1 Introduction

Nowadays, the COVID-19 pandemic has caused significant changes globally, some of the most notorious in economics and health (Garrett & McNolty, 2020). While commercial firms adapt to the market, hospitals must adjust to the COVID-19 infection waves and changes in WHO recommendations (Rosenbaum, 2020). Specifically, regarding hospitals, Latin America has been one of the regions most affected by the pandemic due to its lack of infrastructure, medical equipment, resources, and trained personnel (Hummel et al., 2021). The general population’s high demand for medical care and the medical leaves of health staff generated much pressure on hospitals. Hence, Latin American societies faced difficult situations resulting from the COVID-19 pandemic.

In Bolivia, the effects of the COVID-19 pandemic worsened due to economic informality, inequality, and health disparities. Deaths in the poorest departments were more than seven times higher in July 2020 than in July 2019. Compared to the same period in 2019, the peak of fatalities in the wealthiest departments was only two times higher (Hummel et al., 2021), because more than 70% of the working population lacks employment contracts or employer-based social security, and tight control of health measures is challenging (Baker et al., 2020). Government agencies and municipalities imposed mask and glove mandates, but low-wage employees were expected to obtain and pay for their own personal protective equipment (PPE) and testing. Hence, in Bolivia, numerous firms experienced widespread infections among their staff. For example, many Bolivian hospitals shut down their operations due to the high number of infections among patients and staff (France24, 2021). Consequently, the preventive measures taken by the Bolivian government to stop the spread of the SARS-CoV-2 resulted in a deepening of poverty, which manifested in precariousness or lack of access to resources (monetary and non-monetary), job opportunities, education, and health care (CEDLA, 2021).

In Bolivia, precarious work and the COVID-19 pandemic impacted many people due to job insecurity, low pay, and lack of contributing social safety coverage. The precariousness of working conditions has had a significant influence on low-income workers. According to CEDLA (2021), nine out of ten people in extremely precarious jobs are poor, and three out of ten have seen their status worsen throughout the COVID-19 pandemic. Thus, private and public firms, especially hospitals, must show how they live the social purposes and values that guide and represent them. Because it is at times like the one we are currently going through, they can demonstrate with facts that social responsibility is not just a discourse but that their commitment is real. Available literature suggests that in other countries, the COVID-19 pandemic forced hospitals to adopt new practices, such as Corporate Social Responsibility (CSR) practices, by adopting new measures to improve their response (Manuel & Herron, 2020). Hence, based on the previous arguments, our study examines the perceptions of CSR practices implemented by Bolivian hospitals during the COVID-19 pandemic from the point of view of three stakeholders: hospital management, hospital staff, and patients. In particular, we surveyed 5 hospital managers, 66 hospital staff, and 230 patients from Bolivian hospitals. Our findings imply that Bolivian CSR practices are primarily philanthropic and related to financing or assistance plans for low-income patients and offering different COVID-19 screening tests at an affordable price or even free of charge. Moreover, our results show that hospital staff are satisfied with their jobs. However, patients are somewhat satisfied with the quality of hospital services. In the next section, we present the background and related literature followed by methodology, results, conclusion, and discussion.

2 Background and Related Literature

2.1 COVID-19 and Corporate Social Responsibility

At the end of 2019, scientists found a new virus known as SARS-CoV-2, which can cause COVID-19 disease (WHO, 2021). The COVID-19 pandemic brought challenges to human functioning, including the global economy and health systems (Chakraborty & Maity, 2020). This pandemic has infected over 498 million individuals as of April 18, 2022 (Statista, 2022), with over 6 million people dying from the infectious disease (Statista, 2022), making it one of the century’s worst pandemics (Chakraborty & Maity, 2020; Su et al., 2021). Due to this fact, the world has changed dramatically and forced people to adapt to new lifestyles. Likewise, it has forced organizations to adapt to new realities or face losing their markets.

