Assessing Customer Satisfaction to Support Future Improvement Strategies of Healthcare Systems: Evidences from Russia and Romania

Abstract

The analyses of current healthcare systems in Russia and Romania made by different scholars in the specialty literature highlight a below-medium health quality index worldwide, which is especially low when compared to leading EU countries. The prevailing need to address health features with quantitative customer research has prompted this paper to focus on the challenges of the healthcare systems in two countries from the customer’s perspective. The main goal of the research is to capture the main problems of the analyzed healthcare systems which require certain improvements, changes, and innovations, and to find proper strategies for their future development from a marketing approach. The attitudes of 410 people from Russia and Romania have been collected using an electronic survey, based on a questionnaire that contained some items concerning the marketing mix in the public and private clinics from the two analyzed countries. These items have been evaluated by respondents from both the importance and satisfaction perspectives, and the Importance–Satisfaction (IS) matrix was used to discover marketing strategies that are the best fit for each component of the marketing mix in the healthcare clinics. The outcomes of this study highlight the need to focus efforts mainly on improving the quality of the services in both countries, with some peculiarities for the public and private sectors. It was also revealed that both countries need massive improvements in their public clinic sectors.

1. Introduction

Healthcare services are essential for the well-being and quality of life of people. However, the quality and accessibility of healthcare services vary across countries and regions, depending on various factors such as the economic development, health policies, infrastructure, and culture. For this reason, capturing patient satisfaction is a crucial measure for evaluating the service quality using different methods. Academic publications have investigated the correlation between patient satisfaction and healthcare service outcomes, as well as the factors affecting patient satisfaction in medical and outpatient settings. The findings highlighted by scholars reveal a strong direct relationship between the performance of the medical services and patient satisfaction, with some differences for some demographic characteristics [1,2,3,4,5].

By analyzing the healthcare services provided in Russia and Romania, both by the public and private sectors, it can be seen that throughout the last three decades of the transition to the market economy, these service providers have had to build new tactics focusing on the strong relationships with their customers as a result of the increased competition in the private sector and a change in the service delivery paradigm [6]. In this context, the clinics need to conduct appropriate research to assess the customer’s satisfaction with the product features and other components of the service delivery and to correlate the results with the importance placed by the customers on these aspects. The findings of this research could be used to establish improvement strategies for the healthcare systems using a marketing perspective.

Healthcare marketing, as is defined by the American Marketing Association, “is designed to influence the behavior of target audiences in which the benefits would accrue to the target audience’s physical and/or mental health”. It can be used by different entities, including clinics or national bodies [7]. The use of the marketing approach in healthcare services is becoming more and more important as the healthcare sector is progressing rapidly, which makes it necessary to adapt healthcare services to the needs of patients, including personalization of the services provided [8]. As the activity of medical clinics is included in the wider service sector, the marketing strategies should take into consideration the peculiarities of the services, which are usually marketed differently from physical goods [9]. The personal relationship becomes more important in service delivery so that the classical four Ps of the marketing mix (product, price, placement, and promotion) are not enough and the extended model of the marketing mix should be used by adding: physical evidence, personnel, and process. Even though the topic of using marketing strategies in healthcare services is debated in many scientific papers, a gap could be identified in the literature considering that most research has focused only on particular aspects such as promotion, digital marketing, communication, customer relations, etc. The gap consists in a small number of articles that address marketing strategies based on all components of the marketing mix.

Considering the identified gap in the specialty literature, the aim of this research is to quantify the patients’ attitudes regarding some specific aspects of the marketing mix in the healthcare services provided by clinics in Russia and Romania, and to propose a model for prioritizing marketing strategies using the IS matrix as an analysis tool. These two countries have different levels of economic development, health expenditures, and health outcomes in spite of their common history, and a comparison between the two systems can add value to the research in the field. Starting from this general purpose, the following research objectives were established: (1) to identify the importance and customer satisfaction related to the main items of the marketing mix applied to healthcare services in the analyzed countries; (2) to compute the Importance–Satisfaction matrix for the public and private healthcare services in order to prioritize the improvement strategies.

The remaining part of the article contains the following sections: “Literature Review”, “Materials and Methods”, “Results”, and “Discussion and Conclusions”.

2. Literature Review

2.1. The Importance of Healthcare Systems for Socio-Economic Development

Healthcare represents one of the most important political focuses of every government around the world, regardless of the country’s socio-economic development stage, because it is an essential indicator for the quality of life [10]. The healthcare system should assure and guarantee health and well-being for every person irrespective their age as it is stated in the Sustainable Development Goals (SDGs) formulated by the United Nations General Assembly [11]. Among the main targets of the third SDG is to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” [12]. The achievement of this goal could not be possible in the absence of a strong healthcare system, which becomes crucial in the socio-economic development of every country.

