Now a team of researchers from the Swiss Tropical and Public Health Institute and the University of Basel has conducted a scoping review to systematically examine how process mapping is being used in clinical healthcare settings in these resource-constrained nations. The review, published in Public Health Reviews, followed the Joanna Briggs Institute Manual for Evidence Synthesis and adhered to the PRISMA-ScR framework. The researchers searched four major databases: MEDLINE, Embase, Web of Science Core Collection, and CINAHL, targeting full-text empirical studies published between January 2014 and May 2024. They adapted the Cochrane Effective Practice and Organisation of Care filters for low- and middle-income countries to match the current World Bank list of low-income and lower-middle-income countries. After importing 2,621 articles into the Rayyan web application and removing duplicates, 1,570 articles remained for title and abstract screening. Full-text screening independently and blindly assessed the eligibility of 76 remaining studies, of which 26 papers ultimately fulfilled the inclusion criteria.

The 26 included studies exhibited considerable variation in their characteristics, and the geographic concentration was striking. Only 13 of 81 low-income and lower-middle-income countries were represented in the published literature, a mere 16 percent. India had the highest number of studies with six, followed by Malawi with five and Ghana with three. The majority of studies were conducted at the tertiary level, accounting for 62 percent of the total. Infectious disease and maternal and child health were the most common clinical focus areas, each represented in six studies. The number of publications on process mapping has increased over the past five years, with a peak of six studies published in 2023, suggesting growing recognition of the methodology’s value in these settings. This marked increase contrasts sharply with a 2021 systematic review that reported only five studies from low-income and lower-middle-income countries out of 105 included studies published up to 2019, indicating that the technique is gaining traction rapidly.

The researchers identified four overarching objectives for conducting process mapping in these clinical settings. The most common was process and quality improvement initiatives, found in nearly half of the studies, comprising twelve studies that aimed to improve processes within structured improvement frameworks. Of these, four applied the Plan-Do-Study-Act Cycle, one used Lean Management, one employed A3 Problem Solving, and one applied Failure Mode and Effects Analysis. Seven studies, accounting for 27 percent, primarily aimed to identify, understand, and map processes or procedures in a certain healthcare system under the category of health systems process analysis and assessment. Four studies used process mapping to support the design, implementation, and evaluation of health systems tools, including two that implemented digital tools. The smallest category, three studies, aimed to map costing using the widely recognized Time-Driven Activity-Based Costing approach, which provides a comprehensive estimation of patient-related costs encompassing personnel, logistical, and infrastructural expenses.

Three different types of processes were observed during process mapping activities. Patient flow in a specific clinical setting was observed in twelve studies, involving shadowing and mapping the different processes and steps of a patient’s flow to create a process map. The emergency room was the most common clinical setting for this type, appearing in six studies, followed by outpatient settings in four studies. A workflow in a clinical setting was observed in nine studies, aiming to map a workflow or standard procedure, including hospital payment processes, infection prevention workflows, perioperative standard care, and work processes in a home care delivery team. Most of these were conducted in inpatient settings, though two spanned both inpatient and outpatient areas. Five studies performed process mapping to analyze a patient journey through a health system in relation to a specific symptom or disease. One examined patients’ journeys with breast disease navigating through different hospitals in the Niger health system, while another mapped the process of care and cost-related factors for tuberculosis treatment in the Zimbabwean healthcare system. One focused on the emergency obstetric referral system in Ghana, and two studies observed the journey of individuals who sustained injuries in the Malawian health system.

The methodological analysis revealed important patterns in how process mapping was conducted. Observations were the most prevalent method, used in fifteen studies, followed by interviews in eight studies and workshops in six studies. Seventeen studies used a single method for collecting process mapping data, while six combined two methods. Three studies did not provide detailed information on how they gathered data for their process map. During observational data collection, researchers reported having gathered the data themselves in seven cases, while in five cases the data collectors interacted with local healthcare workers while collecting data through observations. All studies justified these informal interactions as a means of deepening understanding or clarifying unclear aspects of the observed workflow. In interviews, participants were local healthcare workers with expertise in their field and experience with the process under review. Notably, none of the included studies described the involvement of patient representatives during their data collection or at a later phase to generate the process map, a striking gap that the researchers highlight as a critical limitation.

