literature review of health sector

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Towards Green and Sustainable Healthcare: A Literature Review and Research Agenda for Green Leadership in the Healthcare Sector

Justyna berniak-woźny.

1 Department of Management, University of Information Technology and Management, 35-225 Rzeszów, Poland

Małgorzata Rataj

2 Department of Cognitive Science and Mathematical Modeling, University of Information Technology and Management, 35-225 Rzeszow, Poland

Associated Data

All data relevant to this work are included in the article or are uploaded as Supplementary Information .

The health sector is one of the keys to sustainable development. Although it is directly related to only one Sustainable Development Goal (Goal 3, “Ensuring a healthy life and promoting well-being at all ages”), the sector itself, which aims to protect health, is paradoxically at the same time the main emitter of environmental pollutants that have a negative impact on health itself. Therefore, sustainability has become a key priority for health sector organizations, and leadership in this area is essential at all levels. Scientific research plays a particular role here, helping to more clearly define the links between environmental sustainability and the health effects of a polluted environment and climate change as well as indicating the direction of actions needed and disseminating good practices that can help accelerate the adoption of efforts towards climate neutrality and sustainable development of health sector organizations. The aim of this article is to present the current state of the art and future research scenarios in the field of green and sustainable healthcare through a literature review by using the Preferred Reporting Items for Systematic Reviews Meta-Analyses (PRISMA) method to perform a bibliometric analysis of papers published in 2012–2022. The Web of Science Core Collection (WoSCC) database is used for this purpose. A total of 144 papers are included for analysis, categorized based on eight fields: author(s), title, year of publication, country, journal, scientific category, and number of citations. Based on the results, themes for future research on green leadership in the healthcare sector are identified and recommended.

1. Introduction

Sustainable development is one of the greatest, if not the greatest, global challenges of the 21st Century. However, the importance of sustainable development had already been recognized and declared as early as the United Nations Conference on the Human Environment in Stockholm in 1972 [ 1 ]. Fifteen years later, sustainable development was defined by Gro Harlem Brundtland, former Norwegian Prime Minister and Chair of the World Commission on Environment and Development (WCED), as “meeting the needs of the present without compromising the ability of future generations to meet their own needs” [ 2 ]. In 1992, the United Nations organized the Earth Summit in Rio de Janeiro, during which one of the most important documents related to sustainable development was prepared, Agenda 21, a comprehensive plan of action for the 21st Century for the United Nations, governments, and social groups in every area in which man has an impact on the environment. The Earth Summit was attended by representatives of 172 governments, 2400 NGOs, and 10,000 journalists, and 172 countries signed the Agenda [ 3 ]. The document includes the statement that humanity has reached a turning point in history, and a cautionary tale that by continuing the present policy we contribute to the widening of the economic gap in societies and between countries, the expansion of poverty, hunger, disease, and illiteracy. We cause a progressive degradation of the natural environment on which life on Earth depends [ 4 ]. Additionally, a proposal to change procedures in the future was defined. Recommendations range from new teaching methods to new methods of using raw materials and contributing to a sustainable economy. The overall ambition of Agenda 21 is a safe and just world in which every living thing is able to maintain its dignity. In parallel, the United Nations has launched a number of initiatives for sustainable development. The first comprised the Millennium Development Goals (MDGs), including eight interrelated goals as a holistic process, set at the 2000 Millennium Summit for a period of 15 years to 2015 [ 5 ]. Given its achievements and importance, in 2015 the United Nations established the 2030 Agenda for Sustainable Development, agreed to by 195 countries and consisting of 17 goals and 169 measures related to economic, environmental, and social objectives [ 6 , 7 , 8 ].

Sustainable development is one of the key issues in the healthcare industry. While of the 17 Sustainable Development Goals (SDGs) only the third goal of “ensuring healthy living and promoting well-being for all ages” is directly relevant to the health sector, other SDGs (such as on hunger, gender equality, clean water and sanitation, affordable and clean energy, sustainable cities and communities, climate action, peace, justice and strong institutions) with 43 health-related indicators apply to this industry indirectly. Even though the last two decades have been called a golden age for global health due to the increase in national health spending and donor funding by low- and middle-income countries, which has translated into increased access to health determinants (such as clean water and sanitation) and health services (such as vaccination, antenatal care, and HIV treatment) [ 9 ], recent years have only seen improvements in 24 (56%) of the 43 health-related SDG indicators, as WHO data shows [ 10 ].

However, satisfying the health needs of the population is associated with a negative impact on the natural environment, as health care is one of the main emitters of environmental pollution that has a negative impact on health. In Brazil alone, hospitals consume 10.6% of the energy used for commercial purposes [ 11 ]. In the UK, the National Health Service (NHS) emits 18 million tonnes of CO 2 annually, accounting for almost a quarter of the total emissions coming from the public sector [ 12 ]. In the US, total gas emissions from healthcare organizations increased by 6% from 2010 to 2018 [ 13 , 14 ]. India generated over 33,000 tonnes of medical waste during the seven months of the COVID-19 pandemic [ 15 ]. Healthcare, including pharmaceuticals, is responsible for 4.4% of global greenhouse gas emissions globally. In addition, the global market for medical waste management is expected to grow from an estimated USD 6.8 billion in 2020 to USD 9 billion by 2025 [ 16 ]. This negative impact was further exacerbated during the COVID-19 pandemic, mainly as a result of the increased intensity of health sector activities and the increased use of personal protective equipment (PPE) as well as diagnostic tools and vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which in both cases translated into an increase in the generation of medical waste. [ 17 ] Thus, the healthcare sector strives to transform itself into a sustainable one.

Sustainable healthcare can be defined as suggested - “a complex system of interacting approaches to the restoration, management and optimisation of human health that has an ecological base, that is environmentally, economically and socially viable indefinitely, that functions harmoniously both with the human body and the non-human environment, and which does not result in unfair or disproportionate impacts on any significant contributory element of the healthcare system” [ 18 ]. Sustainable healthcare is often referred to as green healthcare, which means the provision of healthcare services in an environmentally friendly manner that aims to promote health while having a positive impact on the community [ 19 , 20 ]. The concept of green hospitals defined by Howard in a report of the US Office of the Federal Environmental Executive is popular in this regard, and is defined as the practice of increasing the efficiency with which buildings and their sites use energy, water, and materials while reducing building impacts on human health and the environment through better siting, design, construction, operation, maintenance, and removal. [ 21 ] Indeed, according to Kreisberg [ 22 ], green healthcare facilitates a sustainable future for medicine, physicians, patients, and the environment. According to Fadda [ 19 ], green health systems are based on the following ten components.

• (1) Leadership through education, goal setting, accountability, and incorporating these priorities in all external relations and communications
• (2) Substituting harmful chemicals with safer alternatives
• (3) Reducing, treating, and safely disposing of healthcare wastes
• (4) Implementing energy efficiency and clean renewable energy generation
• (5) Reducing hospital water consumption and supplying potable water
• (6) Improving transportation strategies for patients and staff
• (7) Reducing food waste and the environmental footprint while improving patient and worker health by making changes in hospital service menus and practices
• (8) Reducing pharmaceutical pollution and developing safer pharma
• (9) Taking advantage of green buildings to develop safer, more resilient, greener, and healthier building products and systems
• (10) Changing purchasing habits in ways that reduce environmental and human rights impacts.

Unfortunately, the awareness of the healthcare community regarding the negative impact of the sector on the natural environment and society, and in turn the responsibility for dealing with it, is very low [ 23 ]. To support sustainable health systems, leadership is essential at all levels [ 24 , 25 , 26 , 27 ], both at the level of green politics [ 28 , 29 , 30 ] and at the level of influencing and shaping the attitudes of members of the health community and organizations [ 31 ]. Fortunately, in recent years there have been promising examples of green leadership at the international level, such as by the following organizations:

• The Alliance of Nurses for Healthy Environments (ANHE), a nursing organization focused solely on the intersection of health and the environment [ 32 ].
• Health Care Without Harm (HCWH), an international nongovernmental organization (NGO) that works to transform health care worldwide to ensure that it reduces its environmental footprint and becomes a community anchor for sustainability and leader in the global movement for environmental health and justice [ 33 ].
• The Health and Environment Alliance (HEAL), the leading European not-for-profit organisation addressing how the natural and built environments affect health in the European Union (EU) and beyond [ 34 ].
• The Global Climate and Health Alliance, made up of health and development organizations from around the world united by a shared vision of an equitable and sustainable future. Alliance members work together to (1) ensure that health impacts are integrated into global, regional, national, and local policy responses to climate change to reduce them as far as possible, with a particular focus on reducing health inequalities through mitigation and adaptation; (2) encourage and support the health sector to lead by example in mitigating and adapting to climate change; (3) raise awareness of the health threats posed by climate change and the potential health benefits of well-chosen climate mitigation policies in areas such as energy, transport, food, and housing [ 35 ].
• Irish Doctors for Environment is an NGO and registered charity consisting of doctors, medical students, and allied healthcare professionals in Ireland who aim to create awareness and interest and implement action around environment health and the impact it has on patient health [ 36 ]
• OraTaiao: The New Zealand Climate and Health Council comprises health professionals in Aotearoa/New Zealand concerned with (1) the negative impacts of climate change on health; (2) the health gains that are possible through strong health-centred climate action; (3) highlighting the impacts of climate change on those who already experience disadvantage or ill-health (equity impacts); and (4) reducing the health sector’s contribution to climate change [ 37 ]
• The Canadian Association of Physicians for the Environment, which takes action to enable health for all by engaging with governments, running campaigns, conducting research, and drawing media attention to key issues [ 38 ]
• Doctors for the Environment Australia (DEA), an organisation of medical professionals that protect human health through care of the environment. The devastating impacts of climate change on human health and the solutions needed to address this grave threat are a major focus of their work. DEA members include GPs, surgeons, physicians, anesthetists, psychiatrists, pediatricians, public health specialists, academics, medical students, and researchers, bringing leadership and expertise from every branch of medicine [ 39 ].

To provide better guidance for the development and adoption of new practices and procedures in the field of sustainable and green healthcare, the aim of this article is to present the current state of the art and future research scenarios in the field of green and sustainable healthcare.

The rest of this paper is organized as follows. Section 2 defines the methodology and datasets. In Section 3 , the main results of the review are presented and discussed. Finally, our conclusions are outlined, including the implications and limitations of the paper and future research directions.

2. Materials and Methods

As mentioned in the Introduction, the aim of this article is to present the current state of the art and future research scenarios in the field of green and sustainable healthcare. To achieve the assumed goal, the authors conducted a review of the literature on green and sustainable healthcare published in 2013–2023 (early access) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 40 ]. The review was supplemented with a bibliographic analysis to analyze large numbers of publications and identify research trends and patterns in the defined research area [ 41 ]. This allowed for a holistic view of the constantly growing knowledge resources and the assessment of specific research directions as well as the outlining of the anatomy of current knowledge in a green and sustainable healthcare field [ 42 ].