Taking into account the importance of the healthcare systems, some improvement strategies are needed and researchers have the mission of finding the best solutions for decision makers. Among these solutions, innovative processes and products can contribute to the system’s development and increased productivity [6]. Among the debated issues regarding the development of healthcare services is the quality management of the organization. The relationships with the employees, the process quality, the knowledge transfer, the leadership, and the trust management are considered in the literature as key actions in healthcare services [13]. Other research has emphasized the importance of information systems for healthcare service providers, which can improve the process by better visualizing the steps taken, establishing relationships with customers, or developing screening programs for preventive medicine [14]. One of the most important trends discussed in the literature concerns the management of healthcare systems from a marketing perspective, which can bring benefits to both individuals and society as a whole [15].

The recent COVID-19 pandemic crisis has widely highlighted the need for better services in healthcare systems, which were not sufficiently prepared for a large number of patients. Such situations require the better management of risk and special attention from the authorities, as many economic sectors could be affected simultaneously [16]. It is also assumed that certain changes in the behavior of individuals occur during such crises and in their perception of risk in the use of medical services [17]. In this context, most healthcare systems have proven that they are not sufficiently prepared in terms of the protocol to receive patients, hospitalization places, or adequate management of human and material resources [18].

All the aforementioned aspects debated in the literature reveal a strong need to improve healthcare systems. In this sense, the marketing approach is considered the most beneficial [15]. This is the reason why the present research is carried out from a marketing perspective, which includes an analysis of the customer appreciations regarding the overall components of the marketing mix in services: product; price; placement; promotion; physical evidence; personnel; and process.

2.2. Healthcare Marketing and Customer Attitudes

Quality in the healthcare sector is influenced by many factors, such as the customer satisfaction, marketing mix elements, digital marketing strategies, governance approaches to sustainability, and external factors such as the COVID-19 pandemic [19]. By using marketing strategies, service providers could persuade consumers to use some healthcare services or to choose certain clinics, but also negative behaviors (e.g., consumption of products with health risks) could be discouraged through marketing campaigns [15]. Even if marketing strategies are considered useful in relation to patients, healthcare institutions should first understand the needs and expectations of patients, and create value through patient-oriented services and healthcare service management [19]. Among these expectations, the use of the Internet to find health-related information is becoming increasingly popular, and service providers cannot ignore such needs [20]. They have to gain trust of the customer through empathy, reliability, and transparency based on diverse experiences that go beyond the interaction with a doctor [21]

In order to put into practice the mentioned marketing actions, service providers must know and evaluate the attitudes of customers towards their products and company. The concept of attitude comes from psychology, which broadly means a person’s beliefs or evaluations made toward an object, people, or other aspects of everyday life [22]. The attitude has three components: affective (based on emotions), cognitive (based on knowledge), and behavioral (based on previous experience) [23]. Customer attitudes are an important factor that influences the effectiveness of healthcare marketing. A study exploring how customer attitudes toward telemedicine affected their intention to use it during the COVID-19 pandemic found that these customers were impacted by a variety of elements, such as the perceived value, perceived usability, perceived reliability, perceived risk reduction, and social influence. The customers who believe that telemedicine is useful, easy to use, trustworthy, reduces their risk of exposure to illness, and is endorsed by their social circle are more likely to have positive attitudes towards telemedicine and to use it in the future [24].

One of the most-investigated attitudes in the literature is customer satisfaction, a concept that represents the essence of relationship marketing. Some authors define it as the emotions that arise at the level of individuals from comparing their expectations with the performance or the perceived outcome of a product [25]. Simply put, when a product’s performance falls short of expectations, the customer is dissatisfied, and when it does not, the customer is satisfied. If the performance exceeds the expectations, the customer is extremely satisfied or even sometimes delighted [26].

In the particular case of healthcare services, customer satisfaction is defined as the degree to which the healthcare consumers are pleased with the quality of services they have received in healthcare clinics [27]. Studies have found that customer satisfaction in healthcare is influenced by various factors such as communication, trust, accessibility, and the provision of quality care [28,29,30]. Effective communication, for instance, involves the provision of clear and concise information that healthcare consumers can understand and use to make informed decisions [31]. Effective communication between healthcare providers and patients can lead to an increased patient satisfaction. This is because communication helps the patients feel more comfortable and confident in their care. The patients are more likely to be happy with their care when they feel understood and heard [32]. Communication is vital for engaging trust between the healthcare providers and patients, as patient satisfaction is greatly influenced by trust, so that patients who have faith in their healthcare providers are more likely to be happy with the treatment they receive [33]. Accessibility is also considered a determinant of patient satisfaction. It can be characterized as the ease with which healthcare services can be obtained. This includes factors such as the availability of healthcare providers, the cost of care, and the transportation options available to patients. The patients who have easy access to healthcare services are more likely to be satisfied with the care they receive [34]. By enriching the services with the mentioned features, a real partnership could be established with the patients, who will be determined to get involved in designing the personalized services according to their needs [35].

