INTRODUCTION
Marketing is a scientific field that is constantly changes. First of all, we are witnessing major changes taking place in the information technology field and marketing communication media. Accordingly, marketing sees in this a chance to incorporate the aforementioned changes through the development of strategies, tactics and tools that will respond to the demands of business entities. The concept of marketing is defined as a process that includes the planning and implementation of four activities: production, pricing, promotion and distribution of ideas, goods or services - in order to achieve an exchange in which the goals of individuals and organizations will be satisfied (Bajraktarević, 2014).
Given that we perceive marketing as a scientific discipline that offers significant benefits to companies and society, the fact is that marketing is a business function and as such is exposed to strong public criticism. Criticisms are directed at the following things: marketing „forces” people to buy what they don't need, marketing „beautifies” the demand for products, marketing discriminates against people because it carries out consumer selection, marketing contributes to the increase of environmental waste, marketing invades people’s privacy, etc (Bajraktarević, Bajraktarević i Solaković, 2013). Needs for healthcare services can be considered existential, such as those for food, drink, clothing and housing. However, the needs for healthcare services are generally not known in advance, they are unexpected, unwanted and unpredictable. The concept of health need is different from the concepts of demand and use of healthcare services. While the demand for healthcare exists when the individual needs and wants it, and the use of it when the individual achieves it, health needs can be defined as those conditions that justify the intervention of the healthcare service in order to preserve or improve health. The process of experiencing the need for healthcare services occurs before the healthcare demand is even expressed. Meeting the needs of users of healthcare services is very difficult (Kurtović, 2015).
Most studies indicates that the key to profitability is knowing and meeting the needs of targeted consumers with a competitively superior offer. There are many definitions of marketing, and therefore it is not easy to decide on the one among them that best approximates the essence of marketing. Marketing consists of strategies and tactics used to identify, create and build satisfying relationships with consumers and create value for consumers (Kotler, Wong, Saunders i Armstrong, 2004).
Healthcare marketing is by its specificity an interdisciplinary field because it uses certain concepts, methods and techniques specific to both classical and social marketing. The specificity of marketing in healthcare is that there are services and markets, but not the money. The involvement of patients in the achievement of the medical act has become a necessity of current life with wide and complex meanings, not only beyond the change of mentality of service providers, but also with significant changes such as the lifestyle, consumption habits and medication taking of users. From a marketing perspective, the process of providing healthcare services must be carried out in full accordance with the demands of the patients, and activities are designed to meet those demands. However, achieving such a goal implies the identification of all points of interference between healthcare personnel and consumers of healthcare services and an assessment of the extent to which the activities carried out at those points correspond to the needs and expectations of patients. Since the behavior of healthcare users is difficult to predict, the presence of the patient in the delivery process can be a source of great uncertainty (Kilibarda, Sinanović, Bubanj, Trgovčević, 2021).
For an even greater competitive advantage, the power of claims-based analytics should be used to identify detokenized patient activity in inpatient and outpatient settings so planners can understand not only market share, but also procedural level share of care (Stojić a. 2022). Content marketing is a great manner to build a repository of expertise. Content marketing includes creating and sharing blogs, videos, social media posts, forum posts, and more. It is used to stimulate interest in the products and services of the business, although it does not promote the brand as advertising. Accurate, relevant information can promote your brand as an industry leader and help connect with patients. If done right, content marketing can even drive meetings and increase sales (Ferrell, 2021). Online and print media reputation management is essential. Bad media coverage and negative reviews can damage a facility's reputation, affecting the perception of potential patients and the medical community. This can easily translate into fewer patients and fewer referrals. A negative perception may even predispose patients to expect a bad experience (Tvede, Ohnemus, 2008).
The call for marketers to become more responsible for their actions leads to the development of a code of ethics by companies and professional organizations. The company's code of ethics defines the behavior of company members. For example, some companies have their own code of ethics document that clearly states what is expected of employees (Čujić i Berber, 2009).