The search was carried out in October 2022. The search process used the Web of Science (WoS) Core Collection database, which is the leading database for classifying academic research. The Web of Science Core Collection contains over 21,100 peer-reviewed, high-quality scholarly journals published worldwide in over 250 scientific disciplines. Conference proceedings and book data are available as well. The WoS Core Collection was analyzed to find related publications based on the following keyword combination: “sustainability” OR “green” AND “healthcare/health care”. We searched for articles with these phrases in the title, abstract, or keywords. Additionally, the search was limited to records published from 2013 to 2022 in English. The results of these searches contributed to the selection of a database consisting of 4289 documents that matched our query. The WoS database was downloaded as a file in PDF format. Further, we screened the titles and abstracts, which limited the database to 836 records. The selection process involved two independent reviewers and two steps: (1) selection based on inclusion criteria (publications on sustainable and/or green healthcare systems or institutions and publications with a minimum of ten citations) and (2) final inclusion in the review. Discrepancies between reviewers were resolved through discussion and agreement. The database was downloaded in the TXT format, as the authors planned to use it for visualization in VOSviewer software, which requires CSV or TXT files. As WOS has built-in analyzer features, initial descriptive analysis was carried out using these features, and further Excel analyzing features were employed. Tables were created to provide quantitative data. Additionally, VOSviewer software version 1.6.18 was applied to quantitatively and visually analyze keyword co-occurrences.

Next, as we wanted to have access to the full content of the articles, the database was narrowed to 653 records. Further, in order to focus on scientific contributions and avoid editorials and other unrelated material, reviews, editorial materials, and notes were excluded. The database was narrowed down to articles and proceedings only, and 219 records were excluded. The analysis of the full text of the publications resulted in the exclusion of a subsequent 163 records. The next round of full text analysis eliminated a further 127 records, as they were considered to be irrelevant to the review aim or were not published in a journal with sufficient impact factor. As shown in Figure 1 , the final database consisted of 144 documents, including 142 articles and two proceedings papers.

PRISMA flow chart [ 43 ].

To provide a holistic academic landscape and understandable overview of the latest trends in research related to green and sustainable healthcare, the results of the review are presented from the perspective of (1) the number of publications between 2013–2022 and the keywords clusters, (2) leading countries, (3) leading journals, (4) the most impactful papers, and (5) major disciplines.

3.1. Results—Total Number of Publications

The number of publications over time, or the growth trend, is one of the most relevant factors as to how much scholars are interested in a specific topic, and is an indicator of the expansion of a field of research [ 44 , 45 , 46 ]. Figure 2 shows the yearly distribution of the selected articles on green and sustainable healthcare in the last decade. The growth in the annual number of published articles in 2020–2022 reflects the growing popularity of the subject around the world.

Number of articles published in the years 2013–2022.

The significant increase in the last three analyzed years is interesting. These dynamics of publication growth in the area of a sustainable and green healthcare may be related to the crisis caused by the pandemic. Examples of the articles on the issues analyzed from the perspective of COVID are as follows:

• “Implementation of Obstetric Telehealth During COVID-19 and Beyond” [ 47 ],
• “Framework for PESTEL dimensions of sustainable healthcare waste management: Learnings from COVID-19 outbreak” [ 48 ],
• “Selection of the best healthcare waste disposal techniques during and post COVID-19 pandemic era” [ 49 ],
• “Leveraging nurse practitioner capacities to achieve global health for all: COVID-19 and beyond” [ 50 ],
• “Development of a Multi-Criteria Model for Sustainable Reorganization of a Healthcare System in an Emergency Situation Caused by the COVID-19 Pandemic” [ 51 ]
• “How Can Health Systems Better Prepare for the Next Pandemic? Lessons Learned from the Management of COVID-19 in Quebec (Canada)” [ 52 ].

3.2. Results—Keyword Analysis

The keyword analysis began with the initial sample of 836 publications, on which mapping was performed based on VOSviewer software. Figure 3 shows a graphical representation of keyword co-occurrences. Only keywords which appeared at least ten times in our sample were covered by the analysis. Keywords that occurred more frequently are represented with a larger font size and circle. Keywords that appeared together are linked with lines. A thicker line between two keywords indicates that these two keywords appeared together more often in one publication. Looking at Figure 3 , four different thematic clusters can be seen, represented by different colors.

Keywords co-occurrence map.

First, the red cluster is the medical branch of research, which deals with sustainable development of health management. Keywords such as “health system”, “health policy”, “quality”, “design”, and “optimalization” indicate that the focus is on understanding implementation of green scenario in the context of health care.

The blue cluster focuses on the natural environment, and consists of keywords such as “sustainability”, “environment”, or “climate change”. The blue cluster is about education, with keywords such as “knowledge”, “medical education”, and “attitudes”. In most cases, the ultimate goal of the articles within the green cluster is about implementation of green solutions in medical institutions.

The green cluster is driven generally by prevention and risk assessment in the context of eco-health. In this cluster, “behavior”, “perception”, and “empowerment” are among the keywords. Closely related to the green cluster is general health, with terms such as “overweight”, “physical activity”, and “nutrition”.

The yellow cluster is sustainable development in medical care, underlying how important is education in this field both for students and medical personnel.

Overall, the keyword “co-occurrence network” in Figure 3 underpins the multidisciplinary nature of the green and sustainable health sector.

By conducting a comprehensive analysis of the Authors’ Keywords in the final database generated from WoS (144 papers), the following three thematic clusters were formed.

Cluster 1—“Sustainability”. Presented in Figure 4 , this cluster includes 20 terms: building sustainability assessment methods, environmental sustainability, sustainable development, sustainable employability, sustainable enterprise, sustainable healthcare, sustainable healthcare supply chain, sustainable healthcare systems, sustainable transportation, environmental sustainability, social sustainability, sustainable behaviors, sustainable business models, sustainable competitive advantage, sustainable design, sustainable development goals (SDGs), sustainable diets, sustainable physical healthcare pattern recognition, sustainable policies, sustainable health care education. In general, the papers referring to this cluster focus on:

• The 2030 Agenda of United Nations for Sustainable Development Goals (SDGs), for example, “Sustainable development goals and mental health: learnings from the contribution of the FundaMentalSDG global initiative” [ 53 ], “Soft power and global health: the sustainable development goals (SDGs) era health agendas of the G7, G20 and BRICS” [ 54 ], “Approaches to protect and maintain health care services in armed conflict—meeting SDGs 3 and 16” [ 55 ].
• Sustainability assessment methods and competitive advantage: “Assessment of Environmental Sustainability in Health Care Organizations” [ 56 ], “Advanced therapy medicinal products and health technology assessment principles and practices for value-based and sustainable healthcare” [ 57 ], “Development of a healthcare building sustainability assessment method—Proposed structure and system of weights for the Portuguese context” [ 58 ].
• Sustainable healthcare organization and systems: “AMEE Consensus Statement: Planetary health and education for sustainable healthcare” [ 59 ], “Faculty development and partnership with students to integrate sustainable healthcare into health professions education” [ 60 ], “Empowering Patients to Co-Create a Sustainable Healthcare Value” [ 61 ].
• Sustainable supply chains: “Integration of a Balanced Scorecard, DEMATEL, and ANP for Measuring the Performance of a Sustainable Healthcare Supply Chain” [ 62 ], “The Healthcare Sustainable Supply Chain 4.0: The Circular Economy Transition Conceptual Framework with the Corporate Social Responsibility Mirror” [ 63 ], “Managing a sustainable, low carbon supply chain in the English National Health Service: The views of senior managers” [ 64 ].

Sustainability cluster Authors’ Keywords.

Cluster 2, “Climate”, is presented in Figure 5 , and includes 19 terms: climate change, climate change and health, environmental hazards, environmental health, environmental health inequalities, Environmental scan, environmental sustainability, green care, green economies, green exercise, green gentrification, green growth strategies, green hospital, green public health, green space, hazardous waste, healthcare waste management, waste minimization assessment, creating and utilizing resources, ecological crisis. In general, the papers referring to this cluster focus on:

• Climate change and health: “Towards Climate Resilient and Environmentally Sustainable Health Care Facilities” [ 65 ], “Nurses’ perceptions of climate and environmental issues: a qualitative study” [ 66 ], “Impact of a Telemedicine Program on the Reduction in the Emission of Atmospheric Pollutants and Journeys by Road” [ 67 ].
• Green health facilities: “Greening healthcare: systematic implementation of environmental programmes in a university teaching hospital” [ 68 ], “Residential Greenery: State of the Art and Health-Related Ecosystem Services and Disservices in the City of Berlin” [ 69 ], “Using the World Health Organization health system building blocks through survey of healthcare professionals to determine the performance of public healthcare facilities” [ 70 ].
• Healthcare resources management: “Healthcare waste generation and management practice in government health centers of Addis Ababa, Ethiopia” [ 71 ], “Impact of intervention on healthcare waste management practices in a tertiary care governmental hospital of Nepal” [ 72 ], “LCA of Hospital Solid Waste Treatment Alternatives in a Developing Country: The Case of District Swat, Pakistan” [ 73 ].

Climate cluster Authors’ Keywords.

Cluster 3, “Digital transformation”, is presented in Figure 6 , and includes 17 terms: digital innovation, digital platforms, digital policy, Internet of Health Things (IoHT), telemedicine, decision support, decision-making, decision-making tool, digital health, digital health ecosystem, telehealth, telemedicine, telemedicine service, ecosystem services (ESs), digital dentistry, health technology development, healthcare informatics. New technology has numerous applications in healthcare allowing for lowering medical costs, upgrading the quality and efficiency of medical procedures, improving healthcare pathways, and giving better control over resource management. All these factors in the healthcare sector contribute to the implementation of sustainable development as promoted and recommended by the United Nations. In general, the papers referring to this cluster focus on:

• Digital innovations and policy for healthcare: “Sustainable Value Co-Creation and Digital Health: The Case of Trentino eHealth Ecosystem” [ 74 ], “Engagement in Healthcare Systems: Adopting Digital Tools for a Sustainable Approach” [ 75 ], “Pursuing Sustainability for Healthcare through Digital Platforms” [ 76 ].
• Decision making support: “Sustainability of knowledge translation interventions in healthcare decision-making: a scoping review” [ 77 ], “Sustainability in health care by allocating resources effectively (SHARE) 3: examining how resource allocation decisions are made, implemented and evaluated in a local healthcare setting” [ 78 ], “Pinch Analysis as a Quantitative Decision Framework for Determining Gaps in Health Care Delivery Systems” [ 79 ].
• Telemedicine: “Improving the Cost-Effectiveness of a Healthcare System for Depressive Disorders by Implementing Telemedicine: A Health Economic Modeling Study” [ 80 ], “Impact of a Telemedicine Program on the Reduction in the Emission of Atmospheric Pollutants and Journeys by Road” [ 67 ], “Adoption mechanism of telemedicine in underdeveloped country” [ 81 ].

Digital Transformation cluster Authors’ Keywords.

3.3. Total Number of Publications Per Location

One of the basic criteria for bibliographic analysis is the index of countries that contribute most in this field [ 82 , 83 ]. The twelve leading countries in terms of the number of published articles in the field of the green and sustainable health sector are presented in Figure 7 . The country selection criterion for multi-author publications was the country of the corresponding author. Most productive in this field were researchers from the USA, England, and Australia. The leading country in the European Union was Italy.

Number of articles per country.

3.4. Total Number of Publications Per Journal

The 144 articles selected were published in 66 different journals. The Impact Factor (IF) of the journals ranged from 202.731 for The Lancet to 0.863 for Quality in Ageing and Older Adults. Out of 66 scientific journals, we identified seven which are the most popular among researchers ( Figure 8 ). The remaining 89% of journals only occasionally publish articles about eco-health sustainability.

Number of papers per journal.

