Therapeutic healthcare centers play a crucial role as strategic locations designated by the government to deliver urgent medical services to recipients. The selection and distribution of these centers within a city are vital considerations, taking into regard factors like location, accessibility, and convenience for visitors based on time constraints and other relevant aspects. These factors contribute to the variety of services available in these centers, which can range from general to specialized or mobile services. Despite their continuous efforts to provide the necessary advisory and therapeutic 

services, beneficiaries often perceive these centers as less significant due to occasional shortcomings in healthcare service delivery. The rise of private healthcare facilities and clinics offering competitive pricing, specialized care, and convenient access has influenced how these healthcare centers are viewed.

1. Previous Studies 

Studies focusing on medical service centers have highlighted the importance of location, an undisputed factor. [1] emphasized the significance of location and ease of access to the service site, noting a deficiency in appropriate distribution of centers in Mosul. Other studies have concentrated on the quality and satisfaction levels achieved by patients [2]

Some studies addressed the infrastructure and available medical supplies, while others combined these aspects. Consequently, satisfaction levels vary from one environment to another [3]. Satisfaction rates reached 82% compared to 29% in cases of inadequate center infrastructure. However, studies have not observed the potential outcomes of these centers facing a shortage of medical services, particularly medications. The availability of services in private centers and clinics at reasonable prices and convenient schedules chosen by patients, without being pre-determined by the service provider, has impacted patient perspectives. Despite high drug prices, obtaining them from government centers is possible after a long wait and irregular availability, especially for chronic conditions. Studies have shown that patients' attitudes vary; despite the resources provided to them, some seek more, while others' perspectives may not always align with medical staff [4]. This situation is consistent with countries offering superior healthcare services to patients; medical staff may exhibit some reservation towards patients, particularly towards female and elderly individuals [5]. This aligns with a study [6]

However, it is worth mentioning that issues concerning the location and accessibility of healthcare services have not been adequately addressed. This is primarily due to the substandard quality of services provided and challenges in accessing medications, particularly for chronic illnesses with expensive treatments. Additionally, the lack of health insurance coverage from different sources contributes to the reliance on government medical centers despite their service deficiencies. Moreover, the center's insufficient facilities and the inability to utilize necessary equipment and supplies have led to a situation where a significant number of medical personnel, who have graduated from various government and private medical colleges, are accommodated. Unfortunately, this does not reflect positively on their ability to fulfill their roles due to space limitations and the absence of essential medical resources.

4.1 Research Problems

Iraqi medical centers are currently unable to fulfill their intended role due to service delivery deficiencies and the increasing presence of private medical clinics as alternative options. This situation has resulted in a noticeable shortfall in service provision as originally intended. Consequently, the following questions can be raised:

1. Are spatial considerations still crucial in selecting the locations of healthcare centers to achieve beneficiary satisfaction?

2. Do the levels of beneficiaries' response vary with the variation in spatial considerations and beneficiary satisfaction?

3. Have the alternatives represented by private medical clinics been and continue to be a factor in reducing the effectiveness of medical centers?

4.2 Research Significance 

The significance of this research lies in the importance of spatial factors and the services offered by medical centers across Mosul. Elements like location, competition, services, and amenities are vital in the establishment of healthcare facilities, taking into account the population density of the targeted area. Presently, researchers are placing a growing emphasis on their studies and scientific investigations regarding the quality and aspects of healthcare services. These efforts play a crucial role in advancing the healthcare sector by delivering top-notch medical services and providing both material and moral support to patients seeking care.

4.3 Research Objectives

 The research objectives can be outlined as follows:

1. Evaluating the activities of medical centers in providing the required services,

2. Examining the impact of private medical centers on the effectiveness of government medical centers,

3. Exploring the relationships and influences between spatial considerations and beneficiary satisfaction towards government medical centers,

4. Reaching the most prominent conclusions and recommendations that can enhance the healthcare service delivery in government medical centers.

4.4 Research Hypotheses

1. There is a significant correlation between spatial considerations and beneficiary satisfaction.

2. There is a statistically significant impact of the location of the health center on beneficiary satisfaction.

3. There is a statistically significant relationship between the importance of private medical centers and attracting beneficiaries.