One of the most effective ways to improve the service quality and achieve high levels of customer satisfaction revealed in the literature is to use digital marketing strategies such as the following: creating and distributing content that educates and empowers patients; ensuring transparent and patient-centered services; using social media and online forums to connect and engage with patients; and building relationships online [20]. Digital marketing can also help healthcare organizations to collect and analyze data from various sources, and reveal insights into patient behavior, trends, and outcomes. This can help them target their marketing efforts more effectively, and personalize their communication with patients. Digital marketing analytics can also be used to provide real-time feedback, identify patients at risk, and track patient progress [36]. However, digital marketing is not enough to ensure the quality of healthcare, as people can hold stereotypes or bad attitudes created in the past, which can lead to a bad image and rejection of some services [37]. For such reasons, direct relationships with the patients are very important, especially during the treatment of various diseases or in cases that require a major decision [35].

In addition, patient expectations also play a role in determining the satisfaction with healthcare services. The patients who have high expectations for the quality of care will be more likely to be satisfied with their experience if their expectations are met. Otherwise, they may express a low level of satisfaction. Therefore, healthcare organizations should aim to manage patient expectations to improve satisfaction. It is revealed in the literature that customer satisfaction in healthcare is a complex and multifaceted construct that is influenced by various factors [38].

Bearing in mind the above-mentioned issues debated in the literature, healthcare service providers should conduct thorough research to capture patient expectations and satisfaction. Their results could be used to establish marketing strategies that are crucial for improving the quality of medical care. Marketing strategies are plans and actions that a marketer uses to achieve specific marketing goals and objectives. Several studies found that the market orientation, innovation orientation, and entrepreneurial orientation have positive effects on the organizational performance, mediated by a competitive advantage and customer value [39]. Adopting effective marketing mix strategies in healthcare services (using the 7 Ps) could also enhance patient satisfaction and loyalty [19]. Thus, healthcare marketing is a vital tool to provide better patient care. It helps healthcare organizations reach more people, connect with them personally, and increase their satisfaction and loyalty [8].

Beyond the goal of meeting customer needs and improving satisfaction, healthcare organizations should also adopt sustainability governance approaches that can help them reduce carbon emissions, improve resource use efficiency, and promote healthy lifestyles to prevent disease [40].

In the context presented above, healthcare clinics, both in the public and private sectors, are forced to build new tactics, focusing on the strong relationships with their consumers, as a result of the increased competition and a change in the delivery paradigm of services in recent years. Clinics should conduct appropriate research to assess customer satisfaction with their product features and the correlation between satisfaction and the importance placed on those features. They should focus on improving the quality of their services in order to improve patient satisfaction [41].

3. Materials and Methods

3.1. Setting the Scene

In this study, an analysis of customer attitudes towards the healthcare services in Russia and Romania was carried out due to some common characteristics of the healthcare systems in these countries. The Soviet-style Semashko model was used in the past, which was fully controlled and funded by the national governments. The Semashko system was a Soviet model of healthcare that was implemented in Russia, Romania, and other communist countries after World War II. The system was based on the principle of free medical care for all citizens and was organized as a single, unitary service provided by the state [42].

Since the transition to the market economy, after the change of the past communist regimes, there have been major transformations in the healthcare systems of these countries, through the inclusion of the mandatory social health insurance model, but also through the development of the private healthcare sector. Research on the coordinates of the healthcare systems in Russia and Romania found that Romania’s healthcare system is currently more centralized than Russia’s, meaning that its government has more control over it. This can be both a strength and a weakness as it can lead to more efficient use of resources but it can also make it more difficult to innovate and respond to changing needs. On the other hand, Russia’s healthcare system is more decentralized which means there is more autonomy for local governments and providers which can allow for more flexibility and responsiveness to local needs, but can also lead to a lack of coordination and the duplication of services. In reality, progress in both countries has led to a so-called “mixed” healthcare system, with a combination of public and private providers, which can be beneficial because it allows patients to choose what type of care best meets their needs, but it can also lead to the fragmentation of the systems [43]. However, both countries have faced some common problems such as the following: lack of funding; lack of access to healthcare services; poor quality care; and corruption [44].

Regarding the healthcare models better applicable for Russia and Romania, it has been revealed in the literature that there is no single “best” model for both countries. The approach will vary according to the specific circumstances of each country, such as the following: the level of economic development; the size and structure of the healthcare system; and the political and social context. A potential “hybrid” model combining elements of different approaches taken from the experience of developed EU countries and fully private models such as the US could be suitable for the two countries. But a “hybrid” model also has its drawbacks such as the novelty, uncertainty, vagueness, and inconsistency of its elements during the transition from the present models [45]. In addition, there are large differences between the healthcare services offered in urban and rural areas, with major accessibility problems for rural residents [46].

In conclusion, the healthcare systems in Russia and Romania are complex and dynamic, with various factors influencing their performance and outcomes. They face a number of challenges, including a lack of understanding of the target market, a lack of resources, and a lack of coordination between stakeholders. Overall, there is a huge demand for understanding target markets and using the appropriate marketing tools to improve the quality of healthcare systems. Market orientation, which focuses on meeting the needs of the target market, is seen as being key to success [6].

