care provision, privacy for respectful care, and commodity availability [ 54 , 56 ]. Gaps in midwifery leadership were also noted. Lack of leadership by midwives of the midwifery profession may contribute to reduced political will for midwifery care. Country experience shows that professions other than midwives that are positioned as leaders of the midwifery profession sometimes do not fully understand midwives’ expertise and may compete with midwives for maternity care provision roles [ 12 ].

Policies that scale up education and deploy midwives closer to communities were found to have a positive impact on service utilization and health outcomes [ 68 ]. However, gaps in both of these policy areas were also noted. First, adherence to globally recommended midwifery competencies in education programs is often not abided by in countries [ 54 , 66 , 72 ]. Second, World Health Organization (WHO) workforce guidelines define the number of needed health care workers per population, but not the number of midwives needed [ 14 ]. Other gaps related to deployment policy were also identified. For instance, unsupportive workplaces resulted in constraints to optimal midwifery performance in studies in both Pakistan and Bangladesh [ 11 , 28 , 74 ]. In these contexts, midwives either did not perform their duties, or they operated under policies that restricted them from doing so. Governance that did not take into account the inputs needed to create an environment conducive to midwifery within workplace settings was associated with lesser success. One mentoring program that reported no improvement identified restrictive national policies as a barrier [ 28 ]. Across articles, few midwives reported supportive workplace settings, and some reported humiliation, including by their direct managers [ 12 , 39 , 65 , 72 ]. When managers were not fully involved, resistance to midwives in leadership roles, autonomous practice, and quality improvements in clinical care was found [ 60 , 74 , 78 ].

Conversely, local governance supporting midwife-friendly workplace settings improved midwives’ sense of competence and care quality. Webster et al. (2013) and Schuldt et al. (2020) found that midwives felt competent to provide midwife-led care in supportive workplace settings [ 29 , 59 ]. Importantly, involving onsite managers to strengthen ownership of midwifery and quality SRMNAH was identified as a priority in twenty-five articles utilizing a range of methods to measure outcomes [ 30 , 36 , 60 , 74 , 78 , 79 ]. Furthermore, support from managers for midwifery care and improved quality was better when on-site mentoring was present [ 30 , 36 , 60 ]. Seven articles found that initiating the well-known WHO quality improvement process, with a focus on SRMNAH, was an effective and easily accepted method of mentoring managers [ 30 , 36 , 49 , 52 , 58 , 60 , 69 , 79 ]. Taneja et al. (2021) describe initial handholding support and coaching for managers as part of the quality improvement process for SRMNAH in India [ 79 ].

Service delivery

Nearly all selected articles—47—addressed service delivery. Of these, 12 included the introduction of midwives, 29 included mentoring, and six included both (Table 7 ). The themes of care quality , service utilization and health outcomes mapped to the service delivery building block, with 39 articles addressing care quality. Due to their large number, articles addressing service delivery are discussed by theme. Of the service delivery articles, 31 were intervention evaluation, six reported retrospectively on the impact of national programs with a midwifery component (i.e., retrospective country analysis), two were qualitative process reviews, and eight were literature reviews.

Care quality

Among the 39 articles that had a focus on care quality, nine ranked high, 28 medium, and two low. Four included the introduction of midwives, 29 included mentoring, and six included both the introduction of midwives and also mentoring. Gaps in quality education and services were noted in most articles and both introducing ICM-standard midwives as well as mentoring enabled improvements [ 29 , 30 , 34 , 38 , 42 , 60 , 64 ].

Studies on introducing midwives reported that ICM-standard midwives improved service quality as defined by WHO maternity care guidelines. Improvements were seen in tertiary medical centers, sub-district hospitals, and non-governmental organization (NGO) supported facilities, as well as in clinical education for nurse, doctor and midwife students [ 60 , 64 , 74 , 78 ]. Analysis using logistic regression found that midwives significantly increased the number of women laboring in upright positions, delayed cord clamping, and immediate skin to skin contact after the birth [ 60 , 64 ].

The large number of mentorship focused studies found that mentorship contributed to quality improvements in midwifery education, comprehensive and respectful SRMNAH services, and emergency obstetric and neonatal care. Studies found gains made in quality education in both classroom and clinical teaching [ 60 , 61 , 65 , 66 ]. Midwifery educators identified that online mentoring helped them improve curriculum implementation [ 65 ]. Onsite mentoring improved teaching pedagogy, students' access to labs and libraries, and clinical teaching [ 64 ]. In addition, quality of care provided at clinical education sites improved after mentoring [ 60 , 61 , 64 ].

Comprehensive and respectful SRMNAH care quality showed improvements with mentoring in studies Afghanistan, Bangladesh, Rwanda, India, Nepal, Jordan, Botswana, Ethiopia, South Africa, Kenya, and Uganda [ 23 , 44 , 47 , 52 , 58 , 62 , 65 , 69 , 70 , 71 ]. An analysis of program data by Save the Children and UNFPA (2021) from 47 mentored health facilities with newly deployed midwives in Bangladesh, found improved respectful communication, partograph use, upright position for birth, and companionship as well as a notable increase in health facilities receiving obstetric emergencies coming from the community [ 64 ]. Using observation data, Anderson’s et al. (2022) mixed methods observational study found that midwives in Bangladesh without mentoring made quality improvements, but, with the addition of mentoring, use of ANC cards and partograph increased significantly [ 60 , 64 ].

Mentoring also contributed to better identification of high-risk pregnancies, improved diagnosis and treatment of STIs, better sterilization and cleanliness practices, and strengthened laboratory capacity to manage pregnancy and newborn-related emergencies in Rwanda [ 31 , 38 ]. Research in India, South Africa, Uganda, and Rwanda found that mentoring contributed to stronger newborn care services [ 23 , 30 , 38 , 39 ]. Despite the many documented benefits of mentoring, there is also evidence of care quality gaps remaining in programs that received mentorship. For example, Tiruneh et al. (2018) found improvements in newborn care in a study in Ethiopia, with the exception of newborn resuscitation [ 38 ] and Tripathi (2019) found little improvement in post-partum care and newborn resuscitation in India [ 35 ].