As history constantly shows, difficulties also create opportunities. Hence, firms saw the COVID-19 pandemic as an opportunity to improve their CSR practices by making their organizations more genuine and oriented toward contributing solutions to pressing issues (He & Harris, 2020; Manuel & Herron, 2020). For example, Vodafone implemented free access to unlimited mobile data for vulnerable UK customers during the COVID-19 quarantine (BBC, 2020a). These genuine and authentic CSR practices show firms’ commitment to society’s welfare.

Unfortunately, the difficult economic conditions brought by the COVID-19 pandemic caused some firms to abandon ethical practices and try to take advantage of their customers or employees (He & Harris, 2020). Compared to the United States and Europe, in Latin America, stakeholders do not trust the transparency and reliability of firms. This mistrust in firms has increased because some firms were detected doing business irregularly. Moreover, public officials were not complying with their own restraint rules (Balog-Way & McComas, 2020; Estabrooks et al., 2020; Bargain & Aminjonov, 2020). Furthermore, Sharma and Yogi (2020) point out that the COVID-19 pandemic exposed governments and private firms to prioritize their self-interests while neglecting their employees, suppliers, and other stakeholders. For example, in Bolivia, public officials and some private firms did illegal deals by selling overpriced health-care equipment, PCR tests, and biosafety materials (BBC, 2020b). Hence, this contributes to the decreasing credibility of governments and private firms in developing countries, such as Bolivia.

Despite these issues, Latin American firms continue to prioritize environmental and philanthropic CSR practices (Diaz & Sánchez, 2021). Particularly, Coffie and Hinson (2021) point out that even before the COVID-19 pandemic, charitable practices were one of the most widely used CSR practices in developing countries, second only to environmental practices. Loureiro et al. (2012) and Zeler and Capriotti (2019) suggest that this is due to the common practice among firms from developing countries of not sharing adequate CSR information with their consumers and the wider public. As a result, in developing countries, CSR practices have become a marketing tool to share the firm’s philanthropic and environmental practices with the public (De los Salmones & Del Bosque, 2005) to increase its market share instead of being socially responsible.

2.2 CSR Practices in Bolivia

Regarding Bolivia, we found that CSR literature is quite limited. Available research suggests that most CSR practices are focused on protecting the environment (Cameron, 2011; Herbas-Torrico et al., 2018, 2021). Mainly, Cameron (2011) indicates that the mining industry is the industry that most heavily uses CSR practices in Bolivia due to its economic importance and its environmental impact. For example, their CSR practices are related to industry compliance with soil studies in drilling regions and reporting monthly emission measurements.

Nowadays, environmental CSR practices positively influence stakeholders, thanks to the new generation of managers educated on the latest eco-friendly trend. According to Herbas-Torrico et al. (2021), the CSR practices that Bolivians approve of the most are those related to the environment and community support. For example, the Bolivian firm CBN implemented efficient water resources management. Banco Bisa implemented fund-raising campaigns for education centers for people with disabilities following this trend. In addition, given the impact of this trend today, the Bolivian government has implemented guidelines to promote the implementation of CSR practices. Among some of these guidelines, we can mention that the CSR implementation guideline launched by the Ministry of Economy in 2019 provides systematic guidelines and evaluation lists for CSR practices (Ministerio de Desarrollo Productivo y Economía Plural, 2021).

There are also private firms that encourage sustainability and promote CSR monitoring and success stories. For example, the Observatory of Corporate Social Responsibility of the Federation of Private Entities regularly evaluates the sustainability reports of the federation’s member firms. Similarly, the Bolivian Institute of Foreign Trade (IBCE) regularly gathers and publishes examples of successful CSR practices to encourage good initiatives. For example, the IBCE (2019) showed a successful case from Embol, a subsidiary of Coca-Cola Company in Bolivia, indicating that the firm has implemented CSR practices for water reclamation, women empowerment, and glass and plastic bottle recycling. Similarly, the IBCE (2019) reported that UNAGRO, a company dedicated to producing ethanol and its derivatives, had certified most of its processes as green due to the use of solar panels and methods of water reclamation.