Taking into account the characteristics mentioned above, the present research has focused on identifying the perspectives of customers regarding the healthcare services they have received from private and public clinics in the two countries. The ultimate goal has been to find the features of services that are important to patients and how marketing strategies can be prioritized to improve customer satisfaction.

3.2. Research Method and Data Collection

Given the multiple facets of customer satisfaction, we consider that a marketing approach divided by the components of the marketing mix in services could be one of the most suitable tools to identify the current state of the healthcare systems in the analyzed countries and offer support for the best future improvement strategies. To achieve the research objectives, a survey was conducted among Russian and Romanian customers. The data were collected using an electronic questionnaire, which contains 16 items that represent specific attributes of the marketing mix with the 7 Ps used in the service activity: product, price, placement, promotion, physical evidence, service process, and personnel. These items have been formulated as statements that are grouped by the marketing mix components, as presented in Table 1. The respondents were asked to evaluate the importance and satisfaction with each item considered in the questionnaire. In this respect, a 5-level equally distanced rating scale was used (e.g., 5 = very important, and 5 = very satisfied). The same evaluations were made for both the public and private clinics in the analyzed countries. The items used in the questionnaire were inspired by the literature review and from the results of a qualitative research, since we did not find similar research in the literature. Data collection took place via Google Forms over a 3-week period in March 2022. The link used to reach the questionnaire completion page was posted on social networks, blogs, and patient groups of medical organizations or sent by e-mail to various patients. Respondents were asked to share the link with their acquaintances who had recently used public or private healthcare services. Thus, the snowball sampling method was used, following the same procedure for both countries. Filtering questions were used to identify people who used medical services provided by public/private clinics in the last three years. Only these people continued to fill in the answers to the specific questions. After data collection was completed, 110 questionnaires were excluded from analysis due to non-compliance. The final sample contains a total of 410 residents from both Russia and Romania (224 Russians and 186 Romanians).

3.3. Data Processing

The obtained data was processed using the IBM SPSS system and descriptive statistics regarding the mean of each item were computed. Finally, an Importance–Satisfaction (IS) matrix has been computed for public and private healthcare clinics in both analyzed countries. The IS matrix was chosen as an alternative to the Importance–Performance Analysis (IPA) due to the power of satisfaction to more accurately express the customers’ outcome after consuming a service as opposed to service performance, which is usually considered an output of the provider [47]. Therefore, the satisfaction could be considered as the expression of the customer’s attitude towards the service. In the context of our research, importance is used as a cognitive attitude and satisfaction as a behavioral attitude (based on previous experience) [23].

The IS matrix classifies the items according to two dimensions, importance and satisfaction, which are divided into low or high, according to a separation criterion. The purpose of using this matrix is to support two of the most essential criteria for decision making: directing resources toward the aspects that are the most important to consumers and directing resources toward those aspects that are least satisfying to customers [48]. In our study we used the classic IS matrix which is divided into 4 quadrants. The first quadrant is “Keep up the good work”, which includes attributes that are both highly important to customers and with which customers are highly satisfied. These attributes are seen as critical to the success of the product or service, and should continue to be a focus of attention for the organization [49]. The second quadrant is “Concentrate here” zone, which includes attributes that are highly important to customers but where the organization is failing in terms of customer satisfaction. These attributes represent opportunities for quick wins and easy improvements that can have a big impact on customer satisfaction and loyalty [50]. The third quadrant is “Possible overkill” zone, which includes attributes that customers are highly satisfied with, but that are not considered to be highly important to them. These attributes are often seen as “bells and whistles” and may not be worth the investment for the organization unless they can be tied to specific business goals [51]. The fourth and final quadrant is the “Low priority” zone, which includes attributes that are neither highly important to customers nor highly satisfying. These attributes are seen as low priority and may not be worth the investment of time and resources to improve [47].

By using the IS matrix, our research makes comparisons between public and private clinics in Russia and Romania. The matrix was computed for every type of clinic in the two countries. Finally, strategic directions from the marketing perspective were proposed.

4. Results

The descriptive statistics of the analyzed items in terms of the importance and satisfaction were computed by using SPSS system. The mean values for each item are shown in Table 1. The results highlight some differences between the two countries both in terms of importance of some attributes of the healthcare services and the satisfaction with them. Thus, the most important attribute in the opinion of the Russians is the competence of the personnel, followed by the quality of the services in the clinics, while the Romanians consider the existing equipment in the clinics to be the most important, followed by the quality of the services. In both countries, in last place in terms of importance is placed the price of paid services. The assessment of customer satisfaction also reveals differences both between public and private clinics and between the two countries. According to the values of the overall mean, in both countries the customers are more satisfied with the private services than with the public ones. There are also differences between countries, as the private services in Romania obtained a higher score (3.73 points) than in Russia (3.60 points) and the public services are better appreciated in Russia than in Romania.