Health insurance in Federation of Bosnia and Herzegovina
In all of Bosnia and Herzegovina, health insurance is based on the Bismarck model of organization and financing of health insurance, and healthcare is organized on the principles of an organization that strives for well-being, which derive from the Law on healthcare of the Federation of Bosnia and Herzegovina. The principles of healthcare policy in Bosnia and Herzegovina represent specific solutions for the social security of citizens. The fundamental goals of these principles are the objective, principled and consistent application of social insurance norms, as well as the regulation of certain relations between the subjects of the social health insurance legal relationship. All legal solutions of health insurance and politics as a whole in Bosnia and Herzegovina are based on common principles (Vukić, 2017).
In addition to the mentioned basic forms of health insurance in Bosnia and Herzegovina, there is voluntary (principle of voluntariness and community) and private health insurance. Such health insurances are organized by private insurance companies and function on the principles of free regulation of the obligation relationship. Such forms of health insurance are not so developed in our region and, due to difficulties with mandatory health insurance, they will certainly be introduced more often (Sl novine FBiH 46/10, 2010).
Due to the introduction of the system of federal solidarity within the framework of mandatory health insurance, the federal authorities passed the Law on Amendments to the Law on Health Insurance (the same was passed in 2002 in the amendments to the Law on Health Insurance), which fully defined the jurisdiction of federal solidarity at the Institute health insurance and reinsurance (Zakon o zdravstvenoj zaštiti Federacije Bosne i Hercegovine, Sl. novine FBiH br. 46/10, 2010).
The fast-growing field of healthcare contracting and advocacy includes contractors in the clinical research system, especially those focused on protecting human participants in medical research, advocates for specific disease associations, especially those focused on genetic disorders or widespread chronic conditions, and advocates serving clients in private practice. alone or within large companies (GBD 2019 Healthcare Access and Quality Collaborators, 2022). Patients are of vital importance for healthcare and medical institutions, because without their patronage, institutional action would not be possible. The stages that consumers go through on their journey to becoming customers and patients must really be at the forefront as healthcare facilities design their marketing communications campaigns, because any opportunity to craft vehicles in a way that accelerates patronage provides obvious benefits for a given health and medicine, institutions and those they serve. Advertising - a method of marketing communication that involves the paid use of mass media to deliver messages to a desired audience - is one of the most common and effective ways to attract current and future patients (Erold i Fortenberry, 2020). Maintaining awareness of current developments in healthcare advertising can be facilitated by gaining operational perspectives and practices from peer institutions. Most all healthcare professionals can benefit from experiential views as they can shape and refine advertising approaches. Gaining such insights can be difficult, given the sensitivity to competition, but occasionally healthcare facilities are forced to share knowledge in published reports (Korda i Kralj, 2022). The behavior of healthcare professional’s workers may be determined, but not limited, by knowledge, social influences, intention, emotions and goals. Understanding healthcare worker behavior change is critical to ensuring advances in healthcare psychology are applied to maximize population health (Godin, Bélanger-Gravel, Eccles i Grimshaw, 2019).
MATERIAL AND METHODS
The main goal of this research is to examine the importance of marketing of healthcare institutions and healthcare services in the FBiH healthcare system. The purpose of this research is to examine how and to what extent the advertising of healthcare institutions and services is carried out. According to the goals a main hypothesis is set - H1: "Responsible staff in FBiH healthcare institutions have good knowledge about the legal regulations related to the marketing of healthcare institutions and healthcare services, as well as a positive attitude towards marketing." The study was conducted in healthcare institutions (clinics and polyclinics) in FB&H that operate in public and private ownership. Responsible persons of healthcare institutions (directors, associates in the management of the institution) participated in the study from the Sarajevo, Central Bosnia, Zenica-Doboj, Bosanskopodrinje, Tuzla, Herzegovina-Neretva cantons and Canton 10.
This study is quantitative, cross-sectional, descriptive and comparative. An author's questionnaire created on the basis of a review of professional and scientific literature was used as a research instrument. The questionnaire was created in the electronic form „Google forms” and was available to respondents by e-mail invitation. The study was conducted in the period from February 15 to March 15, 2023. The questionnaire contains a total of 18 questions, eight of which refer to the sociodemographic characteristics of the respondents and questions about the workplace. The remaining ten questions refer to questions on knowledge of the legal regulations related to marketing in health care, opinions, attitudes, and willingness to apply marketing in healthcare. In this research, all ethical principles related to the protection of the identity of the respondents and the data obtained through questionnaires/interviews were respected. Data confidentiality is guaranteed by the researcher. The respondents had no financial or any other interest in participating in the research.