4. The level of beneficiaries' responsiveness varies with the variation in research variables.

4.5 Hypothetical Framework 

Figure 1. Hypothetical framework

5.1 Procedures 

Through field visits to the management of government medical centers (clinics), interviews were conducted with the center's administrators to gather information on the posed questions. On the other hand, a questionnaire was distributed to beneficiaries who have interacted with the centers.

5.2 Participants 

The study focused on individuals who utilize government medical facilities in Mosul for essential healthcare services. The research sample comprised a purposive random selection of both health center personnel and beneficiaries of government health services. A total of 121 questionnaires were distributed among participants, resulting in the collection of 115 complete and analyzable responses. 

5.3 Instrument

These surveys included introductory sections detailing the characteristics of health center beneficiaries. Additionally, the questionnaire addressed key factors influencing the selection of therapeutic health center locations, such as their geographical positioning, competition, and the perceived quality of healthcare services provided. Responses were recorded using a five-point Likert scale ranging from "strongly agree" to "strongly disagree."

Table 1. Governmental health centers in the city of Mosul

5.4 Iraqi Ministry of Health

Figure 2.  Government clinic sites of the search sample according to Iraqi Ministry of Health

Clinic provides medical and therapeutic services to patients and visitors, especially for chronic diseases. Additionally, these centers offer health services such as counseling and awareness programs to help patients cope with health crises through seminars and health workshops.

6.1 Spatial considerations 

Spatial considerations are important topics that organizations take into account when initiating the study and planning of specific projects such as hospitals, hotels, schools, shopping centers, and others. Spatial considerations are defined as a set of criteria considered by the government and organizations when determining the initiation of specific projects. Additionally, they refer to everything related to the spatial project through which the set objectives are achieved, especially the goal of meeting the needs and desires of the beneficiaries or customers. The importance of spatial considerations in determining or selecting the implementation site and application can be outlined as follows:

1. Proximity to residential areas, which reduces effort, time, and search.

2. Identifying the needs and desires of beneficiaries.
3. Identifying current and potential competitors' locations.
4. Identifying medical services provided by current competitors at the current location.
5. Acquiring skills and experience in service provision compared to competitors.

6.2 Dimensions of spatial considerations

Many researchers, including [7] and agree that the dimensions of spatial considerations for establishing any service or commercial project within major cities or their outskirts consist of the following:

Location

The location refers to a specific place on the Earth's surface, where the geographic location is determined by the coordinates of longitude and latitude of the chosen site. The geographic location is an important term in the study of geographical concepts and is often used as a more precise term than the specified place. The location is considered the fundamental basis for launching economic, social, and developmental projects in the country, which can reflect positive results and benefits for all parties involved in planning, design, and implementation.

Selecting the correct location holds utmost significance in fulfilling stakeholders' objectives, achieved through meticulous site selection and service delivery, thereby setting it apart from others. The selection procedure serves as a pivotal starting point for numerous organizations, particularly those operating in competitive landscapes where products and services are homogeneous and akin. When selecting a location, the following should be considered:

1. The geographic nature of the chosen site.
2. The climate and surrounding environment of the chosen site.
3. The needs and desires of the target beneficiaries.
4. Studying what competitors offer.
5.  Availability of necessary amenities.
6.  Ease of access to the location.
7. Studying the nature of individuals and their lifestyle (purchasing power and price sensitivity).

Quality of provided services

Ensuring beneficiaries' needs and desires are met necessitates stakeholders to make utmost efforts in providing services of superior quality and uniqueness compared to competitors. To accomplish this, organizations focus on examining service quality dimensions and incorporating them when delivering services to beneficiaries.

Reliability

It refers to the ability of service providers to perform in a manner that can be relied upon, in addition to delivering services with a high degree of accuracy. It also shows the service provider's ability to perform the required service with a high degree of accuracy and proficiency, ensuring a balance between what is paid for and the services received [8]. Reliability is one of the most stable and crucial dimensions in determining customers' perceptions of service quality. Reliability is defined as fulfilling and committing to providing services with high reliability and trust [9]. It signifies the company's ability to deliver the promised service accurately and correctly to customers [10]. It also means the capability to reliably deliver service promises.