Table 1. Importance–Satisfaction means recorded for items regarding medical clinics.

7-Ps	№	Question Directions (Variables)	Satisfaction				Importance (Ranking)
			Russia		Romania		Russia	Romania
			Public	Private	Public	Private
Product	1	Existence of emergency services	3.08	2.95	2.85	3.27	4.19 (8)	4.08 (7)
	2	Diversity of medical services	3.11	3.68	2.50	3.85	4.09 (4)	3.02 (2)
Price	3	Price of paid services	3.24	2.53	2.56	2.64	3.66 (1)	3.00 (1)
	4	Existence of free of cost services	3.18	2.85	2.60	2.79	4.14 (7)	3.60 (3)
Placement	5	Booking of services online	2.42	3.68	2.46	4.39	4.12 (6)	4.22 (10)
	6	Websites and mobile apps	2.38	3.84	2.67	3.80	4.00 (3)	4.37 (13)
Promotion	7	Accuracy of the information	2.75	3.59	2.73	3.86	4.37 (10)	4.41 (14)
	8	Information about clinic’s location	3.17	3.71	3.87	4.04	3.66 (2)	4.01 (6)
Physical Evidence	9	State of equipment in clinics	2.81	4.10	2.59	4.03	4.51 (13)	4.57 (16)
	10	State of interior of clinics	2.21	4.29	2.56	4.28	4.56 (14)	4.31 (12)
	11	State of exterior of clinics	2.19	4.14	2.51	4.22	4.10 (5)	4.14 (8)
Service Process	12	Quality of services in clinics	2.73	3.53	2.65	3.67	4.67 (15)	4.51 (15)
	13	Time spent in clinics	2.67	3.61	2.59	3.57	4.28 (9)	3.69 (4)
	14	Organizational process	2.70	3.69	2.53	3.60	4.51 (12)	4.17 (9)
Personnel	15	Personnel’s competence	2.94	3.62	2.44	3.70	4.69 (16)	4.26 (11)
	16	Relationship between the doctor and the patient	2.86	3.73	2.41	4.01	4.44 (11)	3.92 (5)
Overall mean			2.78	3.60	2.66	3.73	4.25	4.02

Table 1. Importance–Satisfaction means recorded for items regarding medical clinics.

7-Ps	№	Question Directions (Variables)	Satisfaction				Importance (Ranking)
			Russia		Romania		Russia	Romania
			Public	Private	Public	Private
Product	1	Existence of emergency services	3.08	2.95	2.85	3.27	4.19 (8)	4.08 (7)
	2	Diversity of medical services	3.11	3.68	2.50	3.85	4.09 (4)	3.02 (2)
Price	3	Price of paid services	3.24	2.53	2.56	2.64	3.66 (1)	3.00 (1)
	4	Existence of free of cost services	3.18	2.85	2.60	2.79	4.14 (7)	3.60 (3)
Placement	5	Booking of services online	2.42	3.68	2.46	4.39	4.12 (6)	4.22 (10)
	6	Websites and mobile apps	2.38	3.84	2.67	3.80	4.00 (3)	4.37 (13)
Promotion	7	Accuracy of the information	2.75	3.59	2.73	3.86	4.37 (10)	4.41 (14)
	8	Information about clinic’s location	3.17	3.71	3.87	4.04	3.66 (2)	4.01 (6)
Physical Evidence	9	State of equipment in clinics	2.81	4.10	2.59	4.03	4.51 (13)	4.57 (16)
	10	State of interior of clinics	2.21	4.29	2.56	4.28	4.56 (14)	4.31 (12)
	11	State of exterior of clinics	2.19	4.14	2.51	4.22	4.10 (5)	4.14 (8)
Service Process	12	Quality of services in clinics	2.73	3.53	2.65	3.67	4.67 (15)	4.51 (15)
	13	Time spent in clinics	2.67	3.61	2.59	3.57	4.28 (9)	3.69 (4)
	14	Organizational process	2.70	3.69	2.53	3.60	4.51 (12)	4.17 (9)
Personnel	15	Personnel’s competence	2.94	3.62	2.44	3.70	4.69 (16)	4.26 (11)
	16	Relationship between the doctor and the patient	2.86	3.73	2.41	4.01	4.44 (11)	3.92 (5)
Overall mean			2.78	3.60	2.66	3.73	4.25	4.02

In the following paragraphs, the IS matrix will be computed for every type of medical service in the analyzed countries. Since the importance of all analyzed items was rated with mean scores above 3 points, we could not use the mean of the scale as a separation criterion as suggested in the literature [46] because all the items would be placed in the right-side quadrants of the matrix. As the scale used is quite heterogeneous in terms of the items used, an ordinal approach was considered to be a better fit. Therefore, the separation criterion for the items related to the importance was the median value obtained by ranking the items according to the mean score. The item with the highest mean score was given the highest rank, followed by the variable with the second highest mean, and so on. The item with the lowest mean score was placed last in this ranking order. The items were classified in two equal groups (eight items each), as factors of low importance (below the median) and factors of high importance (above the median). For the other dimension, related to the satisfaction, the separation was made according to the overall mean of the 16 items. Items with mean scores lower than the overall mean are less satisfying, while those with higher mean scores generate high satisfaction.