Finally, similar to other developing countries, the COVID-19 pandemic revealed that Bolivia’s economic context was too complex. Specifically, Bolivia is the poorest country in the Americas (Pagina Siete, 2021a; La Republica, 2019); hence during the pandemic, unemployment has risen to 70%, economic informality was at an all-time high, and people were working in precarious conditions (e.g., without contracts, health insurance, social safety nets) (Hummel et al., 2021). These findings suggest that the government efforts to mitigate COVID-19 pandemic consequences have been ineffective. Specifically, unemployment has increased by 1.4% between January 2020 and January 2021, closing the year with a rate of 8.4% (Pagina Siete, 2021b), inflation increased by 2.95% in comparison to 2020 (Statista, 2021), and a staggering 14.9% of firms have filed for bankruptcy between January 2020 and January 2021 (Fundempresa, 2021). Due to these dire economic conditions, CSR practices have become less important in a firm’s operations and fight for survival. However, some private firms have flourished during the pandemic and kept working on implementing CSR practices. Consequently, private-sector donations became the most significant contributor to hospitals, improving health services for low-income patients (CBN, 2021). Hence, this example suggests that philanthropic and charitable activities are among the most common CSR practices, even during the COVID-19 pandemic.

2.3 CSR and Hospitals

Due to the COVID-19 pandemic, social and economic structures have been tested worldwide. Consequently, society demands more from firms, such as hospitals. Before the pandemic, stakeholders expected firms to take more social responsibility because they had experienced an unprecedented economic expansion due to globalization (Puaschunder, 2018). Now, this health crisis has brought a diversity of new expectations. Hence hospitals should identify, assess, and prioritize stakeholder demands to build a realistic and pragmatic corporate responsibility in this new period (Duan et al., 2020). COVID-19 social, health, and environmental concerns imply that the health-care industry, especially hospitals, has been given additional and varied responsibilities. Specifically, the number of stakeholders’ responsibilities to consider in hospitals has increased and now includes more than simply patients: physicians, administrative employees, nurses, managers, and service and supplier providers are just a few examples.

Complications in organizing stakeholders’ care and the optimal use of resources to meet their needs give many improvement opportunities. Therefore, the relationship between CSR and hospitals has evolved in the context of health-care delivery as a new paradigm for improving their shortcomings (Brown, 2000). Moreover, in a health-care context, CSR means that there is also an ethical responsibility that requires hospitals and other organizations to do something beneficial for the quality of their health-care service (Gharaee et al., 2013). Duan et al. (2020) suggest that CSR becomes a tool to facilitate the relationship between stakeholders and defend the patient’s rights against possible abuses by the hospital staff. Moreover, it protects hospital staff from inappropriate orders or mistreatment at work and protects the organization from immoral profit-oriented managers.

Furthermore, the COVID-19 pandemic has highlighted the existing hospital problems even more. According to Creixans-Tenas et al. (2020), ambiguous social mission policies impeded patient treatment. Moreover, Garrett and McNolty (2020) indicate that hospitals have functioned unorganized due to continual changes in WHO COVID-19 safety guidelines, lack of control over infections, and medical leaves. As a result, Virani et al. (2020) indicate that hospitals’ CSR practices must focus on patient care: for example, allow separate rooms for COVID-19 patients to be cared for and receive better treatments. Other consequences of the COVID-19 pandemic were anxiety and depression problems experienced by people when hospitals experienced high demand due to COVID-19 infections (Xie et al., 2021; Alsharif, 2020). To avoid these problems, hospitals experimented with different possible solutions, such as offering rest rounds to the medical and administrative staff so that, in addition to resting, they had medical check-ups due to their high virus exposure (Virani et al., 2020; Garrett & McNolty, 2020).