RESULTS
The results are presented in tables and charts by number of cases and percentage. The Spearman's rank correlation test is used to test the influence of all parameters on the variable indicators of healthcare marketing. The level of statistical significance was set at 95% or with p<0.05. The analysis was carried out using the statistical package for sociological research IBM Statistics SPSS v 23.0. In relation to the type of ownership of the institutions, 129 or 92.1% of respondents work in public, and 11 or 7.9% of respondents work in private healthcare institutions. According to the FB&H cantons, the questionnaire was most often filled out by respondents from Sarajevo Canton in 93 or 66.9% of cases, followed by Tuzla Canton in 15 or 10.8% and Central Bosnia Canton in 9 or 10.8% of cases (Table 1).
Table 1. Overview of institutions included in the survey
Source: own source, 2024.
In relation to gender, the majority of respondents were female in 112 or 80.0% of cases, compared to 28 or 20.0% of males. An overview of the age structure shows that the largest number of respondents were in the age group of 46-55 years - 59 or 42.1% of cases, followed by respondents in the age group of 37-45 years in 42 or 30.0% of cases. The smallest number of respondents is in the youngest age group of 18-25 years in 3 or 2.1% of cases. The questionnaire was most often answered by chief nurses-technicians of departments in 80 or 57.1% of cases, then chief nurses-technicians of institutions in 29 or 20.7%, heads of departments of healthcare institutions in 22 or 15.7%, heads of healthcare institutions in 8 or 5.7%, and one or 0.7% head of OJ or department in a non-medical discipline or service (Table 2).
Table 2. Overview of the sociodemographic characteristics
Source: own source, 2024.
Respondents most often stated that they partially know the legal regulations in the field of health and healthcare, and completely in 47 or 33.6% of cases. Only 4 or 2.9% of respondents stated that they do not know the legal regulations for this area (Figure 1).
Figure 1. Review of knowledge of legislation in the field of healthcare
[CHART]
Source: own source, 2024.
Respondents most often have the opinion that it is partially allowed to advertise a healthcare facility and services in 61 or 43.6% of cases, then completely in 43 or 30.7%, while 36 or 25.7% of respondents have the opinion that it is not allowed to advertise a healthcare facility and services. Respondents most often believe that it is desirable for healthcare institutions and services to be advertised in public, as well as partially in 59 or 42.1%. In 18 or 12.9% of cases, the respondents believe that it is not desirable for healthcare institutions and services to be advertised to the public. According to the answers of the respondents, in 65 or 46.4% of cases, the advertising of healthcare institutions in the public is represented, in 58 or 41.4% of cases partially, and in 12 or 12.1% that the above. In relation to the ways of advertising healthcare institutions in public, respondents most often mention social networks in 7 or 43.8% of cases, then through the institution's website in 6 or 37.5%, through billboards or billboards in 2 or 12.5% of cases, and in one case through public services or the media.
As ways of presenting the healthcare institution for marketing purposes, the respondents most often cite new diagnostic and/or therapeutic methods that are implemented in the institution in 18 or 25.7% of cases, and the way of providing healthcare services in 15 or 21.4% (Table 3).
Table 3. Review of respondents' familiarity with the rules and methods of healthcare institutions advertising
Source: own source, 2024.
The majority of respondents do not know whether the number of healthcare services or demand for the same has increased as a result of presentations in 39 or 30.2% of cases, and 38 or 29.5% believe that it has partially increased and 10 or 7.8% that it has certainly increased (Figure 2).
Figure 2. Analysis of the increase in the number of healthcare services and the demand for them due to the presentation of the institution to the public with a marketing objective [CHART]
Source: own source, 2024.