Tangibility

The level of tangibility is considered less significant in comparison to the five dimensions, unlike reliability, which holds the highest importance. This is because tangibility aspects of a service encompass buildings, information technology, communication tools, internal facilities, necessary equipment, staff appearance, internal company arrangements, waiting areas, and more. It involves physical facilities, equipment, tools, and staff utilized during service delivery [11]. Companies often utilize tangibility to enhance their reputation and ensure effective communication with customers as a measure of quality [12]

Response

It refers to a company's preparedness to serve customers, demonstrated by the speed of service delivery and how customer needs are addressed. Providing excellent service and interactions gives customers a positive signal that dispels any doubts they may have while waiting [13].It indicates the service provider's capability and promptness in addressing customer requests and inquiries [14]. Views it as the ability, willingness, and readiness of service providers to always be at the service of beneficiaries and their ability to deliver the service when required [15]. Therefore, response reflects the extent of the ability to handle all beneficiaries' needs and responses, working to resolve them swiftly and effectively to assure customers that they are appreciated and respected by the organization [16]

Empathy

According to [17] empathy involves employees in the organization showing a personal interest in the beneficiaries, understanding their needs, adjusting working hours to accommodate them, the organization's dedication to the beneficiaries' best interests, and having sufficient awareness of their needs. Compassion also includes showing friendship and concern for the beneficiary, acknowledging their importance, and a willingness to provide services based on their needs and preferences [18]. Additionally, [19] explained that it entails treating the beneficiary as individuals personally. Therefore, compassion can be defined as promptly reaching the beneficiary by enhancing the personal relationship and delivering products as requested.

Assurance

The significance of assurance lies in the services perceived by customers who benefit, such as risks or the challenge of evaluating the benefits of the services offered. The organization fosters trust among employees who engage with beneficiaries. This involves earning trust and confidence from service providers. This aspect is notably crucial for services perceived by customers because trust or confidence is a key and foundational element in successful exchange relationships, reflecting the provider's willingness and preparedness to embrace them in specific settings, allowing customers to have complete trust in all staff members within the company [20]

Competitors

Competition involves the rivalry among organizations offering similar products, operating in the same sector, or targeting specific market segments to increase sales, revenue, and gain a larger market share compared to other competitors. Competition typically drives organizations to enhance the quality of their goods and services by prompting improvements in their operations and tasks, focusing on meeting customer needs, and fostering customer relationships through effective customer relationship management [17]. This includes building databases, understanding actual needs, anticipating them, and delivering solutions at the right time and place.

The positioning of competitors in the market significantly influences how organizations prioritize offering high-quality products at fair prices, ensuring easy accessibility with minimal effort. Organizations aim to maximize the value of their offerings by addressing the genuine needs of customers, considering the various stages of the product life cycle (introduction, growth, maturity, decline). To sustain their presence in the market over the long term, especially during the maturity stage, organizations focus on product development and staying current with modern technologies in production and marketing [9]. Furthermore, competition encompasses factors such as price sensitivity and product/service quality. Quality is often linked to pricing, necessitating that organizations implement effective strategies to balance price and quality amidst competitive pressures.

6.3 The current status of healthcare services

Organizations in general, and healthcare organizations in particular, strive to coordinate their efforts to deliver healthcare services that cater to the needs of benefiting customers and evolve them periodically to stay competitive in the market and uphold their current standing against rivals.

Healthcare organizations are also required to gather data and information from customers, beneficiaries, competitors, and suppliers using effective market intelligence systems. This helps organizations identify the real market needs and work towards meeting them.

It has been noted that numerous healthcare organizations fail to meet market demands because they do not adequately study market requirements, comprehend and address their customers' needs and preferences, or keep pace with external environmental changes, particularly technological advancements. These results in beneficiaries opting not to engage with them in the short or long term, turning to other organizations that can fulfill their needs, earn their satisfaction, and ultimately foster strong loyalty.

In conclusion, when considering the spatial aspects of selecting locations for healthcare facilities, it becomes evident that governmental healthcare organizations, when compared to non-governmental ones, do not adequately address the needs of beneficiaries or patients due to various reasons. These include poor selection of appropriate facility locations, requiring significant effort and time to access them, as well as subpar quality of services, cleanliness, and interior design in dispersed healthcare centers. Moreover, there is inconsistency or non-compliance among healthcare staff with regards to working hours, regulations, and operational protocols, along with inadequate availability of modern medical equipment. This underscores the importance of developing service design plans and initiatives to enhance competitiveness with other entities such as non-governmental healthcare organizations and private clinics.

