Quality assessment of global health care system in the shadow of COVID-19: – a systematic review | BMC Public Health


The nine studies collectively suggest that patient satisfaction during the COVID-19 pandemic varies depending on factors such as quality of care, communication, safety measures, and availability of personal protective equipment (PPE). Despite the challenges posed by the pandemic, overall satisfaction levels remained high in most cases. The review found that patient satisfaction varied across countries, with Saudi Arabia, India, and the U.K. reporting the highest levels of satisfaction, while Ethiopia reported the lowest level [10,11,12]. Several factors were associated with higher patient satisfaction, which includes the availability of drug, sign and direction indicators, social distancing measures, and hygiene facilities at healthcare centres [7]. Patient satisfaction is essential for the early detection and effective treatment of chronic diseases, which can result in improved clinical outcomes [13]. However, some studies found that the pandemic led to a decrease in patient satisfaction, especially for those with chronic diseases. Factors contributing to this decrease included the unavailability of drugs and the lack of preparedness of some healthcare facilities to handle these conditions. Overall, patients’ expectations were highest for the assurance provided by staff, followed by reliability, responsiveness, empathy, and tangibles [14]. However, there were areas that needed improvement, such as toilet and hygiene facilities and the explanation of illness and treatment by doctors [12]. The review also identified some human resource planning practices that positively influenced patient satisfaction, while others had a negative impact [15]. These findings highlight the importance of evaluating patient satisfaction during a crisis like the COVID-19 pandemic to identify areas that need improvement in healthcare systems. By addressing these issues, healthcare systems can become more patient-centered and better equipped to handle future crises.

Overall, the studies suggest that healthcare providers should focus on providing high-quality care, effective communication, safety measures, and ensuring the availability of PPE to improve patient satisfaction during the COVID-19 pandemic. According to a service quality model developed by Parasuraman, Zeithaml, and Berry, there are five factors that determine quality, and they are listed in order of relevance to the patients/consumer. The five factors are Reliability, Responsiveness, Assurance, Empathy, and Tangibility (Fig. 3) [16].

Fig. 3
figure 3

Factors for Quality Assessment

Based on the above-mentioned quality determinants, this systematic review attempts to discuss the included studies for thematic evaluation based on the five factors listed above.


Reliability can be defined as the ability to perform the services which are promised in a reliable and accurate manner [17]. This includes the easy availability of medical facilities, easy procedure of patient admission, appropriate waiting time and easy availability of medical professionals.

The reliability aspect, which considered all the points, was found to be 3.5 on a 4- point Likert Scale and occupied the lowest score out of all five aspects [18]. It was also revealed that to receive the laboratory results, 43.8% of the study participants waited an average of 15 to 29 min [7]. Out of all the study participants, 68.9% of the patients were found to be satisfied with the reliability aspect of patient satisfaction [8]. The majority of the respondents, i.e., 91.9% stated that the working hours of the medical facilities were convenient for them, while 87.9% of them claimed that they were satisfied with the punctuality related to their medical visits. The percentage of the respondents who stated that they were able to obtain medical aid in emergency was found to be 69.7%. However, 27.3% of the study participants claimed that they faced problem while trying to book an appointment with a doctor of their own choice [13]. According to the evaluation of the dimension of reliability, the issue that received the highest rating (92.1%) was ‘hospitals keep patient data accurate and error-free’ followed by the next most highly rated issue which was that doctors do not rush through patient examinations (86.4%) [14].


Responsiveness is the willingness to help consumers and provide services quickly [17]. This includes serving patients deftly, and responding to their complaints efficiently and on time.

The responsiveness aspect was rated at a value of 3.47 [18]. Approximately two-thirds of the patients (67.2%) claimed that hospital staff made sure all their issues were resolved prior to discharge [10]. According to 52.7% of respondents, the response to patient complaints was extremely satisfactory [12]. Only 6.9% of the patients were satisfied with the responsiveness aspect of patient satisfaction [8]. The health issue addressed by 29.3% of patients was somewhat resolved, and for 48.5% of respondents, it was completely resolved [13]. Similarly for 48.5% patients in Albania responsiveness assessment was at good level with 53% [14].


Assurance is the knowledge and courtesy of providers and their ability to generate trust and confidence among consumers. The provision of readily available information to the patients and a clear explanation of the drugs that have been prescribed to them constitutes the assurance aspect.