4.1. Importance–Satisfaction Matrix for Russian Clinics

Russia has poor outputs in public clinics as only three of the attributes are at “Keep up the good work”: the personnel’s competence, the relationship between the doctor and patient, and the state of the equipment in clinics (Figure 1). This reveals that the Russian healthcare system is in bad shape and patients generally are dissatisfied with the services they require. Most of the attributes need more attention in the future development programs of the public clinics or are placed in the category “Possible overkill” (see

Table 2. The distribution of items within the IS matrix for Russian public clinics.

“Keep Up Good Work”	“Concentrate Here”	“Low Priority”	“Possible Overkill”
(15) Personnel’s competence; (9) State of equipment in clinics; (16) Relationship between the doctor and the patient.	(10) State of interior; (12) Quality of services; (14) Organizational process; (13) Time spent in clinics; (7) Accuracy of the information provided.	(11) State of exterior of clinics; (6) Websites and mobile apps of clinics; (5) Booking online.	(3) Price of paid services; (8) Information about clinic’s location; (2) Diversity of medical services; (4) Existence of free of cost services; (1) Existence of emergency.

).

In Table 2 there is presented the attributes included in every quadrant of the IS matrix for the public sector in Russia. There are five items in the “Concentrate here” quadrant and three items in the group that needs less focus, called “Low Priority”. The Russian public clinics mostly lack in the following attributes: the state of the interior of the clinics; the quality of the services; the organizational process; the time spent in the clinics; and the accuracy of the information provided. Low priority should be given to the state of the exterior of the clinics; the websites and mobile apps of clinics; and the booking services.

If we observe the situation of the private clinics in the Russian healthcare system (Figure 2), there are still two points in the “Concentrate Here” quadrant consisting of the quality of services in clinics and the accuracy of the information provided. The good points that were found for private clinics in Russia are as follows: the personnel’s competence; the state of the interior of the clinics; the state of the equipment in the clinics; the organizational process; the relationship between the doctor and the patient; and the time spent in the clinics.

We can observe in

Table 3. The distribution of items within the IS matrix for Russian private clinics.

“Keep Up the Good Work”	“Concentrate Here”	“Low Priority”	“Possible Overkill”
(15) Personnel’s competence; (10) State of interior of clinics; (9) State of equipment in clinics; (14) Organizational process; (16) Relationship between the doctor and the patient.	(12) Quality of services in clinics; (7) Accuracy of the information provided.	(3) Price of paid services; (4) Existence of free of cost services; (1) Emergency services.	(8) Information about clinic’s location; (6) Websites and mobile apps; (2) Diversity of medical services; (11) State of exterior of clinics; (5) Booking of services online.

a large number of attributes included in the “Possible Overkill” section, where we have around five items such as the following: information about the clinic’s location; the websites and mobile apps of clinics; the diversity of medical services; the state of the exterior of the clinics; and the booking of services online. The clinic’s focus on these attributes involves much effort, which is not considered important by customers, while other attributes need attention but have a low priority: the price of the paid services; the existence of free of cost services; and the existence of emergency services.

The distinction between the public and private clinics in Russia is obvious (see Figure 3). There are more attributes in the “Good work” section in the private sector than in the public one and there is a greater need for the public sector to improve their healthcare services (“Concentrate here”).

This may be impacted by the characteristics of the Russian healthcare system, which does not require a high degree of quality and profit from public clinics. As a result, the entire system needs a major restructuring.

4.2. Importance–Satisfaction Matrix for Romanian Clinics

The IS matrix for the Romanian public clinics (Figure 4) reveals a small number of attributes that exceed the overall mean. There are four attributes in this situation, two of them being included in the “Keep up the good work” quadrant and the others in “Possible overkill”. The accuracy of the information provided and the websites and mobile apps of clinics are the only attributes for which the Romanian public clinics should maintain the good work, which means, evidently, a large number of improvements that should be implemented in near the future. There are six variables in the “Concentrate here” quadrant and another six in “Low Priority”.

The attributes existing in each quadrant of the IS Matrix are presented in

Table 4. The distribution of items within the IS matrix for Romanian public clinics.

“Keep Up the Good Work”	“Concentrate Here”	“Low Priority”	“Possible Overkill”
(7) Accuracy of the information provided; (6) Websites and mobile apps.	(9) State of equipment in clinics; (12) Quality of services in clinics; (10) State of interior of clinics; (15) Personnel’s competence; (5) Booking of services online; (14) Organizational process.	(3) Price of paid services; (2) Diversity of medical services; (4) Existence of free of cost services; (13) Time spent in clinics; (16) Relationship between the doctor and the patient; (11) State of exterior of clinics.	(8) Information about clinic’s location; (1) Existence of emergency services.