The review also examined how the studies progressed through the phases recommended in Antonacci’s comprehensive process mapping framework, which comprises preparation, data and information gathering, process map generation, process map analysis, and taking it forward. Only 35 percent of studies reported on preparation activities in the local setting prior to initiating process mapping. Over half reported on generating a process map during or after data collection, but six of those failed to report any further detailed information. Analysis of the process maps was reported in 85 percent of studies, but only 35 percent described the analysis in detail, focusing on identifying bottlenecks, inefficiencies, and potential improvements. Six studies specifically sought validation of the final process map through feedback from local healthcare workers. Most strikingly, taking action and implementing changes were reported in only 27 percent of studies, all classified under process and quality improvement initiatives. Another 69 percent highlighted processes or system challenges that required improvement but did not report to what extent the proposed changes were actually implemented. Complete reporting of all variables was observed in only two studies, while sixteen had multiple variables missing and lacked significant data.

The findings on local involvement reveal a nuanced picture. Almost all studies involved local healthcare workers, yet researchers generally remained the leaders of the process mapping activities. Only 15 percent reported local healthcare worker leadership. While the involvement of local stakeholders is valuable, the researchers argue that local leadership of process mapping activities is crucial for fostering ownership and ensuring long-term sustainability of the outcomes. A notable example from a 2017 study in Ghana highlighted the potential of locally led process mapping. While researchers facilitated the activity, the overall project was locally led with continuous collaboration between researchers and local healthcare workers. Following the end of the study’s activity, local staff adopted process mapping to aid in the design of several new initiatives, demonstrating how local ownership can sustain process improvement methods beyond the research period. This case emphasizes the importance of collaboration and local ownership in ensuring that quality improvement methodologies take root and flourish in resource-constrained settings.

The researchers also identified potential sources of bias that may affect process mapping data collection in these settings. During observational data collection, the Hawthorne effect may occur, where observed participants alter their behavior due to being watched. Five included studies reported direct contact with workers involved in the observed process, which can offer valuable insights but should be weighed against the risk of altering participants’ behaviors. Social desirability bias may have affected data collected during meetings, particularly when participants from different hierarchical levels were involved. Although understanding diverse viewpoints from different organizational levels is vital for a comprehensive understanding of processes, the potential impact of such bias must be acknowledged and addressed, for example by separating participants into groups. The limited reporting of data collection methods and sampling during process mapping precluded a comprehensive assessment of potential biases affecting the respective process maps, underscoring the need for more transparent methodological reporting.

The review concludes that process mapping has demonstrated significant potential as a versatile and adaptable method for improving clinical processes in low-income and lower-middle-income countries. The researchers recommend that clinical and non-clinical stakeholders involved in improvement initiatives consider process mapping as a valuable tool well-suited to strengthening processes in diverse clinical healthcare settings. Future initiatives should consider all phases of the framework and triangulate multiple research methods where feasible to enhance validity. Process mapping led or co-led by healthcare providers is especially encouraged, both to promote ownership and support sustainable improvements. Efforts should include diverse stakeholders’ perspectives with prioritization of patient involvement, and greater attention must be paid to the final step of taking improvements forward to ensure that process mapping leads to tangible, contextually tailored changes in healthcare delivery. As the technique continues to spread across the global health landscape, its success will depend not just on the elegance of its visual maps but on whether the people who know these systems best are empowered to lead the change.

Subject of Research: Process mapping in clinical healthcare settings in low-income and lower-middle-income countries: a scoping review

Article Title: Process mapping in clinical healthcare settings in low-income and lower-middle-income countries: a scoping review

Article References: Boegli, J., Gross, K., Beynon, F., & Bohle, L. F. (2026). Process mapping in clinical healthcare settings in low-income and lower-middle-income countries: a scoping review. Public Health Reviews, 47, Article 1609105. https://doi.org/10.3389/phrs.2026.1609105

Image Credits: AI Generated

DOI: 10.3389/phrs.2026.1609105

Keywords: Process, mapping, clinical, healthcare, settings, low-income, lower-middle-income, countries, scoping, review, scientific research