The most popular journal, Sustainability, is published by MDPI. It is an international, cross-disciplinary, scholarly, peer-reviewed, and open-access journal on the environmental, cultural, economic, and social sustainability of human beings. The Impact Factor of this journal is 3.889. The second-most popular journal is the International Journal of Environmental Research and Public Health, which an interdisciplinary, peer-reviewed, open access journal published semimonthly online by MDPI. It covers Environmental Sciences and Engineering, Public Health, Environmental Health, Occupational Hygiene, Health Economic, and Global Health Research. The Impact Factor of this journal is 4.614.

Further, we highlight the three BMC journals. These are Health Research Policy and Systems, which covers all aspects of the organisation and use of health research, including agenda setting, building health research capacity, and how research as a whole benefits decision makers, practitioners in health and related fields, and society at large, and has an impact factor of 4.139; BMC Public Health journal, with a special focus on the social determinants of health, the environmental, behavioral, and occupational correlates of health and disease, and the impact of health policies, practices and interventions on the community, which has an impact factor of 4.135; and Globalization and Health, a transdisciplinary journal that publishes papers on how globalization processes affect health through their impacts on health systems and the social, economic, commercial, and political determinants of health. The focus of this journal is on policy, systems, technological, organizational, clinical, community and individual perspectives, and it has an impact factor of 10.401.

Similarly impactful is the Journal of Cleaner Production, which serves as a platform for addressing and discussing theoretical and practical cleaner production, encompassing environmental, and sustainability issues in corporations, governments, education institutions, regions, and societies, with an impact factor of 11.072.

Figure 7 covers the International Journal for Quality in Health Care (IJQHC), an interdisciplinary journal in the field of health services research, health care evaluation, policy, health economics, quality improvement, management, and clinical research focused on the quality and safety of care, with an impact factor of 2.257, as well as Medical Teacher, the official journal of the Association for Medical Education in Europe (AMEE). This international journal publishes research on medical education, including the developments in teaching approaches and methods, and has an impact factor of 4.277.

3.5. Total Number of Citations Per Paper

The most cited article has at least twice as many citations as any other article in the field ( Figure 9 ).

The total number of citations per paper.

The most cited article was published in the Lancet in 2015 by researchers from the USA. The title of the article is “Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015” [ 84 ]. The research focuses on analysis of 33 health-related SDG indicators based on the Global Burden of Diseases, Injuries, and Risk Factors Study 2015. The indicators have an impact on sustainable or pro-environmental behavior. The objective of the study was to meet a core dimension of SDG Goal 3, aiming to “ensure healthy lives and promote wellbeing for all at all ages”.

Second is the article “The Roles of System and Organizational Leadership in System-Wide Evidence-Based Intervention Sustainment: A Mixed-Method Study” [ 85 ], published in the Administration and Policy in Mental Health and Mental Health Services Research in 2016 by an international team from Asia, the USA, and Europe. The article highlights the role of positive sustainable leadership in positively contributing to the implementation of the sustainable development goals in the context of public health.

Third is the article “Implementation of Obstetric Telehealth During COVID-19 and Beyond” [ 47 ], published in the Maternal and Child health Journal (Springer) in 2020 by an American research team, which concludes that “due to the COVID-19 pandemic, implementation of telehealth and telehealth have become crucial to ensure the safe and effective delivery of obstetric care”.

The fourth most cited article is entitled “Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019” [ 86 ], and was published in the Lancet in 2021 by the GBD 2019 Under-5 Mortality Collaborators. It reveals that global child mortality declined by almost half between 2000 and 2019, although progress remains slower in neonates, and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and southern Asia, are not on track to meet either SDG 3.2 target by 2030.

The fifth most-cited article is entitled “Making change last: applying the NHS institute for innovation and improvement sustainability model to healthcare improvement” [ 87 ], and was published in Implementation Science in 2013 by a UK research team. The paper states that the Sustainability Model presented by authors is an important attempt to enable teams to systematically consider determinants of sustainability, provide timely data to assess progress, and prompt action to create conditions for sustained practice. Tools such as these need to be tested in healthcare settings to assess strengths and weaknesses and their findings disseminated to aid development.

3.6. Most Popular Subject Categories

The final stage of the bibliographic analysis was focused on the most popular WOS subject categories in which the sample papers were published. As presented in Figure 10 , the green and sustainable healthcare papers most often related to the categories of Green and Sustainable Science and Technology, Health Care Science and Services, and Public, Environmental, and Occupational Services. It is worth highlighting that green and sustainable papers are popular among professional healthcare categories such as Psychiatry, Anesthesiology, and Nursing as well. The presence of green and sustainable healthcare research topics in educational categories can be seen as a good signal, as everything starts with attitude, knowledge, and skills.

The most popular subject categories.

4. Discussion and Conclusions

The problem of sustainable development has been widely discussed in the health sector since the United Nations Conference on the Human Environment in Stockholm in 1972 [ 1 ]. On the one hand, this sector is essential to the achievement of the United Nations Sustainable Development Goal (UNSDG) “Good health and well-being” and related goals [ 9 ]. At the same time, healthcare, including pharmaceuticals, is responsible for 4.4% of global greenhouse gas emissions [ 13 ]. Therefore, green and sustainable development of the health sector is a highly complex, integrated, and interconnected phenomenon. In the last decade, the demand for green healthcare has increased and become more urgent, as health care facilities, in particular hospitals, are organizations that require large amounts of resources for medical services (such as water, electricity, gas, and food), and generate both medical and hazardous waste. Therefore, the green transformation of this sector is crucial to achieving climate and sustainable development goals.

A special role in the green transformation of the health sector is played by scientific research disseminated in the form of scientific publications. Researchers around the world diagnose the current state of affairs, disseminate good practices, develop models, frameworks, and tools, and indicate future directions of development [ 88 ]. Thus, the aim of this paper was to present the current state of the art and future research scenarios in the field of green and sustainable healthcare. The authors performed a literature review supplemented by a bibliometric analysis of scientific publications on green and sustainable healthcare published in 2013–2022 using the WOSCC database. A total of 144 papers were included in the final analysis and categorized into eight fields, including author(s), title, published year, country, journal, scientific category, and paper citations.

As a result of the bibliographic analysis, it was found that the concept of green and sustainable health care is becoming more and more popular among researchers, especially during the last three years. As a result of our systemic review, we can state that the interests of researchers are encapsulated in three thematic clusters: the first (general) focuses on sustainable development in the health sector; the second (climate) focuses on the impact of health sector organizations on the climate or wider environment; and the third (digital transformation) focuses on new technologies applied in healthcare that can support the sustainable development of the sector.

Taking into account the other analyzed indicators, it can be concluded that most research work is concentrated in English-speaking countries such as the USA, UK, Australia and Canada in several interdisciplinary journals, mainly from the publishing houses MDPI, Elsevier, and BMC, and is related to several scientific categories consistent with the thematic clusters identified earlier, namely, technology, environment, health systems, and professions.

The analysis of the publications selected for review revealed blank spots in the issues raised by researchers. For example, regarding resource management, the focus lies mostly on waste management. Little or no research was found within the scope of other green elements of the health care system, such as energy management, water management, transportation, and food, as well as medicines and other chemicals used in this sector.

There is a lack of work devoted to green leadership in the health sector, which translates into continuing insufficient awareness in the health sector community regarding the negative impact that the sector has on the natural environment and possible steps to be taken to reduce or completely eliminate this impact. Although, as discussed in the introduction, there are numerous international, national and professional initiatives for the green and sustainable recovery sector around the world, these represent only a drop in the ocean of needs, although the intensification of research in this area may lead and guide practice. Thus, the authors recommend that researchers undertake the following research agenda:

• Development of comprehensive green healthcare assessment tools and maturity models for green and sustainable healthcare organizations to support a holistic transformation of the healthcare sector. This will make it easier for decision makers to make strategic decisions. In addition, such tools and models allow for objective comparison of the level of transformation progress of individual organizations and entire health systems.
• Further development of the concept of green hospitals and the related evaluation standards, which may be the basis for certification of such facilities. Systematic updating of concepts allows us to capture the latest and most effective process and product solutions and innovations.
• Diagnosing the use of water and energy resources in the health sector, defining good practices, and proposing paths to optimize the consumption of these resources, as well as initiating innovations in this area.
• Analyzing and shaping mobility behavior across the entire health sector chain and developing policies and good solutions (especially technological/digital) to minimize the impact of the sector on climate change.
• Assessing waste management (especially hazardous and medical waste) and developing good practices to minimize harmfulness and waste generation and maximize waste recycling.
• Exploring current and potential solutions in the area of food systems in order to reduce the environmental footprint of hospitals while shaping healthy eating habits of patients and staff.

The study presented here has a number of limitations. First, the researchers focused on a single database (WOSCC); in the future, it is advisable to use the resources of other databases such as Scopus, PubMed, Cochrane, or EMBAS as well. Moreover, only English-language publications were selected for the analysis. In the future, it would be worthwhile to examine publications on green and sustainable health care in other languages in order to assess their consistency with or differences from the main English-language research stream. The analysis presented here is quantitative, and in subsequent studies it would be well worth supplementing with a qualitative content analysis, which would allow for an overview of the available definitions, models, tools, and measures. It would be most useful to analyze publications in terms of their research methodology and to review the good practices presented in selected publications.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph20020908/s1 , File S1: The database of final 144 records included in review (excel). File S2: The database of 836 records included in the VOSviewer visualisation (TXT format). File S3: he database of 836 records included in the VOSviewer visualisation (RIS format).

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, J.B.-W.; Data curation, M.R.; Formal analysis, M.R. and J.B.-W.; Investigation, M.R. and J.B.-W.; Methodology, M.R. and J.B.-W.; Writing—original draft, J.B.-W. and M.R.; Writing—review and editing, J.B.-W. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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A systematic literature review of health information systems for healthcare.

1. Introduction

2. material and method, 3. discussion, 3.1. the evolution of health information systems, 3.2. his structural deployment, 3.3. health information systems benefits, 3.4. information system and knowledge management in the healthcare arena, 3.4.1. information system, 3.4.2. knowledge management, 4. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Epizitone, A.; Moyane, S.P.; Agbehadji, I.E. A Systematic Literature Review of Health Information Systems for Healthcare. Healthcare 2023 , 11 , 959. https://doi.org/10.3390/healthcare11070959

Epizitone A, Moyane SP, Agbehadji IE. A Systematic Literature Review of Health Information Systems for Healthcare. Healthcare . 2023; 11(7):959. https://doi.org/10.3390/healthcare11070959

Epizitone, Ayogeboh, Smangele Pretty Moyane, and Israel Edem Agbehadji. 2023. "A Systematic Literature Review of Health Information Systems for Healthcare" Healthcare 11, no. 7: 959. https://doi.org/10.3390/healthcare11070959

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Introduction, conclusions, supplementary data.

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Frameworks to assess health systems governance: a systematic review

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Thidar Pyone, Helen Smith, Nynke van den Broek, Frameworks to assess health systems governance: a systematic review, Health Policy and Planning , Volume 32, Issue 5, June 2017, Pages 710–722, https://doi.org/10.1093/heapol/czx007

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Governance of the health system is a relatively new concept and there are gaps in understanding what health system governance is and how it could be assessed. We conducted a systematic review of the literature to describe the concept of governance and the theories underpinning as applied to health systems; and to identify which frameworks are available and have been applied to assess health systems governance. Frameworks were reviewed to understand how the principles of governance might be operationalized at different levels of a health system. Electronic databases and web portals of international institutions concerned with governance were searched for publications in English for the period January 1994 to February 2016. Sixteen frameworks developed to assess governance in the health system were identified and are described. Of these, six frameworks were developed based on theories from new institutional economics; three are primarily informed by political science and public management disciplines; three arise from the development literature and four use multidisciplinary approaches. Only five of the identified frameworks have been applied. These used the principal–agent theory, theory of common pool resources, North’s institutional analysis and the cybernetics theory. Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multi-level frameworks acknowledge this. Three frameworks were used to assess governance at all levels of the health system. Health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. There is a need to validate and apply existing frameworks and share lessons learnt regarding which frameworks work well in which settings. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice.