Because of their limited health-care capacity, inadequate emergency response, and deficient hospital infrastructure, Latin American nations have been worst impacted by the COVID-19 pandemic (Hummel et al., 2021). Many individuals could not visit a hospital due to lack of income, poverty, and informal employment (Callejas et al., 2020; Martinez, 2021). As a result, many individuals used untested alternative medicine or just ignored their symptomatology, resulting in severe sickness (Callejas et al., 2020). Despite the COVID-19 pandemic, Latin American firms copied CSR practices from industrialized nations (Sharma & Swati, 2020). For example, in countries such as Perú and Brazil, firms moved big factories from urban zones to places far from cities to improve air quality and environmental conditions for neighboring areas (Sharma & Swati, 2020). Furthermore, they were attempting to enhance their methods in support of the local community to improve community members’ lifestyles (Agrawal & Sharma, 2022). Some of the CSR practices used by Latin American firms included the use of positive messaging to promote prevention behaviors such as “stay at home” or “get vaccinated” (Argote et al., 2021) and the donation of equipment, medical supplies, and other supplies for hospitals (Unicef, 2020).

In Bolivia, the COVID-19 pandemic has overwhelmed clinics, hospitals, and care centers in cities, causing the death of many infected individuals who required medical care. Moreover, entire families became infected, lost family members, and were left with significant debts. Consequently, local cemeteries and crematoriums in cities could not satisfy demand, and local governments around Bolivia had to build mass graves and buy additional incinerators for low-income individuals (Fundación Connectas, 2020; El Pais, 2020; New York Times, 2020). Moreover, private cemeteries and funeral service firms experienced the loss of their personnel due to COVID-19 infections (El Pais, 2020). In the Bolivian countryside, individuals lacked access to medical care and thus mainly used untested traditional medicine promoted by the government. Hence, death statistics in the Bolivian rural area are practically unknown. Moreover, exacerbating infections, the Bolivian senate authorized the production, distribution, and use of a potentially toxic chemical known as chlorine dioxide (a bleach derivative) as a COVID-19 treatment (Saavedra et al., 2021). Overall, the COVID-19 pandemic highlighted the improvised response of the Bolivian government, which increased poverty by reducing household income, widening the gap in access to information and communication technologies, interrupting school attendance, increasing unemployment and forced inactivity, increasing job insecurity, increasing unpaid work at home, and decreasing access to health care (CEDLA, 2021).

Another negative impact of the pandemic in Bolivia was a lack of staff, infrastructure, and health supplies needed to care for patients in hospitals (Mahmud et al., 2021; Singh & Misra, 2021; Yulita & Hidajat, 2020; Calla et al., 2020). This situation showed that the Bolivian health-care system’s painful condition had been historically neglected (WHO, 2021; France 24, 2020). Since the beginning of the COVID-19 pandemic, the actual death toll is still unknown to this day. However, a recently published study by Uzin (2022) (not peer-reviewed) estimates that the death toll in Bolivia due to COVID-19 infections might be three times (64,542 deaths) higher than the official records of the Ministry of Health. Therefore, the available information in Bolivia indicates that the COVID-19 pandemic overwhelmed the health-care system, causing significant uncounted deaths.

2.4 Stakeholder Theory and Hospitals

The stakeholder perspective provides a practical method for understanding how firms might flourish in today’s and tomorrow’s uncertain environments (Austen, 2012). The stakeholder theory emerged in the private sector due to a desire to comprehend the firms and their surroundings (Mitchell et al., 1997). In addition, stakeholder theory can be considered as the management and ethical theory that focuses on more than just increasing shareholder value (Phillips, 2003). Stakeholder theory is the most comprehensive and widely used theory for CSR practices (Frynas & Yamahaki, 2016). According to Freeman (1994), stakeholder theory relates to the study of stakeholders and how they can be affected by a firm’s activities. Specifically, stakeholder theory suggests that firms are interested in how their customers react to their behavior and how this contributes to their financial performance (Berman et al., 1999). Some studies have shown results where practices such as volunteering in the local community or environmental protection have positively influenced consumer behavior (Handelman & Arnold, 1999; Bhattacharya & Sen, 2004; Maignan et al., 1999). Similarly, customers’ ethical expectations about a firm’s CSR practices influence managerial attitudes (Mandhachitara & Poolthong, 2011). Therefore, the literature suggests that stakeholder theory relates consumers, stakeholders, and their relationship with a firm’s governance (Berman et al., 1999).