The necessity for specific medications for chronic illnesses offered at affordable prices and the public's requirement for vaccines exclusively accessible through governmental institutions emphasize the ongoing essentiality of governmental healthcare services.

6.4 Customer satisfaction 

Achieving satisfaction is one of the important objectives that organizations strive to accomplish through their marketing activities. It is a fundamental pillar for establishing the relationship between the organization and the customer and serves as a differential criterion for the continuation and development of this relationship [21]. Customer satisfaction refers to the positive feeling that arises from evaluating the aspects of the relationship between the customer and the organization [22]. It is the impression resulting from the sacrifices borne by the customer during the purchase [7]. It is also defined as "the psychological state of the customer when they feel they have received sufficient products in exchange for money and effort [23]

6.5 The importance of customer satisfaction

Customer satisfaction holds great importance in organizational policies [24] and is considered one of the most effective indicators for assessing organizational performance, especially when the organization is concerned with product quality [25]. The importance of customer satisfaction in organizations can be identified through the following points [26]

1. When the patient is satisfied with the organization's performance, they speak positively to others, generating new customers.

2. When the customer is satisfied with the products offered, the decision to repeat purchases is made quickly.

3. Reducing the degree of deviation and non-conformance in order to compare between customer expectations and perceptions.

In the case of dealing with government centers, as previously mentioned, achieving satisfaction – even after waiting and enduring difficulties to obtain subsidized and rare medications – is a relative matter compared to the low prices of private medications or government medical services, compared to the high prices of these medications available in the pharmaceutical market.

7.1 The status of healthcare centers in Mosul

It is important to mention the situation that the establishment of medical treatment centers in Iraq in general, and in Mosul in particular, has gone through. These centers have been known since the 1950s, providing urgent medical services at a time when medical specialties were not well-established. The number of working doctors was limited, with only one medical college in Baghdad. The same applies to medical equipment and various factors that made Iraqi individuals resort to these centers for treatment.

The healthcare centers expanded and spread widely during various periods in the seventies and beyond in the last century. They witnessed a clear shortage during the economic blockade imposed on Iraq in the nineties. The medicine market experienced a high scarcity and price increase due to the limited income of the Iraqi individual. Medical centers became the sole refuge for obtaining medication, especially for chronic diseases, following a specific approach where individuals would receive their monthly medication through a set process, at nominal prices, but with long waiting hours. After 2003 and the subsequent devastation in Mosul in 2014, most medical centers and hospitals were demolished amidst a notable surge in private clinics. The government's incapacity to supply free medication resulted in a surge in demand for private medical facilities, which offered essential services at affordable rates. These circumstances restricted interactions with government medical centers, as individuals faced challenges such as securing children's vaccinations at specific times or accessing medication at reasonable prices, subject to availability.

We must not forget that the absence of health insurance in Iraq had a significant impact on forcing individuals to resort to other sources to obtain medication and treatment, increasing the burden on citizens.

7.2 Testing the research hypotheses: 

7.2.1 Testing the overall and partial correlation of the main research variables A- Testing the relationships between the spatial considerations and customer satisfaction at the overall level

Table 1: The correlation between spatial considerations and customer satisfaction

Table 1 indicates a strong and statistically significant relationship at a significance level of 0.05 between spatial considerations and customer satisfaction. With a correlation coefficient value of 0.780 for the overall dimensions, it suggests that addressing spatial considerations with their various dimensions leads to satisfaction among beneficiaries. Therefore, focusing on spatial considerations in healthcare centers and integrating them into service provision and medical consultations can foster ongoing communication with beneficiaries. This approach helps address some of their health and treatment needs and preferences, such as chronic medication or obtaining necessary vaccinations, typically offered by government facilities. Thus, the first main hypothesis was verified. 