Key Messages

Health system governance is one of the neglected agendas in health system research.

There is currently a lack of evidence with regard to how governance can and is assessed at both national and sub-national level.

Existing frameworks can be adapted to assess governance overall or specific components of governance.

Governance is defined as the rules (both formal and informal) for collective action and decision making in a system with diverse players and organizations while no formal control mechanism can dictate the relationship among those players and organizations ( Chhotray and Stoker 2009 ). Some authors criticize the concept of governance for being too vague ( Schneider 2004 :25) and there is confusion over how best to conceptualize it ( Kohler-Koch and Rittberger 2006 :28). Governance has been discussed in many disciplines such as political science, economics, social science, development studies and international relations using different theories. Governance matters as it is concerned with how different actors in the world function and operate and the reasons behind their decisions.

Political scientists are of the opinion that governance is not a science which can be ‘adequately captured by laws, statues or formal constitutions’ ( Chhotray and Stoker 2009 ). Governance is not easily attained with laws, statutes or formal constitutions, rather it is a system level concept (macro level) in which systems or societies are driven by networks. Each network involves multiple nodes (organizations) with many linkages collaborating on different activities ( McGuire 2010 :437). The assumption is that passing a law or decree from a formal authority cannot in itself achieve engagement of key actors, and negotiation is key to success of governance within networks ( Chhotray and Stoker 2009 ). Political scientists have also expressed concerns that there are insufficient tools to hold people accountable as governance is characterized by complicated policy networks and responsibility is diffused and shared among many stakeholders ( Stoker 2006 ).

Governance in new institutional economics focuses on the role of institutions which shape interactions among actors within the constraints of the institutions ( Chhotray and Stoker 2009 ). Choices are made within the context of institutional rules that shape and govern what is decided ( Chhotray and Stoker 2009 ). This concept of governance has received support from other disciplines including political science. New institutional economists describe governance as a series of actions which secure voluntary co-operation among key actors.

Governance is becoming more important in international development, particularly due to the movement towards ‘good governance’ in international aid. The World Bank has played a central role in bringing governance into the development agenda, introducing the concept of ‘good governance’ in 1989 in a landmark report on sustainable growth in sub-Saharan Africa ( World Bank 1989 ). The report encouraged donor countries to be ‘selective’ and to give aid to countries with a ‘good policy environment’ ( Chhotray and Stoker 2009 ). In many ways, governance has been used as a political tool in international development, although this is often denied ( Chhotray and Stoker 2009 ).

In relation to health, governance was introduced in the World Health Report in 2000, where the World Health Organization (WHO) defined it in terms of ‘stewardship’, and called for strategic policy frameworks combined with effective oversight, regulation, incentives and accountability. This definition is based on political ideology; that the health system can be influenced by transparent rules, governed by effective oversight and strong accountability ( WHO 2007 ). More recently, health system governance has been described as ‘an aggregation of normative values such as equity and transparency within the political system in which a health system functions’ ( Balabanova et al. 2013 ). As efforts to strengthen health systems and health service delivery have accelerated during the last few decades, governance has received increasing attention. Prominent international development partners have described governance as being the ‘most important factor’ for poverty alleviation and development ( Graham et al . 2003 ).

Governance comprises different functions both within and outside the health sector. In the literature these are commonly described as ‘principles’, ‘concepts’, ‘dimensions’, ‘components’ or ‘attributes’. These terms tend to be used synonymously in the literature. For this review, we used the term ‘principles’. Research is needed both to explore each of the principles of governance in more depth and, to describe and assess governance more generally, in order to identify ways of improving health systems ( Lowenson 2008 ).

Our own work is predominantly around improving availability and quality of maternal and newborn health services in low- and middle-income countries; and we hypothesize that governance principles, if implemented effectively, can make a difference to the functioning of healthcare facilities. Our primary aim was to understand which frameworks for assessing governance in health systems have been developed and how these try to operationalize and/or assess how governance principles at different levels of a health system are implemented. Duran and Saltman (2015) describe hospital governance as dependent on three interrelated levels; (1) the macro-level (health system within which the health facility operates); (2) the meso-level (institutional decision-making) and (3) the micro-level (hospital management focusing on day-to-day operations). Our motivation for summarizing and critiquing frameworks for governance is to understand whether and how they might inform the assessment of governance at the operational service delivery level of a health system (the health facility). In doing so, we acknowledge that frameworks can provide direction on what to consider in assessing governance, but, given the diffuse nature of governance, there is unlikely to be a generic way of assessing governance in health systems.

We conducted a systematic review of the literature to: (1) describe and critique how the concept of governance and the theories underpinning it have been applied to health systems globally; and (2) identify if and how frameworks have been developed and used to assess governance in the health system.

Search strategy and inclusion criteria

Inclusion criteria used to select papers for each stated objective

We searched five electronic databases (Scopus, Medline, CINAHL, Global Health Database, Cochrane Library) using key words combined with the Boolean operators (AND, OR). For example, the key words for governance (governance, leadership, accountability, stewardship) were combined with terms relating to the health system (healthcare system, healthcare industry, healthcare reform, health system strengthening) and terms for frameworks (model, framework, indicator, definition, measure). All the terms were searched in abstracts, key words, subject headings, titles and text words. We searched Medline first, and adapted this search strategy for use with other databases. Search strategies used in each database, including search terms, search strings and results, are outlined in Supplementary Table S1 .

In addition to the database search, we searched the online archives of specific journals that publish research on health systems and policy including ‘ Health Policy and Planning ’ and ‘ Health Policy ’ using ‘health systems governance’ as the key search term. Web portals of institutions including the Basel Institute for Governance, the World Bank and USAID Leadership, Management and Governance project were also searched. Furthermore, we checked the reference lists of studies that met our inclusion criteria and contacted the authors of identified frameworks to ask for any unpublished reports which were considered relevant.

Assessment of quality of included studies

We did not appraise the quality of studies describing frameworks health systems governance, as these were largely descriptive reports (Objective 1). For objective two, we included articles reporting empirical research, and we assessed the quality of these studies using simple criteria based on published checklists ( Crombie 1996 ). Because the study designs were diverse, we appraised studies based on: the description of the study (aim, participants, methods, outcomes); the methods (appropriate to the aim, selection of participants, valid and reliable data collection methods, and adequate description of analysis) and presentation of the study findings. For qualitative studies, this included questions about appropriateness and reliability of analysis; and for those reporting quantitative data, we assessed whether the basic data were adequately described, and whether statistical significance was assessed.

The review identified a total of 10 empirical studies of which 9 were peer-reviewed, 3 were rated as high and 7 as medium quality. ( Supplementary Table S2 ) All studies provided adequate descriptions regarding information of the study such as aims, study participants, methods employed and their intended measures. Seven studies used qualitative methods (interviews, focus group discussions), one used a quantitative method (survey) ( Abimbola et al. 2015b ) and two were mixed-methods studies (Mutale et al . 2012; Avelino et al. 2013 ). Seven studies provided information on how study participants were selected ( Huss et al. 2011 ; Avelino et al. 2013 ; Mutale et al. 2013 ; Vian and Bicknell 2013 ; Abimbola et al. 2015a , b , 2016).

Seven studies provided information on methods of data analysis Baez-Camargo and Kamujuni 2011 ; Avelino et al. 2013 ; Mutale et al. 2013 ; Vian and Bicknell 2013 ; Abimbola et al. 2015a , b ,2016. Among the seven studies which used qualitative methods, quotes were included in five; ( Baez-Camargo and Kamujuni 2011 ; Huss et al. 2011 ; Vian and Bicknell, 2013 ; Abimbola et al. 2015a , 2016). All three studies which conducted statistical analysis provided a rationale for statistical calculations used.

Synthesis of review findings

As governance originates from many different disciplines, we undertook an in-depth analysis offering a theory-informed critique of the identified frameworks and of the literature on governance, extending beyond health systems. The findings of included studies were synthesized using narrative synthesis which is useful in synthesizing different types of studies without losing the diversity in study designs and contexts ( Lucas et al. 2007 ; Barnett-Page and Thomas 2009 ; Wong et al. 2013 ). Included studies are summarized by objective in the results section, and by grouping them by the disciplines from which the frameworks originate.

Description of included studies

Flow diagram of study selection procedure and results (adapted from PRISMA 2009)

Overview of governance frameworks for health systems by type of discipline used to develop the framework

Sixteen articles describe frameworks for assessing governance and 10 empirical research studies which describe how frameworks can potentially be used to assess health systems governance were identified.

One previous review on governance (a non-peer reviewed report) was conducted to inform the development of a framework which would be specifically used in surveys of the countries included in the Health Systems 20/20 project ( Shukla and Johnson Lassner 2012 ). The report provides an overview of the current literature on governance in the health sector. The authors discuss 10 principles termed ‘enablers’ in detail and outline existing frameworks; highlighting how effective governance is associated with health outcomes in three country-level studies.

I. Description and critique of governance frameworks

Summary table of governance frameworks identified, grouped by discipline

Frameworks originating from new institutional economics

Six frameworks conceptually originate from New Institutional Economics: EC (2009), Baez-Camargo (2011 ), Brinkerhoff and Bossert (2008 ), Baez-Camargo and Jacobs (2013 ), Cleary et al. (2013 ) and Abimbola et al. (2014 ). Among these, five use ‘principal–agent’ theory ( Brinkerhoff and Bossert 2008 ; European Commission 2009; Baez-Camargo 2011 ; Baez-Camargo and Jacobs 2013 ; Cleary et al. 2013 ) while Abimbola et al. (2014) use Ostrom’s theory of ‘common pool resources’.

Principal–agent theory

In ‘principal–agent’ theory, a ‘principal’ hires or contracts an ‘agent’ to undertake a particular service ( Chhotray and Stoker 2009 ). Agents may have similar as well as different objectives from those of the principal. Agents, usually have more information than the principal, providing them with an advantage to pursue their own interests at the expense of the principal. Fundamentally, the theory looks at how much of the value that the agent produces should go back to him/her in the form of incentives i.e. the agent (healthcare provider) produces certain services for the principal (the government), for which the agent expects some form of payment ( Chhotray and Stoker 2009 ).

The other distinctive feature of the ‘principal–agent’ theory is that the principal does not have complete control over the agent and only has partial information pertaining to the behaviour (production) of the agent ( Stoker 1998 ). This can lead to difficulties such as selection of agents, negotiation of services and monitoring of the information. Therefore, governance frameworks using the ‘principal–agent’ theory take into account the uncertainty and complexity of the outcomes of the behaviour of the agent ( Stoker 1998 ).