Regarding hospitals and CSR practices, Ramachandran (2019) suggests that the market mechanism that comprises buyers, sellers, and other stakeholders was developed at the beginning of the modern health-care system. Many beneficial aspects of the free market, such as the power of invention, innovation, and entrepreneurship, are overlooked by a restricted view of markets centered exclusively on costs and profits. Hence, health-care firms such as hospitals must become more flexible, adaptive, and educated to fulfill demands to reduce costs and mistakes while increasing efficiency and quality of the market they offer their health-care services. Notably, for hospitals, stakeholders are the people or firms directly or indirectly affected by their operations (Ramachandran, 2019). Patients (clients), hospital staff, creditors, investors, insurance companies, and the government are among their stockholders. The stockholders may interact with health professionals regularly or irregularly, impacted by changes in health-care systems, policies, and practices. Patients are the ultimate users of a hospital services, and their opinions are essential. Notably, patients care about clinical excellence, but service quality and low prices are important too. On the other hand, high clinical quality (typically articulated in terms of innovative and technologically sophisticated services and facilities) and appropriate support services are the primary demands of hospital staff. Cost minimization, profitability, consistent income, a continuous cash flow stream, and effective utilization of all available resources are the most appealing to hospital management.

When dealing with stakeholders, hospitals are a unique example compared to other commercial firms since they have to deal with more complex issues. They operate in a highly complex environment, as they do not function in a completely free market and must contend with numerous government laws. Hospitals can be considered multidimensional firms with few vocal and influential players pursuing various objectives. Balancing the many stakeholder interests is difficult for hospital governance. Therefore, the available literature suggests the suitability of stakeholder theory to study CSR practices in hospitals in Bolivia. In particular, our study will describe CSR practices related to three stakeholders from Bolivian hospitals: hospital management, hospital staff, and patients.

3 Methodology

To examine whether Bolivian hospitals have implemented CSR practices into their operations during the COVID-19 pandemic, according to Rohini and Mahadevappa (2010) and Hung (2011), we developed three measurement instruments for hospital management, hospital staff, and patients. First, we created an interview guide with five sections to learn about CSR practices in hospitals from hospital managers. The interview guide included the manager’s basic information, prior knowledge of CSR practices, stakeholder degree of importance, COVID-19 pandemic management, staff safety measures, patient and suppliers safety measures, and health-care CSR practices. Due to a nationwide lockdown, we conducted telephone and online interviews to collect data from November 2021 to March 2022. Second, we developed an online survey for hospital staff (attending physicians, fellows, nursing staff, residents, and interns). The survey included sections related to sociodemographic questions, perception of CSR practices (socioeconomic responsibility, labor responsibility, and ethical responsibility), health-care quality, and job satisfaction. Next, we collected data from December 2021 to February 2022 from hospital staff in Bolivia. Finally, we developed a new online survey for patients and collected data from November 2021 to February 2022. The survey included sociodemographic questions, knowledge about CSR practices, COVID-19-related questions, perception of CSR practices (socioeconomic responsibility, labor responsibility, and ethical responsibility), health-care quality, and health-care satisfaction.

4 Results

In the following sections, we will present the results of our analyses for hospital management, hospital staff, and patients.

4.1 Hospital Management Results

The hospital management of health-care firms is one of the most critical stakeholders in CSR. Hospital managers are important actors since they cultivate connections with other stakeholders (Elkington, 1998). Moreover, according to Russo (2016), management at hospital facilities focuses on enhancing parts of the service that improve relationships with other stakeholders. Based on the implementation of our interview guide, we found the following results.

We interviewed five hospital managers, of which four belong to the private sector and one from the public sector. Moreover, all were attending physicians (80% men and 20% female), with an average age of 39 years. According to our results, 80% knew or had previously heard about CSR practices. Mainly, CSR practices are related to the commitments, actions, measures, and responsibilities that a hospital assumes toward society for these hospital managers.

