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

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

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

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

Healthcare represents one of the most important political focuses of every government around the world, regardless of the country’s socio-economic development stage, because it is an essential indicator for the quality of life ^[10]. The healthcare system should assure and guarantee health and well-being for every person irrespective their age as it is stated in the Sustainable Development Goals (SDGs) formulated by the United Nations General Assembly ^[11]. Among the main targets of the third SDG is to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” ^[12]. The achievement of this goal could not be possible in the absence of a strong healthcare system, which becomes crucial in the socio-economic development of every country. Taking into account the importance of the healthcare systems, some improvement strategies are needed and researchers have the mission of finding the best solutions for decision makers. Among these solutions, innovative processes and products can contribute to the system’s development and increased productivity ^[6]. Among the debated issues regarding the development of healthcare services is the quality management of the organization. The relationships with the employees, the process quality, the knowledge transfer, the leadership, and the trust management are considered in the literature as key actions in healthcare services ^[13]. Other research has emphasized the importance of information systems for healthcare service providers, which can improve the process by better visualizing the steps taken, establishing relationships with customers, or developing screening programs for preventive medicine ^[14]. One of the most important trends discussed in the literature concerns the management of healthcare systems from a marketing perspective, which can bring benefits to both individuals and society as a whole ^[15]. The recent COVID-19 pandemic crisis has widely highlighted the need for better services in healthcare systems, which were not sufficiently prepared for a large number of patients. Such situations require the better management of risk and special attention from the authorities, as many economic sectors could be affected simultaneously ^[16]. It is also assumed that certain changes in the behavior of individuals occur during such crises and in their perception of risk in the use of medical services ^[17]. In this context, most healthcare systems have proven that they are not sufficiently prepared in terms of the protocol to receive patients, hospitalization places, or adequate management of human and material resources ^[18]. All the aforementioned aspects debated in the literature reveal a strong need to improve healthcare systems. In this sense, the marketing approach is considered the most beneficial ^[15]. This is the reason why the present research is carried out from a marketing perspective, which includes an analysis of the customer appreciations regarding the overall components of the marketing mix in services: product; price; placement; promotion; physical evidence; personnel; and process.