Exactly half, 70 or 50.0% of respondents fully support marketing in healthcare, 63 or 45.3% partially, and 6 or 4.3% of respondents do not support marketing in healthcare (Figure 3).
Figure 3. Analysis of support for healthcare marketing by respondents
[CHART]
Source: own source, 2024.
Correlation analysis of the independent variables influence on the answer to the question „Is it allowed to advertise a healthcare facility and services? “shows that the Canton has an influence in the sense that there is a greater representation of positive opinion in Sarajevo Canton compared to other cantons (ro=-0.211; p =0.013), the influence of gender in the sense that women more often give a positive answer to this question. The purpose of marketing in healthcare in the sense that respondents who understand the purpose more often believe that advertising is allowed in healthcare (ro=0.206; p=0.015), and that those who believe that advertising is allowed state that there has been an increase in healthcare services and demand for the same (ro=0.200; p=0.023). Correlation analysis of the influence of independent variables on the answer to the question „In your opinion, is it desirable that healthcare institutions and services be advertised to the public?“ shows that the canton from which the respondents come has an influence in the sense that respondents from Sarajevo Canton give a positive answer more often (ro=-0.274; p=0.001), and that respondents who understand the purpose of marketing in healthcare more often give a positive answer to this question (ro= 0.186; p=0.027).
Advertising in the public is more often represented in private compared to public healthcare institutions (ro=-0.429; p=0.0001), and respondents with a higher position at the workplace responded positively to this question as well (ro=0.242; p =0.004), and a positive correlation was recorded between advertising in the public and the increase in the number of healthcare services and the demand for them (ro=0.489; p=0.0001). Support for marketing in healthcare is more often expressed by respondents who understand the purpose of marketing in healthcare (ro=0.186; p=0.028), and it can be seen that in institutions where respondents support marketing in healthcare, there has been an increase in the number of healthcare services and the demand for the same (ro=0.175; p=0.047) (Table 4).
Table 4. Correlation analysis
Source: own source, 2024.
DISCUSSION
Based on the obtained results, the main hypothesis of this paper was proved, which reads: "Responsible staff in FBiH healthcare institutions have good knowledge about the legal regulations related to the marketing of healthcare institutions and healthcare services, as well as a positive attitude towards marketing." For the purposes of this article, study was conducted on a sample of 140 respondents, of which the majority were female respondents (112 or 80.0%), compared to the male gender, which was only 28 or 20.0%. In relation to the age structure, most respondents were between the ages of 46-55 (59 or 42.1%). A greater number of respondents are from the public healthcare sector in 129 or 92.1% of cases, while 11 or 7.9% of respondents filled out the questionnaire from the private sector. As for the canton from which the respondents come, the largest number of respondents was from the Sarajevo Canton (93 or 66.9%), followed by the Tuzla Canton (15 or 10.7%), and the Central Bosnia Canton (9 or 6.4%).
By examining the knowledge of legal regulations in the field of health and healthcare, 89 or 63.6% of the respondents stated that they partially know the legal regulations for the field of health, while 47 or 33.6% of the respondents confirmed that they know the legal regulations. When asked whether it is allowed to advertise a healthcare facility and healthcare services, the respondents answered in the largest number of cases that it is partially allowed (61 or 43.6%), then that it is allowed (43 or 30.7%), and that it is not allowed (36 or 25.7%). Likewise, the majority of respondents believe that it is desirable for healthcare institutions and services to be advertised to the public (63 or 45.0%).