Service availability and utilization/ health seeking behaviors

Sixteen articles touched on service availability and/or utilization [ 22 , 24 , 34 , 38 , 42 , 50 , 64 , 73 , 74 ]. Three were ranked high, 11 medium, and two low. Eight were related to introducing midwifery, five assessed mentoring interventions, and three looked at mentors who supported mentors. For the most part, the introduction of midwives was associated with increased SRMNAH service availability and utilization. In a Lancet article, Van Lerberghe et al. (2014) found increased facility births with multi-pronged interventions that included educating and deploying midwives [ 24 ]. Vieira et al. (2012) and Speakman et al. (2014) found greater uptake of ANC and skilled birth attendance in studies in Indonesia and Afghanistan [ 26 , 27 ]. Tasnim et al. (2011) found increased ANC, facility birth, and postnatal care (PNC) following the introduction of ICM-standard midwives in Bangladesh [ 22 ]. Another study of ICM-standard midwives in Bangladesh found increases of 27%, 13% and 12% for ANC, facility birth, and PNC respectively [ 22 , 64 ]. However, other Bangladesh research looking at ICM-standard midwives using a different sample of hospitals found no difference in facility births nine months after a national deployment of ICM-standard midwives [ 60 ]. Studies that found gaps in enabling policies and/or workplace settings for midwives showed fewer increased in service utilization [ 28 , 50 ].

As discussed in the earlier sections, studies on mentorship interventions showed a consistent association between engaging managers in supportive workplace settings and care quality. Related to this, mentorship also influenced service availability and utilization. Two studies led by Anderson et al. (2022) and one led by Save the Children and UNFPA (2021) documented greater availability of cervical cancer screening, postpartum family planning, gender-based violence screening, and post abortion care with mentors supporting new midwives [ 60 , 64 , 74 ]. In research from Ethiopia, Uganda, and India, ANC and facility birth rates in their studies in Ethiopia, Uganda, and India in which mentors supported midwives. Tiruneh et al. (2018) found higher rates of care seeking for obstetric emergencies as service availability improved [ 38 ]. Namazzi et al. (2015) and Waiswa et al. (2021) found an increase of more than 20% in sick newborn care visits in Uganda [ 30 , 56 ]. Stephens et al.’s (2019) study saw a more than doubling of PAC service use including associated family after a mentoring intervention focused on service quality in Tanzania [ 50 ].

Health outcomes

Twelve articles reported health outcomes. Three ranked high, seven medium, and two low. Seven included the introduction of midwives and five had a mentoring intervention. Program interventions that were associated with improved health outcomes were thought to be the most likely to be transferable and thus were analyzed more closely to identify research methodology as well as intervention components. Ultimately, the goal of health care is to improve outcomes, and selected studies found improvements in health outcomes associated with midwife deployment [ 25 , 28 , 42 ].

Seven midwifery articles described improved outcomes with the introduction of midwives [ 24 , 25 , 26 , 27 , 29 , 43 ]. All were large national interventions that included many components in addition to midwives, making it difficult to ascribe attribution [ 24 , 26 , 43 , 49 ]. One was a multi-country study evaluating the introduction of skilled birth attendants (SBAs). It had mixed results but did find decreased neonatal morbidity in Latin America, the Caribbean and partially for Asia [ 25 ]. Vieira et al. (2012), Webster et al. (2013), The World Bank (2013), and Speakman et al. (2014) found significant reductions in maternal mortality in retrospective national analyses of national midwife deployments in five countries [ 26 , 27 , 29 , 42 ]. However, analyses of similar programs in India and Pakistan did not reduce maternal mortality [ 28 ]. The studies of projects in Indonesia and Bangladesh found that, when midwives were deployed, deaths from obstetric complications, particularly abortion, sepsis, and postpartum hemorrhage, fell over control groups of facilities that did not deploy midwives but rather used doctors and nurses in midwifery roles [ 22 , 60 , 64 , 74 ]. Bartlet et al.’s (2014) LIST modeling exercise estimated that under even a modest scale-up, midwifery services including family planning would reduce maternal, fetal, and neonatal deaths by 34% [ 67 ].

Neonatal outcomes were inconsistent in a systematic review assessing the protective effect of SBAs on neonatal mortality in nine LMICs [ 25 ]. Where SBAs were protective in Latin America, the protection was partial in Asia, and not at all in Africa. An article from Nigeria found that SBA rate was not associated with better neonatal outcomes. Meanwhile, Viera et al. (2012) found a reduction in under 5 mortality in Brazil [ 26 ].

Four of the five mentoring articles reported improved health outcomes. All were mentoring ICM-standard nurse-midwives or midwives [ 52 , 56 , 57 , 69 ]. In addition, all had comprehensive facility mentoring programs that visited at least twice monthly for at least three months, included managers, and strengthened data collection systems. Three were inclusive of training, two with simulation, and three provided medicine and equipment. However, certain outcomes did not improve. One study from Uganda notes declining MMR in project districts[ 56 ]. Studies from Uganda, Rwanda, and South Africa identify declining trends for stillbirths and or neonatal deaths[ 30 , 45 ]. In Uganda neonatal death was reduced from 30.1 to 19.6 deaths/1,000 live births. In addition, declines in neonatal morbidity including, asphyxia were found in Kenya, Uganda, and South Africa [ 57 ].

Health workforce

Like care quality, studies that addressed workforce comprised a relatively even split between focusing on introducing midwives and implementing mentorship programs. Seven examined midwife introduction and five mentorship; one addressed midwifery combined with mentorship. They were largely good quality with six and five rated as high and medium respectively. Two were given a low rating. The theme experiences of midwives and their support staff most aligned with the health workforce building block and is discussed in this section. [ 28 , 29 , 30 , 60 , 66 ]. Research quality varied and it was not always possible to discern whether attitudes were presumed or directly expressed.

Reports on midwives and other maternity staff and managers highlighted both positive and negative experiences. Some articles talked about midwives’ dissatisfaction with their workplace or feasibility to implement what was expected of them. Three studies reported midwives’ discomfort with their deployment status and the impact of those discomforts on their performance. Speakman et al. (2014) found that midwives in Afghanistan were less willing to work in military-controlled areas, stating fears about security and resistance from family [ 27 ]. Mumtaz et al. (2015) reported that newly deployed midwives in Pakistan stated difficulty in setting up private midwifery practices within rural communities, as distances made traveling prohibitive, particularly at night [ 28 ]. One study published in the Canadian Medical Association noted midwives' preference for positions with higher pay and not always choosing to serve the poorest [ 29 ].