Frameworks to assess health systems governance that draw on ‘principal agent’ theory, assume that governance is the result of interactions among principals and agents with diverse interests. Two key assumptions using ‘principal–agent’ theory are; (1) there are incentives and sanctions for the different actors which are performance-based and are used to stimulate accountability and, (2) information asymmetry and power difference among different groups. Healthcare users are normally regarded as ‘principals’ while the state and healthcare providers are ‘agents’ providing healthcare services to users ( Brinkerhoff and Bossert 2008 ; European Commission 2009; Baez-Camargo 2011 ; Baez-Camargo and Jacobs 2013 ; Brinkerhoff and Bossert 2013 ; Cleary et al. 2013 ). Agents provide services to principals as long as they have some incentive to do so, but they have more information than principals. At the same time, principals will find ways to overcome the information asymmetry without incurring high transaction costs. For instance, users will look for alternative providers by comparing price, quality or value. In addition, context matters in these frameworks as the ‘principal–agent’ model is a highly complex set of interactions and not a closed system. It helps to explore how policy makers respond to citizen demands, how health service providers and users engage to improve service quality, and how service providers and users advocate and report on health outcomes.

The framework by Brinkerhoff and Bossert (2008 , 2013 ) is based on a World Bank (2004) accountability framework. The framework depicts three principal–agent relationships: government and healthcare providers; healthcare providers and citizens; and government and citizens. The other framework which uses the ‘principal–agent’ theory is the governance framework of the European Commission (2009). The EC (2009) framework aims to assess governance at sector level especially in the context of development and aid assistance worldwide. The EC framework takes into account the importance of context and assessment starts with context analysis and stakeholder mapping. Similarly to the framework by Brinkerhoff and Bossert (2008 , 2013 ), the EC framework considers power, interactions and functions of stakeholders as core governance issues, but also includes principles of participation, inclusion, transparency and accountability. Among different principles, the framework focuses on accountability among different stakeholder groups. Though the framework is intended to be used for development and aid assistance, the framework does not include citizens among the defined clusters of stakeholders. The EC (2009) framework has a ready-to-use tool with detailed instructions. Examples from previous EC projects globally are provided with suggestions on how to improve governance. Although the authors do not empirically test the framework, they suggest how it might be applied it to a fictional country in sub-Saharan Africa.

Baez-Camargo (2011) and Baez-Camargo and Jacobs (2013) proposed an analytical framework of ‘social-accountability’ by adapting the World Bank accountability model ( World Bank 2004 ). Using the ‘principal–agent’ theory, Baez-Camargo (2011) presented incentives and sanctions within two routes towards accountability: short (direct) and long (indirect) routes. Direct accountability is most suitable in the competitive market where citizens can ‘voice’ their preference or choose other alternatives (exit). On the other hand, with indirect accountability, the link between citizens and healthcare providers is considered ‘indirect’ as the government agent is involved in the accountability relationship; citizens hold the government agent accountable either through political representation (votes) and the government holds healthcare providers accountable to deliver healthcare services. Direct accountability has received the most attention as it can be promoted either through citizens’ participation in service planning, or voicing concern about service providers’ performance (voice), or through citizens’ choosing other providers (exit). However, it is important to be careful about applying the concept of direct accountability to health care in settings where market competition fails to provide healthcare services to the most vulnerable groups. The authors include tools for key informant interviews.

Another framework using ‘principal–agent’ theory is the accountability assessment framework for low- and middle-income countries developed by Cleary et al. (2013) . By adapting the Brinkerhoff and Bossert (2008) framework, the authors emphasize the accountability pathways among three groups of key actors (politicians/policy makers; healthcare providers and citizens). The Cleary framework claims to assess both external and internal accountability mechanisms via three critical factors: resources, attitudes and values. The authors highlight that adequate resources are critical for the health system to function properly while it is important to understand the attitudes of healthcare providers and policy makers without neglecting the values of citizens.

Theory of common pool resources

Our review identified one framework which uses theory derived primarily from economics; Elinor Ostrom’s theory of ‘common pool resources’ ( Ostrom 1990 ). This theory describes governance as an autonomous system with self-governing networks (or systems) of actors ( Stoker 1998 ). The theory assumes that actors in self-governing networks can not only influence government policy but can also take over some of the business of the government ( Stoker 1998 ). Ostrom’s theory focuses on creating different institutional arrangements to manage open resources which are finite. Communities can form self-organized networks or systems composed of interested actors who will develop incentives and sanctions to manage the resources on their own ( Stoker 1998 ). The theory assumes that self-organized systems are more effective than regulation imposed by the government as there will be increased availability of information and reduced transaction costs ( Stoker 1998 ). Indeed, the theory postulates that in situations where government is ‘under-governed’, social norms fill those gaps (Olivier de Sardan 2015). A similar assumption is highlighted by Dixit (2009) civil-society organizations and non-governmental organizations emerge to fill gaps in functioning when government organizations serve poorly. The theory proposes that there are three levels of a common pool resource problem: (1) an operational level where the working rules are set, (2) a collective level where communities set their own rules, and, (3) a constitutional level from where the set rules originate ( Ostrom, 1990 :45).

Using Ostrom’s theory of ‘common pool resources’, Abimbola et al. (2014) developed a multi-level framework to analyse primary healthcare (PHC) governance in low- and middle-income countries. The authors borrowed the concept of ‘governing without government’ in situations where overall governance situations are not functioning. In such situations, communities with similar interest might develop their own rules and arrangements to manage the common pool. Ostrom argued that self-governing arrangements lead individuals or groups to cope with problems by constantly going back and forth across levels as their key strategy. Abimbola’s framework (2014) describes the three collective levels of health system hierarchy as; (1) operational (citizens and healthcare providers), (2) collective (community groups) and (3) constitutional governances (governments at different levels). A multi-level framework is believed to be more effective at assessing governance than a single unit assessment. Operational and collective governance can mitigate the failure of constitutional governance, although, there is also some overlapping of roles and responsibilities.

Frameworks originating from political science and public administration

Three frameworks conceptually originate from political science and public administration disciplines: Berlan and Shiffman (2012) , Brinkerhoff (2004) and Brinkerhoff and Goldsmith (2004) . None of the frameworks mention any particular theory on which their frameworks are based. The concept of governance for political scientists focuses on ‘formal institutions, accountability, trust and legitimacy’ for governance ( Pierre and Peters 2005 :5). They are interested to see how collective decisions are made among key actors (both government and non-government actors) with different power ( Chhotray and Stoker 2009 ). Thus, governance from political science and public administration focuses on both inputs (the processes) and outputs (results of governing networks) ( Chhotray and Stoker 2009 ).

Berlan and Shiffman’s framework (2011) assumes that healthcare providers in low- and middle-income countries have limited accountability to their consumers as a result of both health system and social factors. Oversight mechanisms, revenue source and nature of competition are related to the health system while consumer power and provider norms are considered under social factors. Their framework helps to identify factors which shape the accountability of healthcare providers. In addition, social interactions and norms operating within the system and context are prominent features of this framework.

Brinkerhoff’s framework (2004) is also based on accountability, and aims to map out public accountability mechanisms: financial, performance and political accountability. In this framework, performance accountability is defined as agreed upon targets which should theoretically be responsive to the needs of the citizens. Political accountability emphasizes that electoral promises made by the government should be fulfilled. Brinkerhoff highlights the need to map out the accountability linkages among key actors and to examine actors’ interactions as too few linkages can lead to corruption while too many can undermine accountability effectiveness. Together with his framework, Brinkerhoff proposes three strategies to strengthen accountability; (1) addressing fraud, misuse of resources and corruption, (2) assuring compliance with procedures and standards and (3) improving performance. The framework includes an accountability assessment matrix which allows the user to rate accountability linkages among key actors.

The third framework that draws on political science assesses the patron–client relationship or clientelism in health systems ( Brinkerhoff and Goldsmith 2004 ). Despite the unpopularity of clientelism, it is regarded as an essential principle of governance which can affect corruption and accountability mostly at macro/national level. The purpose of the framework is to identify reasons why clientelistic practices persist and the authors use the concept of realist evaluation theory comprising of context, actions (mechanisms) and outcomes. Although the framework has not been used in the field, the authors present a diagnostic framework with sample questionnaires.

Frameworks originating from international development

In the development literature, governance focuses on predefined principles which development specialists believe to be critical for ‘good governance’ in aid assistance. The three frameworks identified (Islam et al . 2007; Kirigia and Kirigia 2011 ; Mikkelsen-Lopez et al. 2011 ) focus primarily on how governance is defined, how it can facilitate effective aid policy, and, unlike any of the other frameworks, those in international development are concerned with how governance might be measured. Kauffman and Kraay (2007) propose to measure governance in two ways using rule-based measures (e.g. a policy or a procedure exists) and outcome-based measures (e.g. the policy has been implemented or the rule has been enforced) ( Chhotray and Stoker 2009 ).

Islam (2007) present a health systems assessment manual which includes a framework to assess governance, developed under the Health Systems 20/20 project (USAID). The aim is to guide data collection providing a rapid but comprehensive assessment of key health system functions. Based on the six domains of the health system (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines; (5) financing; and (6) leadership and governance. This framework groups indicators into general governance (e.g. voice and accountability; political stability; government effectiveness; rule of law; regulatory quality and control of corruption) and health system specific governance indicators (e.g. information/assessment capacity; policy formulation and planning; social participation and system responsiveness; accountability; and regulation). The authors suggest various sources of data for the different indicators, including interviews with relevant key stakeholders and desk-based review of relevant documents and reports.

Another framework that attempts to measure governance is one based upon Siddiqi et al. (2009) , which also includes principles of macroeconomic and political stability ( Kirigia and Kirigia 2011 ). The authors emphasize that development in health cannot occur without political and economic stability in the form of a national economic development plan or poverty reduction strategy, a medium-term government expenditure framework, and a non-violent electoral process. The authors argue that individual and aggregate scores of governance are needed to alert policy makers to areas needing improvement. This is the only framework identified in our review which tries to quantify governance by using rule-based measures such as existence of certain policy or guidelines. The authors propose a scoring system that determines whether governance is very poor (0%) or excellent (100%) for each function. Kirigia and Kirigia (2011) argue that scoring allows assessors to identify areas for improvement, and an overall index representing the overall governance situation in any given country can be calculated.

The final framework ( Mikkelsen-Lopez et al. 2011 ) is based on systems thinking, and uses a problem-driven approach to assess governance in relation to an identified problem to highlight the barriers to good governance. The framework assesses governance in all four levels of a health system (national, district, facility and community) using the established WHO health system building blocks and five proposed principles of governance: (1) strategic vision and policy design; (2) participation and consensus orientation; (3) accountability; (4) transparency; and (5) control of corruption. The authors developed this approach in response to other frameworks on governance that provide snapshots of any given governance situation, but are unable to identify specific areas of weakness and/or how to intervene. However, despite providing a way to identify barriers to good governance, the framework does not easily allow for comparisons between different contexts, and it is not clear if it has actually been applied in practice.

Frameworks originating from more than one discipline

Four frameworks appear to be based on principles of more than one discipline ( Vian 2008 ; Siddiqi et al. 2009 ; Baez Camargo and Jacobs 2011; Smith et al. 2012 ). Three of these ( Vian 2008 ; Siddiqi et al. 2009 ; Baez Camargo and Jacobs 2011) draw on the ‘institutional analysis’ theory of North (1990) , originally derived from new institutional economics. The frameworks also seem to reflect predefined governance principles in line with the international development literature.

