Facility management adoption in low-resource public hospitals: A systematic review and context-driven model for enhancing operational performance

Abstract

Public hospitals in low-resource settings face continuous operational challenges that lead to poor-quality service delivery. Facility Management (FM) as a strategic discipline in well-developed countries enhances efficiency, safety, and sustainability. But in many Low- and Middle-Income Countries (LMICs), especially post-conflict countries such as Iraq, FM practices are fragmented, reactive, and no longer supported by an integrated administrative structure. Several pieces of evidence on FM decision-making and planning were examined to better understand the drivers, obstacles, and effects influencing FM operational performance during its adoption in public hospitals. A systematic search was conducted across Scopus, Web of Science, and PubMed from 2018 to 2025, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. The inclusion criteria used were considered in including thirty-three studies. The critical appraisal Skills Programme (CASP) and the Mixed Methods Appraisal Tool (MMAT) were used to determine the quality of the methodology, and NVivo was used to assess the thematic synthesis. The findings prove that adoption of FM depends on nine overall practices that are proactive maintenance, digital technologies, sustainability practices, safety management, organizational culture and readiness, government initiatives, data management, digital integration, and outcomes of operational performance. It is on these determinants that the current study has offered a context-based FM model that is particularly tailored to the institutional context of Iraq and other post-conflict environment. This model is a novel and workable mechanism of enabling system-level improvement in poor health FM system.