Anderson et al.’s (2022) study found that midwives expressed un-elicited pride regarding their profession, particularly where midwives were enabled through mentoring. In this and other studies, midwives expressed a desire for professional autonomy, respect, and for midwifery to be a distinct profession [ 27 , 60 , 65 ]. In two of these studies, newly deployed ICM-standard midwives in Bangladesh expressed confidence and competence to provide quality SRMNAH services, while also expressing frustration with imposed limitations by managers and other maternity staff. Anderson et al. (2022) also found that some managers and nurses felt that midwives did not have the competence to practice autonomously or manage emergencies. Managers expressed those nurses’ felt competition with midwives and that this competition led to nurses questioning midwives’ competence.

Many articles on mentoring shared providers’, faculty’s, mentors’, and administrators’ appreciation of and knowledge gained from mentoring [ 52 , 56 , 57 , 69 ]. Mentees in the studies in Bangladesh, Uganda, and Karnataka expressed having increased confidence and feeling happy with the mentorship and what they had learned [ 30 , 60 , 66 ]. Studies in India and Bangladesh observed that mentoring contributed to better teamwork among maternity staff [ 60 ]. In Laos, a mentorship program designed for newly deployed inexperienced midwives was found to be well-received by hospital administrators [ 31 , 40 ]. Overall, mentoring led to positive experiences for maternity staff and maternity staff and managers were more appreciative of midwives when there was mentoring [ 60 ].

Access to essential medicine and supplies

While it was not one of the initial themes identified, eleven articles mentioned improving essential medicines [ 23 , 31 , 32 , 33 , 39 , 44 , 45 , 49 , 52 , 64 , 68 ]. All examined mentoring and two discussed program interventions that introduced midwives with mentorship. Four were rated high and seven medium. Anderson et al. (2022) and Save the Children and UNFPA (2021) addressed the impact of introducing midwives on medicine availability in their studies in Bangladesh [ 60 , 64 ]. In both of these articles, midwives alone did not make an impact on medicine availability. However, with mentoring, medicines became more available [ 60 , 64 ]. In an example from Anderson et al.’s (2022) observational study, oxytocin and MgSo4 availability was as low as 13% in facilities without midwives or mentorship, and as high as 81% in facilities with midwives and mentors [ 60 ]. Articles on mentoring interventions in India, South Africa, Rwanda and Uganda also reported a positive impact of mentoring on availability of essential medicines [ 23 , 30 , 31 , 39 , 44 , 45 , 49 , 52 , 64 ]. Improvements may be a result of capacitating health workers and supply chain staff to activate supply chain systems. They may also be the result of improved confidence of health care providers and managers to provide the needed care and thus ensure supplies.

Data systems

Ten articles reported on data or health information systems, also not an initial theme [ 23 , 30 , 31 , 32 , 36 , 37 , 39 , 51 , 56 , 58 , 69 ]. All ten looked at mentoring and reported strengthening data systems to track SRMNAH services. Articles emphasized the importance of using data to track implementation, such as a detailed clinical record which is sometimes called a case sheet [ 23 , 31 , 32 , 36 , 37 , 56 ]. Namazzi et al. (2015) describes assessing the status of the patient charts and registers at baseline and then having the MOH approve file folders for inpatients to standardize record-keeping and to facilitate data availability [ 30 ]. The introduction of individual client records allows for more detailed monitoring of patient care. Synergizing SRMNAH with existing quality improvement systems included increased emphasis on and of utilization of SRMNAH data for program monitoring [ 36 ]. Taneja from India describes involving government stakeholders to build on existing data systems to ensure data-based decision making within SRMNAH [ 79 ].

Health financing

Eight articles included a focus on health financing, which overlapped with the theme national policies and administration [ 23 , 24 , 26 , 27 , 28 , 29 , 43 , 68 ], Five related to midwifery and three included mentoring. Cost effective programs are essential in low-resource settings as even if projects are effective, sustainability is dependent on resources [ 56 ]. This review found that programs to introduce midwives and those supporting mentorship can be accomplished with minimal expenditure [ 23 , 31 ]. Midwifery models were noted to be significantly less costly then obstetrician led models for care [ 67 ]. Bartlett et al. (2014) found that midwifery models were almost twice as cost-effective as obstetric models ($2,200 versus $4,200 per death averted). The introduction of midwives as well as mentoring can also be implemented within existing government systems using government employees and thus add very little additional cost. However, mentoring projects using government staff sometimes encountered constraints on availability of mentors’ time. Yet, one of the most effective mentoring projects that impacted health was implemented through existing government staff [ 10 ]. Even if project mentors are used, research from India found mentoring only increased cost by $5.60 per pregnant woman, or around $460,000 annually for eight districts, making it a cost effective intervention [ 23 ].

This review underscores the significance of adhering to a global midwife definition and emphasizes the importance of onsite support in creating enabling environments. The health systems building blocks served as an effective framework for interpreting the results through the lenses of its various pillars. It is worth noting that the articles focusing on midwifery, as opposed to mentorship, had fewer intervention studies and more retrospective national and qualitative process research. This research gap limits our understanding of the effective steps required for implementation of successful midwifery programs, as has been mentioned in earlier literature [ 5 ]. Among the themes explored in the midwifery literature, governance and leadership emerged as a critical first step. However, there is a pressing need for implementation research that delves into the process and impact of introducing midwives in LMICs. Drawing insights from the literature on mentoring and quality improvement holds potential for guiding countries in devising effective midwife deployment strategies [ 42 ].

One notable gap identified in this review pertains to midwife leadership [ 59 ]. The significance of midwives leading the midwifery profession has been highlighted in other literature as well [ 80 ]. Competition between professions involved in maternal health—midwifery, medicine, and nursing—for leadership roles is recognized as a hindrance to midwives fully realizing their potential. Concerns associated with non-midwives leading midwives include potential conflicting self-interest and gaps in understanding. Midwives possess unique expertise in providing quality routine SRMNAH care to essentially healthy women and newborns. If midwives are not self-governing, their distinctive vision may not be fully implemented. Therefore, more research is needed to identify best practices for promoting midwives into leadership positions.