With a rating of 3.51 on a 4-point Likert Scale, the assurance component held the position with the second-highest value [18]. 93% of the patients stated that the nurses and doctors answered all their queries in a clear and understandable manner while 76.8% of the patients reported that the hospital staff always explained the name and purpose of the medication being administered. Likewise, 85% of patients concurred that they comprehended the significance of taking their prescribed prescription and a comparable share (86.5%) agreed that they had an excellent grasp on how to manage their health. 64.1% of respondents reported receiving written instructions at the time of discharge [10]. 71% of the patients also stated that the staff always cared to introduce themselves to the patients prior to the start of the treatment [11]. 69.5%, 39.3% ,and 70.7% of the patients reported that the laboratory tests, x-ray/ultrasound tests and the drugs/supplies were ordered for them, respectively. 70.5% of the patients stated that the providers explained to them clearly as to how to maintain a healthy lifestyle and 84.6% of them said the providers used a language that was easier for them to understand [7]. The majority of patients (56.7%) indicated that the doctors spend between two and five minutes of their time examining patients. Approximately one-third of the patients (33.3% and 37.3%) revealed that the doctors provided an explanation regarding the illness and its treatment, respectively. Inquiries about the admission and discharge processes revealed that 58.7% and 32.7% of respondents, found it to be very satisfactory and satisfactory, respectively [12]. 19.5% of the patients were found to be satisfied with the assurance aspect of patient satisfaction [8]. Among all the criteria evaluated for assurance, the highest rating was for the security measure “Patient data is stored using the principle of confidentiality,“ with 92.8% and the alternative measure “Doctors have very good knowledge and technical skills” received a rating of 90.3% [14].


Empathy can be defined as a willingness to care and providing personal attention to customers [17]. This would include non-discriminatory behavior on the part of the healthcare providers towards patients, and the friendly attitude and good listening ability of the medical professionals.

The empathy aspect had the greatest value of the five factors, i.e., 3.52 [18]. 77.6% of the patients said that the nurses and doctors always treated them politely, showed them respect, and paid close attention to what they had to say. 85% of the patients who were surveyed said that staff members did take their preferences and those of their caregivers into account [10]. 94% of the patients reported that they were only rarely able to communicate with their friends and family members during their stay in the hospital [11]. The majority of respondents expressed great satisfaction with how healthcare professionals behaved. According to 64.7%, 68.7%, and 63.3% of the respondents, respectively, the actions of doctors, nurses, and paramedical staff, as well as cleaning employees, were extremely satisfactory. Most respondents (47.3%) found the overall cleanliness to be satisfactory, while 10.7% found it to be unsatisfactory to extremely unsatisfactory [12]. 64.3% of the patients were found to be satisfied with the empathy aspect of patient satisfaction [8]. The majority of patients reported that “Medical staff respects the privacy of patients,“ which received a positive evaluation of 84.9% and the alternative aspect “Staff provides patients with personal attention,“ received a positive evaluation of 81.6% [14].


Tangibility is the appearance of physical facilities, equipment, personnel, and communication materials [16], which would include the availability of complete facilities for medical care and practice, cleanliness of the place of practice and the location of the practice to be easily reachable.

The tangibility aspect had a value of 3.48 [18]. 89.2% of patients claimed that the housekeeping always maintained their room and bathroom clean. Similar to this, 91.3% of patients stated that the area around their premises or surrounding their room was quiet and free of disturbances at night [10]. Three-fourths of patients claimed that there were no signs or direction indicators at the medical facilities they were using. 89% of the overall respondents confirmed about the presence of water at the medical facility. Patients were 3.26 times more likely to report being satisfied than their counterparts if they were able to use the sign and direction markers in the medical institution. Patients who received some or all the prescribed medications from the medical facility were 3.7 times more likely to report being satisfied than those who did not. At the hospital’s entrance, patients who received alcohol for hand washing were 2.7 times more likely to be satisfied than those who did not. Patients were found to be 4.4 times more pleased than their counterparts when hand sanitizer was available at the hospital entrance. Patients who obtained hand sanitizer at the health facility door were 4.5 times more likely to be satisfied than their counterparts [7]. 100% of the study participants were satisfied with the availability of a bed, lighting, and fans. Most of the patients were satisfied with the available facility. Approximately 98.7% of respondents were satisfied with the drinking water facility. According to 98% of respondents, services related to drugs and investigations were extremely satisfactory. According to the 44% of respondents, toilet facilities were adequate [12]. Unskilled or inadequately trained employees was found to be one of the leading causes of patient dissatisfaction [15]. 13.1% of the patients were found to be satisfied with the tangibility aspect of patient satisfaction [8]. Among various tangibility aspects “Hospital staff have visually clean appearance” was rated maximum with 88.1% followed by the alternatives “Rooms are quiet” and “Rooms and the bathrooms are clean,” with 64.9 and 45.8% respectively [14].


This Systematic review has certain limitations. One of the main limitations is the presence of significant heterogeneity found in the various regimens such as durations, center settings, and participant characteristics across the studies included in the review; which may affect the generalizability of the findings and thus creating a roadblock in conducting the meta-analysis. Additionally, many of the studies suffer from sources of bias, which could impact the validity and reliability of the results but still had to be included due to the limited number of studies available that met the inclusion criteria. Inclusion of fewer studies also led to a skewed effect while performing thematic evaluation.


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