Correlation analysis of the influence of independent variables on the answer to the question „Is it allowed to advertise a healthcare facility and services?” shows that the Canton has an influence in the sense that there is a greater representation of positive opinion in Sarajevo Canton compared to other cantons (ro=-0.211; p =0.013), the influence of gender in the sense that women more often give a positive answer to this question, The purpose of marketing in healthcare in the sense that respondents who understand the purpose more often believe that advertising in healthcare is allowed (ro=0.206; p=0.015), and that they who believe that advertising is allowed state that there has been an increase in healthcare services and demand for them (ro=0.200; p=0.023). Correlation analysis of the influence of independent variables on the answer to the question „In your opinion, is it desirable that healthcare institutions and services be advertised to the public?“ shows that the canton from which the respondents come has an influence in the sense that respondents from Sarajevo Canton give a positive answer more often (ro=-0.274; p=0.001), and that respondents who understand the purpose of marketing in healthcare more often give a positive answer to this question (ro= 0.186; p=0.027). Advertising in the public is more often represented in private compared to public healthcare institutions (ro=-0.429; p=0.0001), and respondents with a higher position at the workplace responded positively to this question as well (ro=0.242; p =0.004), and a positive correlation was recorded between advertising in the public and the increase in the number of healthcare services and the demand for them (ro=0.489; p=0.0001). Support for marketing in healthcare is more often expressed by respondents who understand the purpose of marketing in healthcare (ro=0.186; p=0.028), and it can be seen that in institutions where respondents support marketing in healthcare, there has been an increase in the number of healthcare services and the demand for the same (ro=0.175; p=0.047). The author Purcarea (2019) researched the topic „The impact of marketing strategies in healthcare systems“ and pointed out that one of the key factors in the organization and implementation of changes in healthcare organizations as a whole is the application of appropriate strategies, methods and tools, and one of the most effective strategies is change of human resources. Transparency between operatives and supervisors, as well as between different departments for providing services, teams of different experts on the same task and faster and more efficient circulation of information, both internally and in relation to external factors, will be the hallmark of the new, flexible healthcare management.
The authors Gupta, Krishna Naidu and Kakkar (2019), wrote on the topic „ Role of social marketing in promoting primary care to succeed in current era“ and concluded that social marketing in medicine means the application of marketing concepts and approaches, with the aim of achieving behavioral changes relevant to improving health and reducing health differences. Those campaigns in which mass communication campaigns are applied with communication mediated by healthcare professionals have been shown to be effective.
The authors Krupskyi and Stasiuk (2023), researched on the topic „Peculiarities of application of marketing technologies in the medical sphere“, and proved that healthcare tourism is an increasingly popular form of tourism, but that it would not be possible without the application of the concept of marketing. The authors, Trinh and Begun (2019), wrote on the topic „ Strategic differentiation of high-tech services in local hospital markets “, and pointed out that marketing strategy is one of the platforms for market differentiation and strengthening the recognition of each service entity, including typical institutions for the accommodation of elderly and disabled persons.
CONCLUSION
Based on the study results, we can conclude that the responsible personnel in the FBiH healthcare institutions know the legal regulations related to the marketing of institutions and services and have a positive attitude towards marketing.
Based on the obtained results, the main hypothesis of this paper was proved, which reads: "Responsible staff in FBiH healthcare institutions have good knowledge about the legal regulations related to the marketing of healthcare institutions and healthcare services, as well as a positive attitude towards marketing." This is supported also by the fact that the majority of respondents believe that it is desirable for health institutions and health services to be advertised to the public (63 or 45.0%). A small number of respondents answered the question: “How are health institutions advertised to the public?”. Some of the ways of advertising are social networks, websites of institutions, public services/media, billboards, etc. All of the above was stated by only 16 respondents. What healthcare institutions most often present to the public are: new diagnostic and therapeutic methods (18 or 25.7%), the way of providing health services (15 or 21.4%), new services/methods (8 or 11.4%), new/innovative surgical procedures (7 or 10.0%), expansion of spatial and personnel capacities (7 or 10.0%), work success (5 or 4.3%). This question was answered by 70 respondents out of a total of 140 respondents. Respondents believe that the following should be visible to the public: medical technologies that the institution has at its disposal (57 or 40.7%), the best performed medical procedure (37 or 26.4%), only specific rare diagnostic or therapeutic procedures (18 or 12.9 %). The purpose of healthcare marketing, according to respondents' answers, is to inform patients about healthcare services, to be recognizable and attract patients/clients, to develop a competitive spirit in the healthcare market. As the main limitation of this study we can poin out the discrepancy between the public healthcare institutions, which are more dominant, than the private ones. Also the 2/3 of the respondents are from the Canton Sarajevo. For the future studies we would reccomend more targeted sampling, as compared to this random one, in order to obtain more reliable data.