Although the majority of articles included in this review did not explicitly address the importance of globally standard midwives, those that did emphasized its priority. The literature on skilled birth attendants emphasizes the significance of expert maternity care providers and reiterates the components of globally standard midwives. However, gaps persist in countries' adherence to global recommendations [ 77 , 81 ]. Additionally, the scope of practice for midwives includes comprehensive sexual and reproductive health, as called for in the sustainable development goals. However, many non-standard midwives lack this expertise. Articles reporting changes in health outcomes consistently involved globally standard midwives, while those reporting no change often featured non-standard providers lacking basic knowledge. Further research is required to examine the impact and decision-making processes regarding the perpetuation of non-standard midwives within countries.

While all midwives provide aspects of midwifery care, this review identified significant gaps in their ability to perform to their full competencies. These gaps inevitably limit the contributions midwives can make. Enabling midwives to practice fully is particularly urgent in managing life-saving emergencies and is critical for ensuring quality respectful maternity care and comprehensive sexual and reproductive health. Frustrations regarding practice restrictions were expressed by professional midwives in this review, highlighting the importance of evidence-based leadership led by midwives themselves.

Essential medicines play a critical role in enabling environments for midwives. Notably, the findings indicate that midwives without mentoring did not impact the availability of medicine supplies. Weak supply chains are prevalent in LMICs, and stockouts of essential commodities pose significant barriers to delivering quality services. This underscores the essential role of mentoring or other forms of effective supportive supervision, particularly in this area [ 82 ]. The review suggests that mentoring involving managers and staff may help improve the availability of life-saving SRMNAH services. Further research is needed to identify the most effective methods for ensuring the availability of essential supplies and medicines through mentoring interventions.

The importance of data collection highlighted in the mentoring articles cannot be overstated. Midwives require effective monitoring of their performance to identify gaps and solve problems [ 83 ]. However, many countries still do not routinely use patient files, and the use of register books for storing patient information needed for macro data systems was noted. This review emphasizes the importance of effective gathering and utilization of information to ensure quality care and support at the micro-level. By highlighting gaps and facilitating feedback for improving care delivery, quality data at the micro-level is crucial.

The review found that evidence-based leadership and governance reflecting ground realities are essential. The 2018 WHO definition of Skilled Birth Attendant Standards emphasizes the importance of enabling environments [ 77 ]. The International Confederation of Midwives (ICM) defines an enabling environment for midwives as one that supports the necessary infrastructure, profession, and system-level integration for effective work performance [ 84 ]. Facility mentoring emerged as a critical factor in strengthening enabling environments and improving implementation quality [ 1 , 53 , 54 ]. Mentoring programs improve relationships between health system components and between staff and managers involved in care provision, aligning with the literature on addressing complex systems. Onsite facility mentoring, with frequent visits and involvement of all local authorities, integrated into all components of the related health system, proved to be the most effective approach. Further research is needed to determine best practices for mentoring approaches to inform program planners and policies that support workplace setting conducive to midwifery.

The facility mentoring findings in this review align closely with the WHO Quality Maternal Health Network guidelines, which emphasize on-site support, learning and sharing, measurement, community and stakeholder engagement, and program management as the key components for effective quality improvement in maternal health [ 76 ]. While WHO acknowledges the importance of management at the macro-level, this review highlights the criticality of on-site support for managers in facilitating sustainable change [ 85 ]. WHO may want to consider expanding its recommendations for managers to include micro-level support. The interventions evaluated in this review were further disaggregated by measures of success to deepen our understanding of known efficacy. Only a limited number of interventions assessed in-vivo changes in implementation. Self-reported changes or changes based on knowledge and skill were found to have limitations in effectively indicating implementation change, which reinforces the importance of on-site interventions [ 59 , 60 , 74 , 76 ]. Mentoring programs should consider incorporating methods that evaluate observed implementation changes.

Mentoring programs that demonstrated positive outcomes consisted of comprehensive packages including frequent visits, capacity building, manager involvement, and strengthening of data systems. These programs consistently mentored globally standard midwives. The high-performing programs prioritized on-site capacity building activities such as group teaching, case studies, bedside teaching, assessing and advocating for supplies and equipment, establishing and reinforcing data systems, and support for problem-solving. The use of checklists for mentors was also commonly observed in many studies (Fig. 2 ) [ 49 , 50 , 51 ].

Components of mentoring that drive outcomes

Several limitations of this review were identified. Firstly, the included studies exhibited diversity in their approaches, delivery methods, and outcomes, resulting in considerable heterogeneity. This heterogeneity is expected, given the inclusion of studies from different countries, diverse populations, and various public health interventions, but may lead to less accurate comparisons than a more homogeneous study. Secondly, the reliance on self-reporting of outcomes as the primary outcome method of measurement may introduce some bias, either through over- or under-reporting. Third, more nuance in terms of the most effective mentorship interventions would have given more insight, specifically the efficacy of internal versus external mentorship, but although the literature did find that frequency of mentoring contacts improved outcomes, more research is needed for more specific programmatic guidance. Finally, this review might be limited by the fact that we have employed a broad categorization for 'LMIC,' which leaves gaps in understanding specific country or region contexts.

This review highlights the importance of adhering to a global midwife definition and the role of onsite support in creating enabling environments. It identifies gaps in midwife leadership and emphasizes the need for more research to promote midwives into leadership positions. The review also underscores the significance of globally standard midwives and the challenges associated with non-standard midwives. Enabling midwives to practice to their full competencies is crucial for quality care provision leading to life saving and rights upholding, and access to essential medicine plays a critical role in creating supportive environments. Effective data collection and monitoring, as well as evidence-based leadership and governance, are essential for improving midwifery care. Onsite facility mentoring emerges as a critical component of strengthening enabling environments, and more research is needed to identify best practices for mentoring approaches.

Girls’ and women’s lives, and dignity depend on the availability of quality SRMNAH. To succeed in making the needed changes we need enabled, expert midwives. Midwifery literature has focused on the needed national governance and broad country understandings. There remains a need for follow up to ensure globally standard midwives are available for all girls and women. There is also a need for policy makers to include support for successful implementation. Current knowledge of health systems strengthening, and quality improvement, sheds light on the needed planning for midwives to ensure realization of their full potential. Mentoring is cost effective, and can be implemented within existing government systems. A comprehensive mentoring package inclusive of onsite capacity building of maternity staff, managers, data and procurement systems, will enable midwives to improve SRMNAH, and uphold rights for the most vulnerable.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to publication restrictions from journals but are available from the corresponding author on reasonable request.