B- Testing the correlation between the spatial considerations' and customer satisfaction at the partial level

Table 2: Correlations between the dimensions of spatial considerations and customer satisfaction at the micro level

The results presented in Table 2 reveal a strong statistically significant correlation at a significance level of 0.05 between the spatial considerations and customer satisfaction, registering a value of 0.895. This underlines that the location of healthcare centers to where beneficiaries access health and treatment services can enhance satisfaction by meeting their healthcare requirements. Moreover, a strong correlation exists between service quality and customer satisfaction, with a partial correlation coefficient of 0.810. This signifies that the quality of healthcare services rendered by healthcare centers positively impacts the ongoing relationship with beneficiaries by addressing their health and treatment needs, ultimately achieving satisfaction.

Additionally, the partial correlation coefficient of 0.470 indicates a weak relationship and significance between competing private healthcare centers and government facilities concerning beneficiary satisfaction. This suggests that heightened market competition in the healthcare sector might impede the success potential of government healthcare centers in delivering services effectively and consistently. Furthermore, the lack of government support for the health sector could lessen competition from private healthcare centers, particularly in Mosul. This competitive environment offers beneficiaries more alternatives for healthcare and treatment services, highlighting notable differences in services and pricing compared to government healthcare centers, which are the primary focus of the current study.

Lastly, there is a feeble correlation between the current status of government healthcare centers and beneficiary satisfaction with the healthcare and treatment services provided. This was evidenced by weak correlation coefficients, measuring at 0.410. This indicates a tenuous link between the present state of healthcare centers and beneficiary satisfaction with the healthcare and treatment services delivered. This underscores insufficient supervision and oversight of activities within healthcare centers, along with the absence of various health services within these facilities. Consequently, patients and beneficiaries may opt to seek care from competing private healthcare facilities. Thus, the first hypothesis is proved. 

7.2.2 Testing the effect of spatial considerations on customer satisfaction 

Table 3: The effect of spatial considerations on customer satisfaction

Table 3 illustrates a significant causal correlation between spatial considerations and achieving customer satisfaction (beneficiaries of healthcare services). To determine the impact between the main research variables, the results of the statistical analysis revealed that the four dimensions of spatial considerations, as independent variables, collectively influence customer satisfaction as a dependent variable. This is indicated by the calculated value of (F) which is 149.2, significantly higher than the tabulated value of 4.001 at degrees of freedom (1, 114). The determination coefficient value (R²) of 0.740 indicates that 74% of the variance in customer satisfaction is explained by the four dimensions of spatial considerations (location, service quality provided, competitors, and the status of the current health center).

By examining the coefficient values (B) and conducting the (t) test, it was found that the calculated (t) value was 10.815* at degrees of freedom (1, 114) and a significance level of 0.05. This value is statistically significant as it exceeds the tabulated value of 1.68. Thus, the second hypothesis is verified and accepted, which states (There is a statistically significant impact of the location of the health center on beneficiary satisfaction).

8.1 Conclusions

1. Government healthcare centers in Mosul have experienced a continuous decline in service quality due to recent emergency situations. Despite their widespread coverage, the utilization of their services has become limited.

2. In government healthcare centers, there is a noticeable lack of essential services required by patients, including basic services like tests and radiology, reducing their significance to patients.

3. The demand for specific medications, particularly those for chronic conditions, along with occasional wait times, underscores the importance of continued engagement with these centers.

4. While the location of healthcare centers remains important, its significance has diminished compared to the scarcity of services provided. Other factors such as vaccinations and obtaining essential government certificates have become more critical.

5. The absence of health insurance is a primary reason for individuals continuing to rely on government healthcare centers, especially those with low incomes who face challenges accessing services from private medical facilities.

6. Private healthcare centers have emerged as key providers, surpassing government services by offering affordable prices, precise scheduling, and specialized care.

8.2 Recommendations

1. Despite the challenges encountered by government healthcare centers, it is vital to improve operational structures and broaden the range of services provided at the clinics.

2. Simply having a well-staffed medical team is insufficient; it is crucial to furnish the centers with the necessary medical equipment and resources to carry out essential tests and services effectively.

3. The significance of health insurance becomes apparent at this stage. It should be established with equitable standards considering the current market prices for medications and medical services, recognizing the clear inability of patients to afford them.

4. It is advisable to streamline operations at government healthcare centers and extend working hours to cover full-day shifts.

5. Utilizing available electronic concepts and tools to organize and implement a comprehensive medical information system can result in mutual benefits for both patients and the clinics.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Al-Furqan University-Mosul.

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