Theory of ‘institutional analysis’

Douglas North’s theory of institutional analysis assumes that markets are created and maintained by institutions. North defined ‘institutions’ as the rules of the game and ‘organizations’ as the players. Institutions consist of formal rules and informal constraints while organizations consist of groups of individuals with common objectives ( North 1990 ). North’s principal argument is that individuals within an institution have certain opportunities which are the result of specific formal and informal constraints that constitute the institutions. Using the theory of North (1990) , Vian (2008 ), Siddiqi et al. (2009) and Baez Camargo and Jacobs (2011) highlighted that institutional analysis is key to assessing governance in order to understand the institutional arrangement and rules set by the organizations. A mapping of the power distribution can be used to identify the key decision makers who affect the behaviour of health system actors.

In addition to application of North’s theory of institution analysis, Siddiqi et al. (2009) propose a comprehensive framework to assess governance based on the UNDP principles of governance. This framework includes ten principles, disaggregated into 63 broad questions under three relevant domains: context, processes and outcomes. In conceptualizing governance in this way, the authors suggest that their framework could be used to compare governance functions across countries. The framework is intended for use at both national (policy formulation) and sub-national levels (policy implementation and health facility levels) to assess all essential principles of health systems governance; something which other frameworks do not aim to do. In particular, the potential for application of the framework at subnational level is a unique feature as most other governance frameworks are developed for macro-level assessment.

Baez-Camargo and Jacobs (2011) propose an ‘inputs, processes and outputs’ framework for health systems governance in low-income countries. The authors acknowledge the existence of other frameworks to assess health systems, but set theirs apart by focusing on generating information on the complex context within which the health system operates. The framework draws on the values of good governance articulated in the development literature, and ‘Institutional analysis’ to map out key stakeholders and the power distribution among them. The framework is presented as a visual process map of causal links between inputs, processes and outcomes, which they believe helps to provide a better explanation of governance and easier application of the framework. The authors provide detailed methodology, tools and procedures for using the framework in practice, but acknowledge that their model cannot assess health systems governance in its entirety. It is recommended for use in contexts where a particular problem has first been identified.

Vian’s (2008) framework specifically analyses corruption in the health system from the perspective of the government. It draws on North’s principal argument that key players in the health system have certain opportunities which are the product of formal and informal rules and constraints set by institutions ( North 1990 ). The author also employs ‘principal–agent’ theory as the framework takes into account asymmetric information among different actors with diverse interests within a health system. The framework is based on the assumption that corruption in the health sector is driven by pressures of government agents to abuse, opportunity to abuse, and social factors supporting abuse of the system. Therefore, the framework is diagnostic in nature as it aims to identify potential abuse that can occur at each step of a health service delivery process.

Smith et al. (2012) describe a ‘cybernetic’ framework for leadership and governance which uses systems theory. This theory is interdisciplinary and is concerned with discovering patterns in the way systems (including health systems) operate. Smith et al. consider it important to view governance as hierarchical (rules and responsibilities for allocating resources) and horizontal (both incentives and the market regulate purchasing power, and systems produce common values and knowledge through professional norms). Cybernetics focuses on how systems use information, and how systems monitor actions to steer towards their goals. The framework includes three key principles related to this: setting priorities, accountability (inputs into the health system) and performance monitoring (output). The framework focuses on the leadership principle of governance and was developed for use in health systems in high-income countries, so would require adaptation to low-and middle-income settings.

II. Description of how frameworks have been applied to assess governance in health systems

Among the 16 frameworks identified that can potentially be used to evaluate health systems governance, only 5 ( Brinkerhoff and Bossert 2008 ; Siddiqi et al. 2009 ; Baez-Camargo and Jacobs 2011 ; Smith et al. 2013; Abimbola et al. 2014 ) have actually been applied. ( Supplementary Table S2 ).

Among the 12 publications describing how frameworks have been applied, seven use ‘principal–agent’ theory; two make use of the theory of ‘common pool resources’; two use North’s institutional analysis; and one uses ‘cybernetics’ theory.

Studies which used ‘principal–agent’theory

Among frameworks using ‘principal–agent theory’, Brinkerhoff and Bossert’s framework is the most commonly applied (five studies; Mutale et al. 2012; Vian et al. 2012 ; Brinkerhoff and Bossert 2013 ; Cleary et al. 2013 ; Ramesh et al. 2013 ) while the other three studies ( Huss et al. 2011 , Avelino et al. 2013 ; Vian and Bicknell 2013 ) used a variant of the ‘principal–agent’ theory. The USAID health system assessment team used Brinkerhoff and Bossert’s governance framework in their manual for assessing health systems. According to Health Systems 20/20, the manual is currently used in 23 Health Systems 20/20 projects funded by the USAID in countries in East, West, and Southern Africa, as well as in the Caribbean islands ( Health Systems 20/20, 2012 ).

Mutale et al. (2012) adapted Brinkerhoff and Bossert’s framework to assess governance at health facility level in Zambia while Ramesh et al. (2013) used the framework at national level in China. Cleary et al. (2014) adapted Brinkerhoff and Bossert’s framework to assess accountability mechanisms in low- and middle-income countries. Vian et al. (2012) employed Brinkerhoff and Bossert’s framework to assess corruption in the Vietnamese health system.

Three other studies ( Huss et al. 2011 ; Avelino et al. 2013 ; Vian and Bicknell 2013 ) applied the ‘principal–agent’ theory to assess governance in Brazil, India and Lesotho. Huss et al. (2011) applied a variant of the ‘principal–agent’ model in their assessment of governance focusing on corruption in Karnataka State, India. Contrary to the traditional application of ‘principal–agent’, Huss et al. refer to the ‘state’ as ‘principal’ while ‘public service providers’ are ‘agents’ to deliver certain services for ‘citizens’.

All studies used two principal–agent relationships—the relationship between citizens and government and between government and healthcare providers—with the exception of Vian and Bicknell (2013) who use a single principal–agent model (state-healthcare provider). The studies evaluate the principal and agent engage and interact to accomplish a collective effort and clearly highlight the importance of information asymmetry.

Studies which used ‘multilevel framework’ of governance

Two studies ( Abimbola et al. 2015a , b ) applied the ‘multilevel framework’ by Abimbola et al. (2014) .

Abimbola et al. (2015a) adapted the ‘multilevel framework’ to identify the effect of decentralization on retention of PHC workers in Nigeria. The framework was used to assess government, communities and intrinsic health workers’ factors influencing retention of PHC workers in a decentralized health system. The framework helped identify incentives for, and motivation of, PHC workers and the reasons they remain in post despite socio-economic hardship.

The ‘multilevel framework’ was also applied to provide recommendations to improve health system governance at operational level among tuberculosis (TBC) patients in Nigeria ( Abimbola et al. 2015b ). The framework was used to assess the three different levels of governance: constitutional (federal government); collective (communities) and operational (healthcare providers at local health market). In this, the concept of Williamson’s Transaction Cost Theory (1979) was used to identify the costs incurred by TBC patients to receive appropriate anti-TBC treatment from a qualified provider working within the health system. Transaction costs are difficult to measure thus Williamson suggested looking into ‘the issues of governance comparatively’. The central argument of Williamson’s theory is that ‘high transaction costs’ can be attributed to governance failure which requires looking for alternative modes of governance to achieve ‘economizing’ results ( Williamson 1999 ). In both studies, self-governing individuals at three levels of a system are trying to overcome a common problem by identifying ways which are workable for them.

Studies which used North’s theory of ‘institutional analysis’

Siddiqi et al. (2009) used their own framework to assess governance of the health system in Pakistan, and explored governance principles in depth using qualitative interviews. The authors assessed three different levels of the health system—national (policy formulation) and sub-national levels (policy implementation and health facility levels). The authors highlighted the importance of understanding the socio-political context of a country and show that the principles of health systems governance are value driven. In addition, Siddiqi et al. emphasize that health system governance can be improved without improving the overall governance of a country.

Baez-Camargo and Kamujuni (2011) conducted an assessment of the governance of the public sector drug management system in Uganda using the framework of Baez-Camargo and Jacobs (2011) . The assessment started with an institutional mapping which included interviews with both formal and informal sectors of the supply chain in Uganda. Focus group discussions were also conducted with healthcare providers, patients and representatives of patient advocacy groups.

Smith et al. (2012) applied their cybernetic framework at national level to seven health systems in high-income settings (Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland). The framework is composed of three key nodes of governance (setting priorities, accountability and performance monitoring) which serve as the guiding principle for assessing hierarchy, market and network governance. One important lesson highlighted by the authors is that competency and capacity at the different levels of a health system are crucial for successful implementation of the leadership and governance model.

This systematic review brings together the literature on health systems governance, firstly by describing and critiquing how the concept of governance and the theories underpinning it have been applied to health systems, and secondly by identifying which frameworks have been used to assess health systems governance, and how this has been done to date globally. A total of 16 frameworks were identified, which, in principle, can be used at national (policy formulation) and sub-national (policy implementation) levels of a health system. Frameworks originate mainly from three disciplines: (1) new institutional economics; (2) political science and public administration; and (3) the international development literature.

The most commonly used theories which underpin the available frameworks originate from new institutional economics and include the ‘principal–agent’ theory, Douglas North’s theory of institutional analysis and Elinor Ostrom’s theory of ‘common pool resources’. Frameworks that originate from the development literature tend to pre-define principles of governance and are the only ones to attempt to measure governance (for instance, Kirigia and Kirigia 2011 ). The majority of frameworks assess overall governance while some assess specific principles of governance such as accountability, corruption and patron–client relationship.

Most frameworks assess governance in health systems using qualitative methodology, based on the premise that governance is the result of interactions among different actors within a health system, and that studying the reasons for and the extent of interaction can be used to document good governance. Other authors propose using mixed methods; collecting data on framework indicators (e.g. Mutale et al. 2012) in combination with in-depth exploration of specific problems identified.

It is encouraging to see that there are three frameworks that have been used to assess governance at all levels of the health system; Brinkerhoff and Bossert (2008 ), Siddiqi et al. (2009 ) and Abimbola et al. (2014 ). Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multi-level frameworks acknowledge this and recognize the importance of actors at different levels. Some assessment frameworks explicitly mention pre requisites needed for successful application, such as the framework by Baez-Camargo and Jacobs (2011) which requires a governance problem to be already identified, and the cybernetic model presented by Smith et al. (2013) which requires users’ familiarity with the health system.

This review also illustrates that health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. Governance more generally has been debated and studied from many different perspectives. This review attempts to synthesize how these perspectives have led to the development of governance in health systems. Critical analysis shows that frameworks for assessing governance may be applicable in one setting but not another. There is no single, agreed framework that can serve all purposes as the concept of governance will likely continue to be interpreted openly and flexibly. However, for governance principles to contribute to health system strengthening in countries, and ultimately to impact on outcomes, it is critical to at least evaluate and monitor if and how governance works (or not) in practice. As each health system operates in its own context, and different components of governance may need to be prioritized over others in different settings and at different times, it is important that any assessment of governance recognizes the particular circumstances and has a clear purpose. Assessing health systems governance can raise awareness of its importance to health policy makers, identify problems or conversely, document success stories. This can encourage and catalyse improvement in health systems. The aim of this review was to provide an overview of frameworks available and describe how they have been developed, adapted or applied to assess health systems governance in operation. We recognize that the main utility of the synthesis is not to identify features of a single agreed framework, rather the frameworks identified and reviewed can help assessors to identify relevant questions to ask of health systems governance, and identify elements that could be included in an assessment.