Abbreviations

Sexual, reproductive, maternal, newborn and adolescent health

Low- and middle-income country

Quality improvement

International Confederation of Midwives

Skilled birth attendants

World Health Organization

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Anderson, R., Zaman, S.B., Jimmy, A.N. et al. Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review. BMC Pregnancy Childbirth 23 , 712 (2023). https://doi.org/10.1186/s12884-023-06027-0

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Impact of reimbursement systems on patient care – a systematic review of systematic reviews

• Eva Wagenschieber 1 &
• Dominik Blunck   ORCID: orcid.org/0000-0001-8843-2411 1  

Health Economics Review volume  14 , Article number:  22 ( 2024 ) Cite this article

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There is not yet sufficient scientific evidence to answer the question of the extent to which different reimbursement systems influence patient care and treatment quality. Due to the asymmetry of information between physicians, health insurers and patients, market-based mechanisms are necessary to ensure the best possible patient care. The aim of this study is to investigate how reimbursement systems influence multiple areas of patient care in form of structure, process and outcome indicators.

For this purpose, a systematic literature review of systematic reviews is conducted in the databases PubMed, Web of Science and the Cochrane Library. The reimbursement systems of salary, bundled payment, fee-for-service and value-based reimbursement are examined. Patient care is divided according to the three dimensions of structure, process, and outcome and evaluated in eight subcategories.

A total of 34 reviews of 971 underlying primary studies are included in this article. International studies identified the greatest effects in categories resource utilization and quality/health outcomes. Pay-for-performance and bundled payments were the most commonly studied models. Among the systems examined, fee-for-service and value-based reimbursement systems have the most positive impact on patient care.

Patient care can be influenced by the choice of reimbursement system. The factors for successful implementation need to be further explored in future research.

The health care system has a variety of payment and reimbursement systems that provide different financial incentives for patient care. Every payment system carries incentives to over- or underprovide care. There is no optimal solution, as there is constant pressure to adapt and reform in order to ensure the best possible quality of care. Health care systems are reaching their financial limits and therefore it is desirable to achieve an increase in efficiency in patient treatment and, for example, to avoid unnecessary interventions [ 1 ]. To achieve this, health policy must ensure a regulatory framework in which health status is also an economic incentive for all actors in the health system, promoting health benefits and reducing economic disincentives.

Physicians have a stronger position in the physician–patient relationship because of the knowledge and information advantage, and problems arise in the provision of care when physicians’ financial interest do not match the patients’ need for treatment [ 2 ]. In addition to medical necessity, economic and financial factors also play a key role in patient treatment. Medical decisions in the inpatient sector are influenced daily by economic requirements, economic considerations, and financial resources, potentially with negative consequences for the quality of treatment and patient safety. In the hospital setting, economization is exemplified in that physicians often feel ethical conflicts and economic goals occur at the expense of adjustments in length of stay, case numbers, and patient selection [ 3 ]. The influence on patient care is examined under four different reimbursement systems: Salary, bundled payment, fee-for-service (FFS), value-based reimbursement. With a fixed salary, remuneration is based solely on the duration of working hours, whereas the type and volume of service, as well as the number of treatment cases or patients enrolled, have no influence on financial income. At the same time, both an advantage and a disadvantage in this reimbursement system is the dependence of the quality of treatment on the intrinsic motivation of the provider [ 2 ]. Bundled payment is the term for payments such as capitation or disease related groups (DRGs). Services are combined and “bundled” for payment during a single patient contact or over a temporal episode. One disadvantage of this reimbursement system is the incentive for health care providers to treat as many patients as possible with as little effort as possible and thus to engage in risk selection. On the other hand, this can increase the incentive for preventive measures on the part of health care providers [ 4 ]. In FFS reimbursement, the provider’s fee is based on the volume of services rendered. Shared-savings payment models are a mix of FFS and a fixed salary where providers participate from savings they achieve in patient care. This creates the disadvantage of FFS reimbursement that service providers will unnecessarily expand the number of services for monetary reasons, resulting in unnecessary care at the expense of payers and potentially patients. On the other hand, (potentially expensive) diseases can be identified and treated earlier through increased preventive measures [ 2 , 5 ]. Value-based reimbursement additionally promotes the quality and success of medical procedures. Remuneration is expanded to the extent that it is linked to predefined quality targets at the levels of transparency, accessibility to care, indication, structure, process or outcome. While value-based reimbursement can promote the intrinsic motivation of providers, care must be taken to ensure that there is no risk selection for patients who can be treated well or that there are no negative spill-over effects into other areas of treatment. Another disadvantage of this reimbursement system is the large number of factors besides medical treatment that contribute to recovery, such as comorbidities or socioeconomic factors [ 1 ].

Other reviews have addressed effects on patient care in outpatient settings [ 6 ] or included studies from developing countries in their evaluations [ 7 ]. Previous studies only focus on specific areas of patient care [ 8 ], are not methodologically designed as a systematic review [ 9 ], focus only on individual specialties [ 10 ] or reimbursement systems [ 11 ] and do not compare the effect of different reimbursement systems. A comprehensive and structured overview, comparing the outcomes of several reimbursement systems on areas of patient care, is missing.

The objective of this paper, thus, is to provide a review of systematic reviews on the relationship between reimbursement systems and patient care. The research question is narrowed down using the PICOS algorithm: Physicians (Population), Reimbursement systems (Intervention), different reimbursement systems or differences over time (Comparison), effects on patient care divided into the parameters structure, process, outcome (Outcome), systematic reviews and meta-analyses (Study type). The aim is to analyze how reimbursement systems affect patient care across countries.

Materials and methods

The systematic review follows the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Metaanalyses) statement [ 12 ], has been performed via the databases PubMed, Web of Science and Cochrane Database of Systematic Reviews between 02/12/2021 and 22/12/2021 and has been complemented with an additional search on Google Scholar and in the reference lists of relevant studies. The search term was formed by linking keywords and their synonyms from previously published relevant studies on the three aspects of the research questions: impact, reimbursement systems, and patient care (see Table 1 for the full search term for each database).