3. Healthcare Marketing and Customer Attitudes

Quality in the healthcare sector is influenced by many factors, such as the customer satisfaction, marketing mix elements, digital marketing strategies, governance approaches to sustainability, and external factors such as the COVID-19 pandemic ^[19]. By using marketing strategies, service providers could persuade consumers to use some healthcare services or to choose certain clinics, but also negative behaviors (e.g., consumption of products with health risks) could be discouraged through marketing campaigns ^[15]. Even if marketing strategies are considered useful in relation to patients, healthcare institutions should first understand the needs and expectations of patients, and create value through patient-oriented services and healthcare service management ^[19]. Among these expectations, the use of the Internet to find health-related information is becoming increasingly popular, and service providers cannot ignore such needs ^[20]. They have to gain trust of the customer through empathy, reliability, and transparency based on diverse experiences that go beyond the interaction with a doctor ^[21] In order to put into practice the mentioned marketing actions, service providers must know and evaluate the attitudes of customers towards their products and company. The concept of attitude comes from psychology, which broadly means a person’s beliefs or evaluations made toward an object, people, or other aspects of everyday life ^[22]. The attitude has three components: affective (based on emotions), cognitive (based on knowledge), and behavioral (based on previous experience) ^[23]. Customer attitudes are an important factor that influences the effectiveness of healthcare marketing. A study exploring how customer attitudes toward telemedicine affected their intention to use it during the COVID-19 pandemic found that these customers were impacted by a variety of elements, such as the perceived value, perceived usability, perceived reliability, perceived risk reduction, and social influence. The customers who believe that telemedicine is useful, easy to use, trustworthy, reduces their risk of exposure to illness, and is endorsed by their social circle are more likely to have positive attitudes towards telemedicine and to use it in the future ^[24]. One of the most-investigated attitudes in the literature is customer satisfaction, a concept that represents the essence of relationship marketing. Some authors define it as the emotions that arise at the level of individuals from comparing their expectations with the performance or the perceived outcome of a product ^[25]. Simply put, when a product’s performance falls short of expectations, the customer is dissatisfied, and when it does not, the customer is satisfied. If the performance exceeds the expectations, the customer is extremely satisfied or even sometimes delighted ^[26]. In the particular case of healthcare services, customer satisfaction is defined as the degree to which the healthcare consumers are pleased with the quality of services they have received in healthcare clinics ^[27]. Studies have found that customer satisfaction in healthcare is influenced by various factors such as communication, trust, accessibility, and the provision of quality care [28,29,30]^[28][29][30]. Effective communication, for instance, involves the provision of clear and concise information that healthcare consumers can understand and use to make informed decisions ^[31]. Effective communication between healthcare providers and patients can lead to an increased patient satisfaction. This is because communication helps the patients feel more comfortable and confident in their care. The patients are more likely to be happy with their care when they feel understood and heard ^[32]. Communication is vital for engaging trust between the healthcare providers and patients, as patient satisfaction is greatly influenced by trust, so that patients who have faith in their healthcare providers are more likely to be happy with the treatment they receive ^[33]. Accessibility is also considered a determinant of patient satisfaction. It can be characterized as the ease with which healthcare services can be obtained. This includes factors such as the availability of healthcare providers, the cost of care, and the transportation options available to patients. The patients who have easy access to healthcare services are more likely to be satisfied with the care they receive ^[34]. By enriching the services with the mentioned features, a real partnership could be established with the patients, who will be determined to get involved in designing the personalized services according to their needs ^[35]. One of the most effective ways to improve the service quality and achieve high levels of customer satisfaction revealed in the literature is to use digital marketing strategies such as the following: creating and distributing content that educates and empowers patients; ensuring transparent and patient-centered services; using social media and online forums to connect and engage with patients; and building relationships online ^[20]. Digital marketing can also help healthcare organizations to collect and analyze data from various sources, and reveal insights into patient behavior, trends, and outcomes. This can help them target their marketing efforts more effectively, and personalize their communication with patients. Digital marketing analytics can also be used to provide real-time feedback, identify patients at risk, and track patient progress ^[36]. However, digital marketing is not enough to ensure the quality of healthcare, as people can hold stereotypes or bad attitudes created in the past, which can lead to a bad image and rejection of some services ^[37]. For such reasons, direct relationships with the patients are very important, especially during the treatment of various diseases or in cases that require a major decision ^[35]. In addition, patient expectations also play a role in determining the satisfaction with healthcare services. The patients who have high expectations for the quality of care will be more likely to be satisfied with their experience if their expectations are met. Otherwise, they may express a low level of satisfaction. Therefore, healthcare organizations should aim to manage patient expectations to improve satisfaction. It is revealed in the literature that customer satisfaction in healthcare is a complex and multifaceted construct that is influenced by various factors ^[38]. Bearing in mind the above-mentioned issues debated in the literature, healthcare service providers should conduct thorough research to capture patient expectations and satisfaction. Their results could be used to establish marketing strategies that are crucial for improving the quality of medical care. Marketing strategies are plans and actions that a marketer uses to achieve specific marketing goals and objectives. Several studies found that the market orientation, innovation orientation, and entrepreneurial orientation have positive effects on the organizational performance, mediated by a competitive advantage and customer value ^[39]. Adopting effective marketing mix strategies in healthcare services (using the 7 Ps) could also enhance patient satisfaction and loyalty ^[19]. Thus, healthcare marketing is a vital tool to provide better patient care. It helps healthcare organizations reach more people, connect with them personally, and increase their satisfaction and loyalty ^[8]. Beyond the goal of meeting customer needs and improving satisfaction, healthcare organizations should also adopt sustainability governance approaches that can help them reduce carbon emissions, improve resource use efficiency, and promote healthy lifestyles to prevent disease ^[40].