Next, hospital managers indicated that patients are the most critical stakeholders of hospitals (100% of managers), followed by society (60% of managers), the environment (60% of managers), the community (60% of managers), suppliers (100% of managers), shareholders (100% of managers), and hospital staff (100% of managers). Moreover, hospital managers specified that during the COVID-19 pandemic, they took the following steps to protect their staff: providing personal protective equipment, regularly diagnosing symptomatology, and establishing new health-care protocols (e.g., office disinfection between consultations, telemedicine, and isolation wards). Next, hospital managers indicated that the practices implemented to protect their patients and suppliers were related to maintaining recommended COVID-19-preventing methods such as measuring patient’s temperature upon arrival to the hospital, controlling the use of face masks and alcohol-based hand rubs, using checklists with inquiries about COVID-19 and possible exposure to the virus for triage, and maintaining social distancing. In addition, the public hospital manager commented that they worked to increase the number of patients that they serve every day.

Additionally, hospital managers indicated that the main actions taken to face the COVID-19 pandemic were enforcing the compliance of health-care protocols, implementing the use of nasal swab rapid antigen tests and PCR tests before delicate health-care treatments (e.g., surgeries, significant interventions), and sorting and caring COVID-19-infected patients in isolation wards according to the disease progression and their degree of infection. Next, all hospital managers agreed that these practices helped reduce infections among their staff and improve their patient care. Furthermore, according to 80% of hospital managers, the three CSR practices most commonly used in their hospitals were: (1) receiving donations of medicines, drugs, medical supplies, and medical tests for patients; (2) receiving gifts from private and public firms to improve their services, equipment, and patient care capacity; and (3) promoting volunteer campaigns in rural areas (e.g., primary medical care, COVID-19 vaccines supply). Next, 60% of the managers pointed out that other CSR practices in their hospitals included: (a) donating medicines, drugs, medical supplies, and medical tests for people in rural, remote, and low-income areas; (b) implementing campaigns for collecting money, materials, supplies, medicines, equipment, and other practices to help low-income patients; (c) increasing new spaces for intensive care therapy, intermediate care, and other CSR practices to ensure health care for all patients; (d) using hospital’s owned means of transportation for the movement of medicines, supplies, and patients with other branches and other hospitals to support emergencies and critical situations; and (e) implementing counseling, financing, and subsidy programs for low-income patients.

In conclusion, hospital managers in Bolivia associate CSR with the hospital’s commitment to the society in which it operates, emphasizing economic and charitable endeavors. This finding is comparable to the study by Ibrahim et al. (2000), who found that board members in commercial firms are more concerned about financial performance and the legal aspect of Corporate Social Responsibility. Likewise, our results suggest that the efforts taken in response to the COVID-19 pandemic are similar to commercial firms and connected to the actions taken for caring physicians, providers, and patients recommended by the WHO protocols. Hence, as Herbas-Torrico et al. (2021) suggested, our analysis indicates that CSR practices in Bolivian hospitals are mainly related to philanthropy and charitable activities from the perspective of the hospital manager.

4.2 Hospital Staff Results

Staff is crucial to a firm’s success because they provide services or goods that match client expectations and foster customer loyalty (Rangan et al., 2012). As a result, understanding their perception of CSR practices is crucial for following the firm’s desired image to consumers. Next, based on these principles, we show the results we obtained from our survey to hospital staff from different hospitals in Bolivia. We received 66 survey responses from hospital staff (37.9% male, 62.1% female), with an average age of 30 years. Moreover, the majority of respondents were from private hospitals (66.7%), mainly attending physicians (48.5%) and interns (28.8%), and about half of them indicated they knew about CSR practices (48.5%).

Our results showed that hospital staff experienced job satisfaction in their jobs (72.7/100). This result suggests that hospital staff experience a positive impact on situational job factors, such as nature of the job, resources, and hospital environment (Celik, 2011). Moreover, according to Christen et al. (2006), this result also suggests that Bolivian hospital staff believed that, during the COVID-19 pandemic, their job performance and effort were high, and thus they felt satisfied with it. We also found that respondents think their hospitals offered high-quality health-care services (72.6/100). According to hospital staff, this result indicates that the health-care quality of their hospitals is related to the effectiveness of care, patient safety, and patient experience.