Inclusion criteria are defined as (a) the paper must be a systematic review or meta-analysis, (b) the countries considered must be industrialized nations, and (c) the effect of payment/reimbursement systems on patient care was examined.

The search period is set to ten years and only studies published in German or English were included. All records were exported to EndNote 20 [ 13 ] and screened by the authors; disagreements were solved by discussion. All studies categorized as “relevant” or “uncertain” in this step were analyzed in full text.

Studies categorized as relevant after full text analysis were included in this work and assessed for study quality using the AMSTAR-2 score, which is a comprehensive questionnaire to assess systematic reviews of (non)randomized trials [ 14 ]. Using the framework of Donabedian, the results are divided into the three dimensions structure, process, outcome [ 15 ] (see Table  2 ). The structure dimension combines the following parameters: “unintended consequences” and “organizational changes”. Unintended consequences are mostly related to changes in risk selection or spill-over effects, whereas organizational changes are related to effects in personnel structures, for example. The dimension of structure is of particular interest for health care authorities as well as payers as it shapes the organizational characteristics of how care is delivered.

The categories “resource utilization”, “access”, and “behavior” are combined under the parameter process. While resource utilization mostly describes changes in readmission rates or length of stay, the access category reflects socioeconomic inequalities in the utilization of health care services. The behavior category includes effects related to intrinsic motivation, preventive services provided by physicians, or documentation of health parameters, among others. The dimension of process defines how providers deliver care as well as the points of contacts for patients.

The outcome dimension, on the other hand, combines the parameters “quality/health outcomes”, “efficiency”, and “economic effects”. Actual changes in mortality, treatment quality, screening or vaccination rates are mapped in the “quality/health outcomes” category. The “efficiency” category deals with the effects on direct savings in the provision of a specific medical service or effects on salaries, whereas the “economic effects” category records effects that are significant for society. The dimension of outcome could be regarded of the main value driver from a patient perspective as it answers to what extent patients’ original need for care is fulfilled. Furthermore, outcomes are of particular interest for payers, as payers commonly decide, for example, what services are reimbursed and therefore potentially have a high interest in a positive cost-outcome-relation.

For all reimbursement systems described, the number of included studies, as well as the examined medical specialties or physician groups and countries in which the interventions are carried out, are also transferred in each case. For each reimbursement system described, it is examined whether it improved or worsened the outcome categories of patient care, whether there were heterogeneous results, or whether no difference was found in the outcome categories before and after the intervention. The frequency reviews found an improvement, worsening, heterogeneous outcome, or no difference for each payment system per outcome category were summarized in a single table. In this study, increases in healthcare utilization, documentation of health parameters, and higher screening rates or lower mortality rates are defined as improvements. A measurable increase in risk selection, negative spill-over effects, longer hospital stays, or higher readmission rates are considered deteriorations in patient care. In the economic categories of efficiency and economic effects, savings in health care spending and total societal spending, respectively, are considered as improvements. Reviews finding heterogeneous results include studies with conflicting findings, because some of the included primary studies find positive results in one category, whereas other primary studies find negative effects or no significant effects at all, leaving the study or respective review with an overall heterogeneous result. It is assumed that health care is optimized by an increase in health care services, shorter lengths of stay, more efficient care, and lower overall societal health care expenditures.

A total of 1,213 hits were identified by the database search on 02/12/2021, with 2 additional hits identified by the search in Google Scholar. After duplicates were removed, 1,053 abstracts were screened by both authors, resulting in 943 hits being initially excluded. The remaining 110 hits were analyzed in full text, whereupon 34 hits were included in this work (see Fig.  1 ).

Overall, the 34 included systematic reviews describe the influences on patient care based on a total of 971 primary studies. Ten of the 34 included reviews are rated as high quality, 16 as moderate quality, and eight as low quality according to the assessment procedure using the AMSTAR-2 questionnaire (see Table  3 ). Some of the identified systematic reviews examined more than one reimbursement system. Therefore, for the sake of clarity, we refer to a total number of 60 studies in the following. Of these, the reimbursement system salary was investigated in four studies, bundled payments in 15, FFS payments in a further eleven studies and value-based reimbursement in a total of 29 studies. Out of the 60 studies 45 were conducted in the USA, 38 in European countries, 28 in the UK, 23 in other countries and 17 in Canada. An overview of the results is provided in Table  4. . In the following, we describe the results of the systematic review regarding Donabedian’s categories of quality: structure, process, and outcome.

Unintended consequences

No unintended consequences in patient care are found for the salary payment system. Studies find heterogeneous results for this category for bundled payments in form of a decrease in treatment volume while there is an increase in risk selection and case complexity [ 16 , 17 ]. An association was found between bundled payments and patient selection based on sociodemographic factors and comorbidities [ 16 ]. Positive changes were noted in indicators that were not included in the FFS model; these were, however, only short-term [ 18 ]. Some reviews find unintended changes after implementation of pay-for-performance models (P4P), a type of value-based reimbursement, in form of risk selection, spill-over effects, protocol-driven and less patient-centered care and neglect of non-incentive indicators [ 19 , 20 , 21 , 22 , 23 ]. Some studies find no evidence for a change in patient risk selection in their included primary studies [ 24 , 25 ].

Organizational changes

There are heterogeneous results on the impact on patient care after the introduction of different payment systems. One study reports effects in the form of increasing numbers of physicians per patient and decreasing numbers for bundled payments [ 26 ]. While one review finds heterogeneous results for salary, bundled payment, FFS, and value-based payment for the structural organization of patient care [ 27 ], others find both positive and negative effects for value-based payment as an improvement in care management processes or a worse organization of large hospitals [ 28 , 29 ].