. It can be observed that the Romanian public clinics mostly have to concentrate their efforts on improving the state of the equipment in the clinics; the quality of the services; the state of the clinic’s interior; the personnel’s competence; the process of booking services online; and the entire organizational process.

There are also attributes for which the improvement process has low priority but they should be analyzed individually because there are some critical aspects, like the relationship between the doctors and the patients that should be carefully considered.

The difference between the public and private sectors is widely different (Figure 5). This could be influenced by Romania’s legacy from its previous Semashko healthcare system, when there were no private clinics at all; but when they appeared, they immediately offered better services than the paid medical services.

The results presented in

Table 5. The distribution of items within the IS matrix for Romanian private clinics.

“Keep Up the Good Work”	“Concentrate Here”	“Low Priority”	“Possible Overkill”
(9) State of equipment; (7) Placement about what clinics suggest; (10) State of interior; (6) Websites and mobile apps of clinics; (5) Booking services online.	(14) Organizational process; (15) Personnel’s competence; (12) Quality of services in clinics.	(3) Price of paid services; (4) Existence of free of cost services; (1) Existence of urgent services; (13) Time spent in clinics.	(2) Diversity of miscellaneous services; (16) Relationship between the doctor and the patient; (8) Placement about location of clinics; (11) State of exterior.

reveal that the Romanian public clinics should concentrate mostly on three attributes: the organizational process; the personnel’s competence; and the quality of the services. For most of the attributes, the clinics should “Keep up the good work”. The synthesis of the results for the Romanian public and private clinics shows almost the same patterns with those of the Russian healthcare system. For the public sector, there are a few attributes in the “Keep up the good work” quadrant and more attributes that should be improved than in the private sector (see Figure 6).

5. Discussion and Conclusions

The attitudes of customers towards the healthcare services in the public and private clinics operating in Russia and Romania have created a portrait of the current state of these services, which was the main goal of this research. Thus, taking into account the results presented above, we can conclude that the main objectives have been achieved. For the first objective, (1) aim at identifying the importance and customer satisfaction related to the main items of the marketing mix applied to healthcare services in the analyzed countries, the most important attributes of the healthcare services were identified and the satisfaction with the attributes was measured. The most important three attributes in Russia are related to the following components of the marketing mix: “Personnel, “Service process, and “Physical evidence” (see Table 1), which are the additional components specific to the service-providing process. In the case of Romania, the most important attributes belong to “Physical evidence”, “Service process”, and “Promotion”, which are slightly different from Russia. For example, in Romania, the accuracy of the information provided by the clinics (“Promotion”) is considered more important than the personnel’s competence, which is the most important in the opinions of the Russian respondents. The least important attribute in both countries is the price of the paid services, which places the price, as a marketing mix component, in a low position in terms of importance given by the customers. These results are in line with other findings in the literature that reveal the importance of some attributes of the services such as the following: the quality management as an attribute of the process; the communication with the patients as a promotional activity; or the customer relations as a part of the personnel’s involvement in the process [13,14,15,16,19,20,21,28,29,30,31,32,33]. Physical evidence is also considered in the literature as an important factor of the quality of healthcare services [18,34]. For the same research objective, the satisfaction with the analyzed attributes was measured, and the results reveal poor satisfaction with the public clinics in both countries (overall means are below 3 points) and a slightly higher satisfaction with the private clinics, but with overall mean scores below 4 points (3.60 points in Russia and 3.73 points in Romania).

The evidence from the named countries makes necessary a strategic analysis of the service provided in order to create a scientific instrument for future improvements, which was the second objective of our research: (2) to compute the Importance–Satisfaction matrix for the public and private healthcare services in order to prioritize the improvement strategies.

After applying the strategic analysis using the IS matrix, we found that in the private sector, the clinics in each country have tried to act quickly and responsively to the people’s needs. If we focus on “Concentrate here” attributes for Romania’s private clinics we can identify three items: the organizational process; the personnel’s competence; and the quality of the services in the clinics. These items belong to the components of the marketing mix related to “Service process” and “Personnel”. If we look at Russia, only two attributes can be found in the “Concentrate Here” quadrant: the quality of the services in the clinics and the accuracy of the information provided. In this case, the corresponding components of the marketing mix are “Service process” and “Promotion”.

Regarding the public clinics, the strategic analysis reveals that the efforts should be concentrated on more attributes than the private ones. These attributes are presented in comparison for both countries in

Table 6. Comparison of the attributes from “Concentrate here” quadrant for public clinics.

Russian “Concentrate Here” for Public Clinics	Romanian “Concentrate Here” for Public Clinics
(7) Accuracy of the information (Promotion); (10) State of interior of clinics (Physical evidence); (12) Quality of services in clinics (Process); (13) Time spent in clinics (Process); (14) Organizational process (Process).	(5) Booking of services online (Placement); (9) State of equipment in clinics (Physical evidence); (10) State of interior of clinics (Physical evidence); (12) Quality of services in clinics (Process); (15) Personnel’s competence (Personnel).