Regarding CSR practices, we found that hospital staff believe that current CSR practices in Bolivian hospitals are mostly related to patient privacy (77%), patient rights (74%), health-care improvement (73%), and labor responsibility (52%). However, we also found that hospital staff believe that current hospital CSR practices are not related to socioeconomic (42%) and ethical responsibility (39%). Moreover, we also found that CSR practices best perceived by hospital staff are complying with labor regulations (e.g., work schedules, salaries) (54%), providing facilities for training (58%), availability of in-house training to improve their skills (56%), and recording and resolving complaints from internal and external clients (34%).

Lastly, regarding support practices during the COVID-19 pandemic, hospital staff indicated that the hospital provided them with personal protective equipment (PPE) (67%), patient management and training about the correct use of PPE (62%), and design of adequate procedures for triage (66%). However, hospital staff disagreed that the hospital provided proper infrastructure for patient reception, assessment, and isolation (63%).

As a result, according to hospital staff, these results indicate that current CSR practices in Bolivian hospitals are mostly related to fulfilling existing legislation rather than having a social orientation. Moreover, we found that hospital staff mainly value CSR practices associated with fulfilling labor legislation, staff training, and conflict solutions. These results also indicate that during the COVID-19 pandemic, hospital CSR practices were mainly related to triage training and PPE supply and use. Finally, hospital staff demonstrate that hospitals lack the adequate infrastructure to care for COVID-19-infected patients.

4.3 Hospital Patients Results

Patients are an essential element of CSR practices since they are the ones who give a hospital a purpose to exist. They are also the ones who assess and analyze CSR practices and, as a result, give the hospital its reputation (Rettab et al., 2009; Asatryan & Asamoah, 2014). According to Stanaland et al. (2011), patients benefit from good CSR practices since they build a good hospital reputation that favorably influences trust, perceived quality, and patient happiness. As a result, this critical stakeholder determines the efficacy of management CSR practices and their impact on society. In the following paragraphs, we provide the findings of the last survey of our study.

A total of 358 patients were surveyed, and 230 valid responses were received. Male patients made up 40.9% of these surveys, while female patients made up 59.1%. Notably, 67% of the respondents indicated that they had heard about CSR practices or were familiar with them. In addition, 67% of respondents stated that they had COVID-19, and among the infected, 53.5% did not seek medical help in hospitals, 55.7% went to a private hospital, 22.6% visited primary care, and 33.7% went to a tertiary referral hospital. Mainly to explain these last results, we should consider the Bolivian context, where public health care has a bad reputation, and thus patients from higher income echelons instead seek medical care in the private sector (Hummel et al., 2021).

Our results showed that patients believe Bolivian hospitals have acceptable levels of service quality (67.1/100). Moreover, patients indicated they were somewhat satisfied with the hospital service during the COVID-19 pandemic (65.6/100). Overall, both results suggest that around two in every three patients were almost happy with the hospital services; however, one in every three patients was not. Hence, this last result indicates that the quality of Bolivian hospitals is not good enough for all Bolivian patients (Brown & Dacin, 1997). Consequently, Bolivian hospitals should consider improving their service quality, understanding that satisfied patients are an added advantage for the community) and enhance the hospital’s reputation.

Additionally, our results suggest that CSR practices positively influence patients’ perceived value of the hospital service. Servera and Piqueras (2019) found similar results for other contexts, suggesting that CSR practices, policies, and initiatives improve the perceived value of a service, mainly when they are oriented toward the organization’s core business. Notably, as Manuel and Herron (2020) suggest, as a result of the pandemic, firms in general, and hospitals in particular, have decided to increase their philanthropic actions, resulting in increased perceived value among patients. Consequently, as predicted by the theory and supported by our findings, hospital managers in Bolivia increased the use of philanthropic and charitable CSR practices, positively affecting patients’ perceived value of the hospital services.