Resource utilization

Reviews find heterogeneous effects for salary models differentiated by specialty. While induction time and total treatment time increase in anesthesiology, outpatient visits and surgical procedures decrease in gynecology [ 30 ]. When salary and FFS payments are combined, a decrease in clinical services per year and in hospital readmissions is noted [ 27 , 30 ]. Within models of bundled payments, heterogeneous results are found: While one source describes a decline in all-cause hospitalizations and readmissions [ 30 ], other sources find both improvements and deterioration in hospital facility use and the number of acute admissions [ 27 , 31 ]. Deteriorations are described in the following categories: use of patient care resources, number of services provided per patient, shorter lengths of stay, discharges to post-hospital facilities [ 16 , 18 , 24 , 30 , 32 ]. Some reviews find both differences and no differences in the use of health care resources after the introduction of bundled payments [ 17 , 27 , 30 ]. Within DRG models, evidence is heterogeneous and describes no change, an increase, or a decrease in hospital readmissions and in the length of stay [ 26 , 33 ]. For global-based payment, evidence is heterogeneous in terms of higher or lower utilization, and no change in resource utilization [ 34 ]. The heterogeneity of influences on health care resource utilization continues for FFS payments as sources find an increase in the number of physician visits per patient [ 18 , 24 ], a reduction in length of stay and computer tomography exams [ 30 , 31 , 32 ] or heterogeneous results for process indicators [ 27 ]. Negative effects include an increase in the number of patients per physician [ 35 ]. In P4P models, six studies report an improvement in resource utilization as an increase in health care services, physician visits and a shorter length of stay [ 20 , 25 , 28 , 32 , 36 , 37 ]. Other reviews come to very heterogeneous results regarding the change in resource utilization after the introduction of P4P models in the following categories: health care and resource utilization, length of stay, readmission rates, process indicators [ 10 , 11 , 27 , 38 ].

There is no research showing an impact of salary on access to health care. Bundled payments show heterogeneous results in form of changes of the patient structure with respect to insured status or a decline in patients with home dialysis [ 17 , 30 ]. Studies examining FFS payment may also measure the impact on access to care. Improvements are noted in waiting time and a reduction of patients who leave the health care provider without treatment [ 30 , 35 ]. No differences were found in the treatment of social or ethnic inequalities [ 18 , 24 ]. For value-based models, results are heterogeneous regarding the impact on access to patient care. Among them, three studies identify a positive impact after the introduction of P4P models in form of an increase in equity of access to care and a decrease in social inequalities [ 20 , 32 , 36 ]. Other results show no significant reduction in access for disadvantaged groups or no improved access to primary care [ 11 , 19 ].

Salary models lead to a decrease in hours worked per week [ 30 ]. For bundled payment models, the results show both increases and decreases, means heterogeneous results, in the number of preventive consultations [ 18 ] and services as well as increases in preventive consultations, reported illness severity and referral to post-acute care facilities after hospitalization [ 24 , 33 ]. An increased number of services provided were reported for FFS models [ 18 , 24 , 35 ]. Positive changes after the introduction of P4P models were noticed in some categories: increased use of computers and documentation of care, diabetes tests, physician behavior [ 11 , 20 , 35 , 39 ]. Other reviews find results that are more heterogeneous on effects on the behavior in patient care [ 10 , 22 , 23 , 25 , 36 , 40 ]. For example, an improved data collection leads to increased pressure on physicians and thereby provoke negative behavior change [ 36 ]. General heterogeneous effects in terms of a disruption of patient-centered care with less focus on patient needs are reported as well as an increase in blood pressure checks and an improvement in intrinsic motivation among care providers [ 10 , 23 , 25 , 40 ]. Both, an increase and no change in medication prescription is found in two value-based models [ 10 , 41 ].

Quality/health

One review finds a decrease in transfer rates out of hospitals for a salary-based payment [ 30 ]. The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ]. Some reviews notice an improvement in the quality and number of screenings [ 30 , 42 ] or a decrease in the case complexity [ 16 ]. Evidence of the impact on quality of care and health outcomes associated with P4P is also examined in reviews. One review reports improvement in terms of an increase in immunization rates among children for FFS payments [ 35 ], whereas other sources find increases, decreases and no changes in number of treatment cases, treatment outcomes, mortality, and hospitalization rates [ 18 , 27 , 31 ]. The most influences on health outcomes or quality of care are found in models of value-based payment. Nine reviews find evidence of improvement with P4P models in these categories: immunization rates [ 35 , 43 ], specific clinical values (e.g., cholesterol, blood pressure, screening rates, birth weight) [ 21 , 39 , 42 , 44 ], quality of care [ 23 , 28 , 45 ]. Heterogeneous outcomes are found in another ten reviews [ 11 , 19 , 20 , 22 , 27 , 36 , 38 , 40 , 46 , 47 ]. Among these, positive as well as negative results are found in patient-related health outcomes [ 19 , 27 ], complication rates [ 38 ], health outcomes, quality of care and screening rates [ 22 , 47 ]. Other sources report heterogeneous effects in patient satisfaction, short-term health outcomes and mortality [ 20 , 22 , 40 , 47 ]. No effects on mortality, quality of care, health outcomes, rehospitalization or patient satisfaction after an implementation of value-based reimbursement are described in six reviews [ 11 , 20 , 31 , 37 , 38 , 46 ].

When providers are reimbursed with fixed salaries in combination with FFS elements, the annual salary increases [ 30 ]. Bundled payments have a positive impact on the efficiency in terms of a decrease in health care spending and hospitalizations [ 16 , 30 , 42 ]. Furthermore, heterogeneous results, means deterioration as well as improvement, in treatment costs are described in one review [ 26 ]. Shared-savings models were found to lead to a reduction in perinatal care spending [ 42 ]. An improvement in the cost-effectiveness of treatments in P4P models by reducing costs was found in one review [ 19 ]. Other sources present heterogeneous results in terms of both positive and negative effects on the (marginal) costs of care [ 29 , 38 ]. No evidence for changes in efficiency are determined in three other reviews [ 20 , 22 , 45 ].

Economic effects

For bundled payments, the results are very heterogeneous. Cuts in health spending as well as increases, no changes or unclear effects are noted [ 31 , 32 , 34 ]. When payment is based on FFS models, positive effects on health care spending are most often found [ 18 , 32 ]. One study, however, reports heterogeneous effects [ 31 ]. The results on the impact of value-based payment models on economic conditions are mostly positive, as they lead to a reduction in the growth of health care spending and costs [ 32 , 41 , 44 ].

Principal results

To answer the question of the relationship of different reimbursement systems and patient care, we conducted a systematic review of systematic reviews in order to structure the existing body of evidence in this topic. We identified 34 studies analyzing 60 reimbursement systems and structured the results from the perspective of the Donabedian framework.