Outside of the limited evidence on how governance can be assessed in health systems, this review also highlights examples of how governance has been assessed in other disciplines. Both rules-based and outcomes-based approaches to assess governance have been critiqued for their limitations as they largely depend on how and what you propose to measure ( Chhotray and Stoker 2009 ). Though such assessments provide valuable insights, the approach is somehow limited as it often fails to be explicit about the measurement ( Chhotray and Stoker 2009 ). This highlights that it is more important to identify what governance arrangements are considered appropriate for a particular context (prescriptive measures) than to judge the governance of a particular system (diagnostic measures) ( Chhotray and Stoker 2009 ).

The findings of this review could help to inform discussions among policy makers in countries considering governance as a mechanism to support health systems strengthening. Findings will help decision makers form a view on what governance is, and which principles are important in their context. Policy implementers at a more local level may choose and adapt one of the available frameworks or tools to assess governance and/or identify gaps in governance arrangements.

A variety of frameworks to assess health systems governance exist, but there are not many examples of their application in the literature. There is a need to validate and apply the existing frameworks and share lessons learnt regarding which frameworks work well in which settings to inform how existing frameworks can be adapted. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice. Governance is not an ‘apolitical’ process, and there are no absolute principles that define governance; it is a diffuse concept that cuts across disciplines, and borrows from a range of social science theories. However, whether it is applied to health systems or political science, governance is concerned with how different actors in a given system or organization function and operate and the reasons for this. In the context of health systems governance, we believe a multidisciplinary approach to assessment is necessary.

This research was funded through the DFID/UKAid, Making it Happen programme.

Conflict of interest statement . None declared.

Supplementary data are available at HEAPOL online.

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• cybernetics
• health personnel
• accountability

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Service quality in the healthcare sector: a systematic review and meta-analysis

LBS Journal of Management & Research

ISSN : 0972-8031

Article publication date: 16 January 2023

Issue publication date: 4 September 2023

The purpose of this study is to summarize the available pool of literature on service quality to identify different dimensions of service quality in the healthcare industry and understand how it is measured. The study attempts to explore the research gaps in the literature about different service quality dimensions and patient satisfaction.

Design/methodology/approach

A systematic literature review process was followed to achieve the objectives of the study. Various inclusion and exclusion criteria were used to select relevant research articles from 2000–2020 for the study, and a total of 100 research articles were selected.

The study identified 41 different dimensions of healthcare service quality measurement and classified these dimensions into four categories, namely servicescape, personnel, hospital administration and patients. It can be concluded that SERVQUAL is the most widely used service quality measurement tool.

Originality/value

The study identified that a majority of the researchers deduced a positive relationship between SERVQUAL dimensions and the quality of healthcare services. The findings of study will assist hospital executives in formulating effective strategies to ensure that patients receive superior quality healthcare services.

• Healthcare sector
• Service quality
• Systematic review

Darzi, M.A. , Islam, S.B. , Khursheed, S.O. and Bhat, S.A. (2023), "Service quality in the healthcare sector: a systematic review and meta-analysis", LBS Journal of Management & Research , Vol. 21 No. 1, pp. 13-29. https://doi.org/10.1108/LBSJMR-06-2022-0025

Emerald Publishing Limited

Copyright © 2022, Mushtaq Ahmad Darzi, Sheikh Basharul Islam, Syed Owais Khursheed and Suhail Ahmad Bhat

Published in LBS Journal of Management & Research . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and no commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

The quality of healthcare services has long been a subject of concern for both private and public healthcare service providers across the globe. According to Senic and Marinkovic (2013) , integrity and competitiveness of a nation's healthcare structure are gauged by the quality of healthcare services rendered. Indian National Health Policy 2017 envisions that everyone should have access to high-quality healthcare without facing financial suffering ( MoHFW, 2017 ). Adherence to quality standards and improved quality design results in a better-perceived value, which leads to better prices, better income and greater profitability ( Zeithaml, 2000 ). Customers of the healthcare industry in developing countries are becoming more and more aware of their right to quality healthcare. Consequently, delivering high-quality service by healthcare service providers is gaining momentum ( Abuosi & Atinga, 2013 ). According to Yee, Yeung, and Cheng (2010) , healthcare service providers need to provide high-quality services to sustain the trustworthiness of patients. Demand for superior service quality is growing due to an increase in the per capita income of customers and increased aspirations of the customer ( Singh & Prasher, 2019 ). Also, as a result of competition from private healthcare service providers, public care providers are facing pressing demand for delivering high-quality services ( Zarei, Arab, Froushani, Rashidian, & Ghazi-Tabatabaei, 2012 ).

Mosadeghrad (2014, p. 78) defined healthcare quality as “ consistently delighting the patient by providing efficacious, effective and efficient healthcare services according to the latest clinical guidelines and standards, which meet the patient ' s needs and satisfies providers ”. Ovretveit (2009, p. 4) defines quality care as the “ p rovision of care that exceeds patient expectations and achieves the highest possible clinical outcomes with the resources available ”. Parasuraman, Zeithaml and Berry (1985) described service quality as the gap between a customer's expectations of service and the customer's perception of service after the service is rendered. When perception exceeds expectations, the customer will be satisfied ( Kalaja, Myshketa, & Scalera, 2016 ). Several studies have confirmed that customer expectations of service are much higher than the customer perception of services rendered by both public and private sector institutions ( Andaleeb, Siddiqui, & Khandakar, 2007 ; Zarei et al. , 2012 ; Manulik, Rosińczuk, & Karniej, 2016 ). A firm provides quality service when its services at least meet or exceed the expectations of the customer ( Owusu-Frimpong, Nwankwo, & Dason, 2010 ). Service quality evaluation varies from the service provider's and service receiver's point of view. Service delivery professionals evaluate service based on delivery and design aspects, while receivers of service evaluate it based on their overall perception after consuming the service ( Brown & Swartz, 1989 ). Traditionally healthcare quality was judged based on some objective criteria such as mortality rate, morbidity rate, infant mortality rate, etc. However, as time passes, the structure of the industry changed, and the role of patients in deciding quality has been given more and more consideration ( Dagger, Sweeney, & Johnson, 2007 ). To survive in the modern competitive markets, it has become of utmost importance for service providers to understand the needs and expectations of customers. They must deliver what the customer is expected instead of what they feel is important for a customer to maintain the business demand ( Singh & Prasher, 2019 ). Kotler and Keller (2006) suggest that in the consumer-oriented healthcare market where healthcare delivery is commodified and patient-led, the patient should be the judge of service quality. Hence, to provide better quality services, healthcare service providers need to identify the main dimensions of service quality in healthcare and focus on those dimensions rated more important by the patients ( Singh & Prasher, 2019 ).

Studies on healthcare service quality have been conducted in a variety of settings worldwide, namely Albania ( Kalaja et al. , 2016 ), Australia ( Copnell et al. , 2009 ; Dagger et al. , 2007 ; Levesque & Sutherland, 2020 ), Bangladesh ( Andaleeb et al. , 2007 ), China ( Li et al. , 2015 ; Wu, Li, & Li, 2016 ), Denmark ( Engelbrecht, 2005 ; Groene, Skau, & Frølich, 2008 ), Ghana ( Abuosi & Atinga, 2013 ; Agyapong, Afi, & Kwateng, 2018 ), India ( Chahal, 2008 ; Aagja & Garg, 2010 ; Chahal & Kumari, 2010 ; Gupta & Rokade, 2016 ; Singh & Prasher, 2019 ; Upadhyai, Jain, Roy, & Pant, 2019 ; Jog et al. , 2020 ), Iran ( Goshtasebi et al. , 2009 ; Mohammadkarim, Jamil, Pejman, Seyyed, & Mostafa, 2011 ; Mosadeghrad, 2014 ), Malaysia ( Ahmad & Sungip, 2008 ; Hasan, Ilias, Rahman, & Razak, 2009 ), Pakistan ( Irfan & Ijaz, 2011 ; Shabbir, Malik, & Malik, 2016 ; Fatima, Malik, & Shabbir, 2018 ; Dhahri, Iqbal, & Khan, 2020 ), Turkey ( Beyan & Baykal, 2012 ) and USA ( Lee, 2003 ; Hegji & Self, 2009 ; Mustafa, Yang, Mortezavi, Vadamalai, & Ramsey, 2020 ; Thompson, Shen, & Lee, 2020 ). The purpose of this paper is to investigate and summarize the available literature on healthcare service quality to understand what constitutes healthcare service quality and its principal dimensions and also to highlight the prominent research gaps that will provide direction for future research.

Methodology

The study followed a systematic review process to obtain research articles relevant to the research problem understudy. The systematic review process is a structured way of identifying, evaluating and interpreting the available literature related to any particular area ( Kamboj & Rahman, 2015 ). A systematic literature review is a two-step process. First, defining the criteria for inclusion of articles and second, identifying databases and research studies ( McLean & Antony, 2014 ).

Inclusion criteria

Papers published during 2000–2020 were considered for the study. This was done by applying a custom range filter. The reason for selecting the above mention time frame is the most recent two decades were selected for article search.

Research articles related to healthcare service quality were included in the review process. The criterion was adopted in line with the primary objective of the review process.

Empirical and review articles published in peer-reviewed journals were considered.

Only papers in the English language were included.

Database and article selection

The literature search was conducted in the autumn of 2021. The databases selected for the literature search included Emerald, Elsevier, Sage, Taylor and Francis and Google Scholar. Filters such as custom range and sort by relevance were applied to restrict the search results to keywords. The systematic review process is presented in Figure 1 . In stage 1 of the review process, the literature was searched using the keywords such as healthcare, healthcare services, service quality and SERVQUAL. The search obtained 209 research articles. The research papers were selected based on relevance to the topic understudy and the popularity of the articles. Researchers such as Beaulieu (2015) argued that the popularity of journal articles with above 10 citations are considered in top 24% of the highest cited articles, and articles that receive 100 citations are considered among 1.8% of the most popular articles across the globe, which makes the current study a worth addition to the existing body of literature. In stage 2, the screening of articles was then conducted first based on title and abstract and then based on inclusion criteria. Screening of articles based on the title and abstract resulted in the exclusion of 63 research articles, and 146 articles were moved to the next level of screening.

Then articles were screened by applying inclusion criteria to exclude articles that do not fulfill the above-stated criteria ( Kamboj & Rahman, 2015 ). This screening obtained 100 research articles that were finally considered for review, and the rest of the articles (46) were excluded from the study. Finally, in stage 3 of the review process, the study provides a summary (publication trend, journal-wise distribution, methodology that includes sampling method and data analysis tools used and key findings) of the 100 articles included in the review.

Common characteristics of reviewed articles

Classification of articles by research type and hospital setting

Table 1 displays the classification of research articles based on research type and hospital setting. The research type describes the nature of the research and yields that a maximum number of articles were quantitative studies (62 articles) followed by qualitative studies (15 articles) and only 07 studies that were both qualitative and quantitative. A few review articles (14 articles) were also considered during the process. The results of the review substantiate that there is a need of conducting qualitative research that can provide an in-depth understanding of how various service quality dimensions affect the perceived quality of care among patients and the treatment satisfaction level. Qualitative studies can also provide insights into the priorities of patients while receiving medical services.

The classification based on hospital setting yields more than 77 articles that have purposively chosen a specific hospital setting and the rest have collected data from respondents in general. Out of 77 articles, 49% of research studies were conducted in a public hospital setting, and 25% were conducted in a private hospital setting. Around 26% of research were conducted in both public and private hospital settings. The direct comparison of healthcare services and perceived service quality among patients was observed as the main motivator in choosing both hospital settings ( Ovretveit, 2000 ; Mostafa, 2005 ; Taner & Antony, 2006 ; Andaleeb et al. , 2007 ; Owusu-Frimpong et al. , 2010 ; Manulik et al. , 2016 ; Dhahri et al. , 2020 ).