Overall, these last results complement our previous findings, suggesting that philanthropic and charitable CSR practices in Bolivia were perceived positively by patients and favorably increased the quality and value of their services. Moreover, most patients believe that the quality of hospital health care is acceptable and are thus somewhat satisfied.

5 Conclusions and Discussion

According to the findings reported in the previous sections, CSR practices in Bolivian hospitals consist primarily of philanthropic and charitable activities. This result is not surprising because similar results were proposed by Herbas-Torrico et al. (2021) for commercial firms, indicating that private and public firms use philanthropy as their primary type of CSR practice in Bolivia. Hence, this result has two implications. First, service industry sectors, such as the health-care industry, similar to other sectors, considered philanthropic and charitable activities as their primary CSR practices during the COVID-19 pandemic. On the other hand, this result also suggests that in Bolivia in general, and the health-care industry in particular, CSR practices are still lagging from developed countries in becoming sustainable practices to improve Bolivian people’s lives.

According to the findings of the three stakeholders studied, Bolivia’s primary CSR practices focus on financial aid for low-income patients and offering different COVID-19 screening tests at low costs. Moreover, for hospital managers, patients are the most important stakeholders. Moreover, despite hospital staff job satisfaction, patients believe that hospital service quality is acceptable and not excellent, and hence they are somewhat satisfied with it. Hospital staff responses back up this result because they think hospitals lack the adequate infrastructure to care for COVID-19 patients. These results entail putting all of the focus on the patients to help them during difficult times (He & Harris, 2020), such as the COVID-19 pandemic. Following Takahashi et al. (2013), we recommend that Bolivian hospitals implement innovative programs integral to their primary health-care function to reap patient CSR benefits and improve their infrastructure. Similarly, following Kakabadse and Rozuel (2006) recommendations, we suggest that hospitals in Bolivia promote greater hospital staff involvement and interaction to improve stakeholder relationships. For example, Bolivian hospitals can take CSR practices in Bangladesh as an illustration. Specifically, health-care institutions in Bangladesh provide CSR services by delivering medicines, primary nursing care, food distribution, and ambulance services with essential medical support (Werner, 2009). These CSR practices increased patient satisfaction and loyalty through genuine CSR initiatives (Hossain et al., 2019).

As our results shown above, as long as Bolivian patients believe that the CSR practices mentioned above are mostly related to reaping economic benefits instead of improving health-care quality, health-care capacity, and fulfilling the hospital’s social orientation, they will not be sustainable in the long run, nor will they improve hospital’s reputation in Bolivian society. Unlike Bolivian hospitals, other Latin American hospitals have not embraced CSR practices from a philanthropic or charitable perspective. Instead, they used CSR practices to fulfill their social duty and improve the lives of communities where they offer their health-care services. For example, in Colombia, the Hospital Universitario San José, among its CSR practices, set up houses to accommodate patients arriving from distant communities while they complete their treatments and consultations (Hospital San Jorge, 2021). Another example is the British Hospital of Buenos Aires (Argentina), with the AMTENA program, which sends a group of doctors to neighboring areas to provide free clinical and surgical health care (Hospital Británico de Buenos Aires, 2022). Hence, Bolivian hospitals can learn from these examples and create new sustainable CSR practices evolving beyond their current philanthropic and charitable practices.

In conclusion, hospitals in Bolivia should evolve their CSR practices from philanthropy and charitable practices to sustainable CSR practices to fulfill their social purpose. They should also implement new CSR practices that increase the quality and value of their health-care services. Likewise, Bolivian hospitals should keep improving the working conditions of their staff without disregarding legislation and implementing voluntary and sustainable CSR practices. Finally, Bolivian hospitals should seek more significant interaction among hospital managers, staff, and patients to adequately coordinate CSR practices to face future pandemics. As the COVID-19 pandemic changes Bolivian society, hospitals must reaffirm their commitment to CSR practices: “We can only accomplish so much when working together.”