For the reimbursement of health care providers via salary, the results show little to no influence on the subcategories of the dimension structure. For the dimension process, the results are heterogeneous with a tendency toward deterioration, manifested in a reduction in services rendered and hours worked. The classic disincentives of salary-based reimbursement, minimization of the quantity of services and treatments, are confirmed in the results. The categories of the outcome dimension, on the other hand, are clearly improved, with a decrease in hospital discharge rates and an increase in income. The certainty of these results is high due to the high study quality and the risk of bias is low, since three high-quality studies and one medium-quality study were included in the evaluation.

The studies on bundled payments show few and heterogeneous effects on the structural dimension of patient care. The resource utilization subcategory shows heterogeneous results, with most results being equally positive and negative. The remaining categories in the process dimension appear to have mostly heterogeneous effects. Overall, bundled payments are found to have more positive effects on patient care in the outcome dimension categories. The disincentives of bundled payments are confirmed in the form of reductions in services, but also refuted in the form of shorter lengths of stay and lower readmission rates in hospitals. When interpreting the results, the rather below-average study quality must be considered. Although five high-quality reviews examine the effects of the bundled payments, eight reviews with a medium quality and four papers with a low quality are also included in the evaluations, so that the certainty of results is limited and there is a risk of bias.

In the results for FFS models, especially the categories in the dimension process tend to be positively affected. While access to health care and provider behavior tend to be mostly positive, there are as many heterogeneous and negative effects for resource utilization as positive ones. Measured health impact is very heterogeneous and tend to be negative, while efficiency and economic impacts tend to be improved. An increase in the number of health care services, a classic disincentive, is directly confirmed by several studies. The quality of the included reviews and, thus, also the certainty of results tends to be high, since seven reviews with a low risk of bias, four with a medium and only one review with a high risk of bias are included in the evaluation.

For models of value-based reimbursement, results are inconclusive or more negative with respect to subcategories of the structural dimension, noting changes in risk selection, negative spillover effects, and a shift away from patient-centered care [ 19 , 20 , 21 , 22 , 23 ]. In contrast, these payment models achieve substantial improvements in the process dimension and specifically in resource utilization. Although the effects on health outcomes are heterogeneous for P4P models, they indicate a clear tendency toward improvement, whereas no clear improvements or deteriorations were found for the other two subcategories. The misaligned incentives of value-based payment in the form of patient selection described at the beginning are both confirmed [ 21 , 22 , 23 ] and refuted [ 24 , 25 ]. The quality of the included reviews and thus also the certainty of results is average overall. Although seven of the relevant reviews are of high quality, 15 have a medium risk and seven have a high risk of bias, which may affect the results.

Overall, the rate of identified improvements for FFS and VBP is the best compared to heterogeneous effects, deteriorations, or no identified changes. While about 50% of all identified results for FFS show improvements, it is 40% for VBP. On the other hand, only 25% of the identified outcomes for a salary are improvements and 21% for bundled payment. Across all reimbursement systems, most of the results were identified in the categories resource utilization and quality/health outcome. Especially the categories of the process and outcome dimension, specifically the subcategories resource utilization and health outcome are influenced by the choice of reimbursement models and cause a change in patient care. These categories therefore have a greater impact on the overall results than categories in which fewer results have been identified. Mainly models of bundled and value-based reimbursement are affected. The effects of FFS and value-based reimbursement are mostly positive in the results compared to the other two reimbursement systems. Both payment models tend to show positive effects in the categories of the process and outcome dimension, and cite an increase in health care services provided, a reduction in length of stay, an increase in screening rates of patients, and an improvement in health parameters. In the case of value-based reimbursement, however, many endpoints were found to have no or very heterogeneous effects following the introduction of these reimbursement models. Primarily, these endpoints are unintended consequences, resource use, behavior, health outcomes, and efficiency. Bundled payment models show more heterogeneous and more negative than positive results. These are found predominantly in the resource utilization and health outcome categories, indicating a more positive impact of FFS and value-based compensation. Salary receives heterogeneous results, with categories in the process dimension tending to worsen and those in the outcome dimension tending to improve. Although the disincentives of the respective reimbursement systems are confirmed for all models, refutations are found for bundled and value-based reimbursement regarding length of stay, readmission rates, negative spill-over effects and patient selection.

Implication

In particular, the categories of the process and outcome dimension, more precisely defined as the subcategories resource utilization and quality/health outcome, are reported to be influenced by the choice of reimbursement model and cause a change in patient care. Models of bundled and value-based reimbursement seem to be particularly affected. The effects are more positive for FFS and value-based reimbursement in comparison to both other reimbursement systems. FFS as well as VBP models show positive effects in the process and outcome dimension categories, frequently citing an increase in health care services provided, a reduction in length of stay, an increase in patient screening rates, and an improvement in health parameters. Judging by the results and comparison of the four reimbursement systems, it is therefore worthwhile to further expand models of FFS and value-based reimbursement in the health care system and to investigate their successful implementation as well as potential moderating factors.

Limitations

There are some limitations in this review. The AMSTAR-2 tool is only partly appropriate to evaluate the reviews because it also evaluates clinical studies and therefore might underestimate the actual quality of some reviews involved. Not all of the included reviews provide a clear definition of their view on improvement or deterioration of care. Individual primary studies may be integrated into the results of several studies of included reviews and have a greater influence on the analysis than other primary studies included in only one review which bears the risk of overestimation of certain results. When interpreting the results, it is important to note that FFS or P4P models cannot be applied to any health care system; rather, the exact conditions for successful implementation must be individually and critically examined. Finally, publication bias is a limitation and can lead to overrepresentation of improvements due to the implementation of the described reimbursement models. Future studies should also identify more relevant databases to increase the quality of the systematic review and the validity of the results. Additionally, future studies should analyze the monetarization of the effects and aim for a better comparability of study settings as difficulties arise from interpreting health policy analyses which were conducted in different settings as well as causal interpretation might be limited as most underlying studies were not conducted as randomized controlled trials.

Availability of data and materials

No new data generated/Not applicable.

Abbreviations

• Fee-for-service
• Pay-for-performance

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Wagenschieber, E., Blunck, D. Impact of reimbursement systems on patient care – a systematic review of systematic reviews. Health Econ Rev 14 , 22 (2024). https://doi.org/10.1186/s13561-024-00487-6

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