Data analysis tool

Figure 2 presents the frequency of various data analysis tools used by researchers to obtain meaningful results. The examination of articles selected for review revealed that 15 different data analysis techniques have been utilized in the past two decades. Descriptive statistics (29 articles) including mean and standard deviation has been the most frequently applied technique in healthcare service quality research followed by t -test (18 articles). It was also found that both techniques have been applied in combination because service quality can be obtained by ascertaining the difference between service perception and service expectation of patients using the SERVQUAL model ( Ahmad & Sungip, 2008 ; Irfan & Ijaz, 2011 ; Zarei, Daneshkohan, Khabiri, & Arab, 2015 ; Torabipour, Sayaf, Salehi, & Ghasemzadeh, 2016 ). Other major techniques preferred by researchers include correlation (17 articles), regression (17 articles), systematic literature review (12 articles) and ANOVA (11 articles). However, only 20 articles in total have applied structural equation modeling (SEM), MANOVA, content analysis, chi-square test, Shapiro–Wilk test, Mann–Whitney U-test, Kruskal–Wallis tests and Wilcoxon test, making them among the least preferred techniques in healthcare service quality research.

Sampling method

Articles selected for review depict that both nonprobability and probability sampling have been applied to study healthcare service quality and patient satisfaction. The articles have adopted 08 different sampling methods in addition to the complete enumeration (Census), which was employed for 03 articles. From nonprobability sampling techniques, convenience sampling (18 articles) is the most widely used sampling technique, and simple random sampling (19 articles) is the most frequently applied sampling method from the probability sampling group. Cluster sampling was found to be the least applied sampling technique among probability sampling methods because most of the studies were focused on specific regions with a limited geographical area. Targeting a smaller geographical area or specific site increases the feasibility of reaching out to sampling units because of the limited population spread. Therefore, when further segregation based on the geographical area seems impossible, the applicability of cluster sampling becomes impractical ( Cameron & Miller, 2015 ).

Findings and discussion

The systematic review of 100 articles has fetched several important findings in terms of measures of healthcare service quality and the theories applied in examining healthcare service quality.

Measures of healthcare service quality

Healthcare service quality, because of its intangible character and subjective nature, is difficult to define and measure. The comprehensive study of research articles about healthcare service quality illustrated that service quality in healthcare is examined by using different measures primarily related to servicescape, personnel, hospital administration and patients. The study has identified 41 distinctive measures of healthcare service quality ( Table 2 ). The factors commonly used to measure the quality of servicescape are identified as physical environmental quality, diagnostic aspect of care, resources and capacity, tangibility, financial and physical access to care and access ( Herstein & Gamliel, 2006 ; Ahmad & Sungip, 2008 ; Sharma & Narang, 2011 ; Simou, Pliatsika, Koutsogeorgou, & Roumeliotou, 2014 ; Marzban, Najafi, Etedal, Moradi, & Rajaee, 2015 ). Among the mentioned dimensions of servicescape, utilization has been less studied in the past. Future researchers can explore these areas because often in healthcare centers, the infrastructure capacity is overutilized or underutilized, which hinders the delivery of healthcare services. The determinants mostly employed to determine the quality of human resources (personnel) include healthcare personnel conduct, efficacy, efficiency, empathy, interaction quality, physician and staff performance, provider competency/performance, reliability, responsiveness, timeliness and trustworthiness ( Chahal & Kumari, 2012 ; Manulik et al. , 2016 ; Singh & Prasher, 2019 ). Some of the fewer studied factors under personnel characteristics include quality of patient-staff communication, outcome quality, professional quality, provider motivation and satisfaction encounters. These factors can influence the service quality of healthcare centers but are less researched in the past. The factors concerning quality aspects of hospital management/administration include admission, assurance, healthcare delivery system, infection rate, standard operating procedures, leadership and management and medical service ( Ovretveit, 2000 ; Herstein & Gamliel, 2006 ; Taner & Antony, 2006 ; Aagja & Garg, 2010 ; Irfan & Ijaz, 2011 ; Gupta & Rokade, 2016 ; Torabipour et al. , 2016 ). Among the determinants of hospital administration availability of doctors and paramedical staff, discharge mechanism of patients, documentation procedure in the hospital, social responsibility consciousness among the staff, management quality and drug availability in the hospital are some of the key factors that influence the service encounters between staff and patients. These determinants are less studied in the literature. Future researchers can build their research on these less studied variables. Lastly, the factors affecting service quality in terms of patient characteristics include patient satisfaction, the average length of stay, patient cooperation, patient quality/illness and patient socio-demographic variables ( Ovretveit, 2000 ; Mosadeghrad, 2014 ; Gupta & Rokade, 2016 ). It was observed that most of the service quality determinants identified can be summarized under the major 05 SERVQUAL determinants.

Theories applied to healthcare service quality

The list of popular theories that have been applied to examine healthcare service quality across the globe is presented in Figure 3 . A total of 11 different theories were identified during the review process. Less than 50% of papers identified for review have adopted one or the other service quality measurement framework and around 70% (32 research articles) among them have applied the SERVQUAL framework by Parasuraman, Zeithaml, and Berry (1988) . This makes SERVQUAL the mostly widely applied service quality framework. The other theories that have been utilized in the recent decade to examine the service quality of healthcare system include total quality management, fuzzy analytical hierarchy process, service performance model and health monitoring indicators system: health map ( Chahal & Kumari, 2012 ; Ramez, 2012 ; Zarei et al. , 2015 ; Amole, Oyatoye, & Adebiyi, 2015 ; Singh & Prasher, 2019 ; Zaid, Arqawi, Mwais, Al Shobaki, & Abu-Naser, 2020 ). The elements used to measure the perceived service quality of hospitals under different theories other than the SERVQUAL model can largely be classified under five SERVQUAL dimensions. However, outcome quality, process quality, administrative/management quality, utilization, technical quality and trustworthiness are identified as additional new dimensions being used to examine the service quality of hospitals ( Ovretveit, 2000 ; Chahal & Kumari, 2010 ; Simou et al. , 2014 ; Singh & Prasher, 2019 ; Zaid et al. , 2020 ).

Limitations and future research directions

The current study has some shortcomings which open up opportunities for future research. The present study followed a systematic review process to obtain research articles from different databases, like Emerald, Elsevier, Sage, Taylor and Francis and Google Scholar. Several inclusion criteria were applied, and only those full-text articles that are available in the English language were selected for the review. Therefore, there is the possibility of excluding some articles that are not available in these databases or are available in some other languages. Further, most of the studies selected for review were from developed nations. There is a lot of difference between the healthcare system of developed and developing nations. Thus, the findings of the present study cannot be generalized to developing nations without additional validation ( Kamboj & Rahman, 2015 ). Therefore, there is a need of carrying out empirical research in developing nations in this area.

The review of available literature has revealed that there are a large number of measurement tools available for the assessment of service quality in healthcare. However, the majority of these measurement instruments developed by the researchers assess quality from patients' perspectives and do not take into consideration service providers' perspectives. The technical aspect of service quality cannot be assessed by patients alone ( Upadhyai et al. , 2019 ). For a better understanding of service quality evaluation and satisfaction of service encounters, both service providers' and receivers' perspectives should be taken into consideration ( Brown & Swartz, 1989 ). Therefore, future researchers need to explore the knowledge gap (gap 1) of the SERVQUAL gap given proposed by Parasuraman et al. (1985) .

Practical implications

The study has attempted to identify and describe all dimensions and measurement tools relevant to healthcare service quality in light of the available literature. The study provides a thorough description of a vast number of investigations and reflects their outcomes. This research could help understand the diverse conceptualizations of service quality in healthcare compared to other types of services. The study also identified various gaps in the available literature that could be answered by future research.

The results of this study will help hospital executives in understanding the various constituents of quality and their impact on patient satisfaction. This will help hospital managers in formulating strategies that will improve patient satisfaction and ultimately improving the overall performance of hospitals. The study also highlighted the factors in which patients weigh more, thereby helping hospital managers to set priorities and help in proper resource utilization.

The current study presents an in-depth review of the literature concerning service quality and patient satisfaction in the healthcare industry. Service quality is a subjective measure and hence tends to vary from place to place and from patient to patient based on preference. The study has identified different measures that have been utilized to date to examine service quality or quality gaps in various hospital settings. Most of the studies selected for review have employed SERVQUAL dimensions of quality as service quality parameters. Service quality in the majority of the studies was established based on a difference between perceived and expected scores of service quality determinants, and the t -test was identified as the widely used statistical measure for testing its significance. In addition to this, various measures to determine patient satisfaction were identified and classified based on extra 3Ps of services marketing, namely physical evidence, people and process. The maximum number and most weighted factors affecting patient satisfaction are related to human resources actively engaged in providing medical services. It was observed that SERVQUAL determinants are popularly being used as a tool to determine the level of satisfaction among patients. All SERVQUAL determinants were found to have a significant positive relationship with patient satisfaction. Finally, 11 popular theories were identified among which SERVQUAL is widely applied.

Systematic literature review process

Theories applied in healthcare service quality

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Towards Green and Sustainable Healthcare: A Literature Review and Research Agenda for Green Leadership in the Healthcare Sector

Affiliations.

• 1 Department of Management, University of Information Technology and Management, 35-225 Rzeszów, Poland.
• 2 Department of Cognitive Science and Mathematical Modeling, University of Information Technology and Management, 35-225 Rzeszow, Poland.
• PMID: 36673663
• PMCID: PMC9858978
• DOI: 10.3390/ijerph20020908

The health sector is one of the keys to sustainable development. Although it is directly related to only one Sustainable Development Goal (Goal 3, "Ensuring a healthy life and promoting well-being at all ages"), the sector itself, which aims to protect health, is paradoxically at the same time the main emitter of environmental pollutants that have a negative impact on health itself. Therefore, sustainability has become a key priority for health sector organizations, and leadership in this area is essential at all levels. Scientific research plays a particular role here, helping to more clearly define the links between environmental sustainability and the health effects of a polluted environment and climate change as well as indicating the direction of actions needed and disseminating good practices that can help accelerate the adoption of efforts towards climate neutrality and sustainable development of health sector organizations. The aim of this article is to present the current state of the art and future research scenarios in the field of green and sustainable healthcare through a literature review by using the Preferred Reporting Items for Systematic Reviews Meta-Analyses (PRISMA) method to perform a bibliometric analysis of papers published in 2012-2022. The Web of Science Core Collection (WoSCC) database is used for this purpose. A total of 144 papers are included for analysis, categorized based on eight fields: author(s), title, year of publication, country, journal, scientific category, and number of citations. Based on the results, themes for future research on green leadership in the healthcare sector are identified and recommended.

Keywords: PRISMA; bibliometric analysis; green energy; innovation; renewable energy.

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Conflict of interest statement

The authors declare no conflict of interest.

PRISMA flow chart [43].

Number of articles published in…

Number of articles published in the years 2013–2022.

Keywords co-occurrence map.

Sustainability cluster Authors’ Keywords.

Climate cluster Authors’ Keywords.

Digital Transformation cluster Authors’ Keywords.

Number of articles per country.

Number of papers per journal.

The total number of citations…

The total number of citations per paper.

The most popular subject categories.

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