. Each item was associated with the corresponding component of the marketing mix.

It can be observed that only a small number of the attributes belong to the classic components of the marketing mix, most of them being related to the specific service being provided. As it can be seen, the Russian public clinics should focus mainly on aspects related to the service-providing process, while clinics in Romania should focus mainly on the physical evidence. Despite these differences, it is clear that the public clinics in both countries need to direct strategic actions towards almost the same service attributes. These findings also confirm some aspects presented in the specialized literature regarding the impact of information systems on the relationship with patients, the booking of the services, or the dissemination of information [14,15,20,21,36,37]. The competence of the personnel is also revealed as a possible differentiation factor in the market competition and as a determinant of service improvement [18,21,34,35]. Given these results, we consider that the second research objective has also been achieved. Thus, the outcomes of the present research entitle us to reveal the contributions of our article to academia, the business environment and other stakeholders.

First of all, from the perspective of theory, it can be observed that not only the classic marketing mix is important for customers, but also other components that are specific to the services. Often, the customers are interested in the intrinsic attributes of the services but also in aspects related to the service delivery process such as the organization, the quality of the service, or the waiting time for receiving the service. The physical evidence and contact personnel are also important. These components of the marketing mix are often neglected by the managers, and the results of our research confirm this. Moreover, our article highlights the utility of the IS matrix as a powerful tool for research and for establishing future improvement strategies.

For the business environment, the results of this research provide the main attributes that need action to be improved. For both analyzed countries there are issues to be solved in providing the healthcare services, which should be considered for improving the relationship with the customers. Nevertheless, the overview of the healthcare systems presented in this article is based on the general assessments made by the patients who sought the services of a wide and heterogeneous spectrum of medical institutions. The results reveal the major problems and challenges of private and public clinics but each service provider should make evaluations regarding the satisfaction of their own customers. Thus, the IS matrix could also be used to replicate the results in the particular case of each clinic, which could be conducted to obtain results more relevant for the service provider.

Other stakeholders, such as governments, policy makers, and local and regional authorities, could also benefit from the results of our research. They can establish strategies at the level of the macro-environment and public policies meant to develop and improve the national healthcare systems. The approach of all these policies at the micro and macro levels from the marketing perspective could help the stakeholders to enhance their analysis of the current situation but also to set strategic directions for the future development of the healthcare system.

Limitations and Future Research

As in any other research, we identified some limitations that should be acknowledged and addressed in future research. The main limitations come from the sample size and composition. The study relied on a convenient sample of customers who have used public or private clinics in Russia and Romania, which may not be representative of the general population of these countries. The sample size was relatively small (N = 410 for both countries), which may limit the statistical power and does not allow for the generalization of the results. Therefore, future studies should use larger and more diverse samples, preferably based on probability sampling techniques, to increase the validity and reliability of the findings. As such kinds of research can be used by each clinic, it will be easier to use their customer databases for selecting the sample.

Another limitation comes from the data collecting process. The study used a self-administered questionnaire to measure the customers’ attitudes towards various attributes of the healthcare services, which may introduce some biases and errors, such as social desirability, acquiescence, recall, and non-response. The questionnaire was adapted from previous studies and may not capture all the relevant aspects of healthcare quality and satisfaction in the specific contexts of Russia and Romania. Future studies should use more rigorous and comprehensive data collection methods and instruments, such as interviews, observations, or experiments, to obtain more accurate and in-depth data on the customers’ attitudes and experiences.

The study used an IS matrix to analyze the data, which is a simple and useful tool, but may not account for the complexity and diversity of the data. For example, the IS matrix assumes that the importance and satisfaction ratings are independent and linearly related, which may not be true in reality. Moreover, the IS matrix does not consider the interactions and correlations among different attributes, nor the moderating and mediating effects of other variables, such as demographic characteristics, service types, or expectations. For these reasons, the generalization of the results is not possible and a replication of the study in other contexts and places is necessary for validating the research findings.

The study focused on comparing and contrasting the customer satisfaction with healthcare services in Russia and Romania, which are two countries that have different historical, political, and economic backgrounds, but share some common challenges and opportunities in the healthcare sector. However, this focus may limit the applicability and transferability of the findings to other countries or regions that have different healthcare systems, policies, and practices. Therefore, further research should continue the effort to find information about costumers’ perspective on healthcare service providing and to develop more items that could be assessed for every component of the marketing mix. The validation of these results in other contexts and other countries can allow for better development of the knowledge in the field of healthcare.

One of the limitations of this research concerns the general approach of assessing customer satisfaction, which includes a wide variety of clinics offering diverse and heterogeneous services and benefiting from different equipment and staff. Even though the results help us to create an overview of the analyzed healthcare systems and compare them in general terms, the IS matrix could lead to better results at the micro level by assessing customer satisfaction for specific medical units and establishing future improvement strategies at the organizational level.