dc.description.abstract | Background: In Kenya, hospitals are registered by ownership, not by
function making it difficult to assess their performance. Governance theories,
agency, stewardship and resource dependency have been used to suggest
ideal governance structures for the health sector. Hospitals are critical in
providing maternal delivery services, yet how their ownership and governance
structures are associated with hospital performance measured by effectiveness
and equity has been theorized but not examined through a study.
Objective: The study sought to explore the relationship between
ownership, hospital governance and maternal delivery service outcomes
(MDS).
Methodology: A cross sectional, mixed methods study of six primary
referral hospitals, differentiated by ownership, was conducted from 10th June
to 9th October 2015. Six key informant interviews, 40 questionnaire interviews
were held with hospital in-charges, board members and management to
determine the governance structure and processes. Hospital and patient data
abstraction relating to maternal delivery services (MDS) was done to determine
hospital performance in two dimensions: Effectiveness was measured by
perinatal and maternal mortality; Equity was measured by the caesarean
section rate and payment for services. Qualitative data was analyzed
thematically. Tests of associations were used to correlate governance and
hospital performance.
Results: From the three ownership types, two governance types
labelled, public and corporate, were identified. Public governance hospitals had
large boards (>8 members), diverse membership with no fiduciary
responsibilities. Corporate governance hospitals had smaller boards (<8
members) with fiduciary responsibilities. Public governance hospitals were less
effective with perinatal mortality 2.5 times that of corporate hospitals (31 vs 12
per 1,000 births). Having at least 40% of board members registered with the
Medical Practioners & Dentist Board was associated with reduced perinatal
mortality (P<0.001,OR= 3.08 95%CI: 2.6879-3.5362). However, in terms of
equity the picture was mixed, a caesarean section was 1.45 times more likely
to occur in a corporate hospital (P<0.001 95% CI: 1.3729-1.5410); however,
they also charged an average of Kshs 30,818 per delivery (US$304), while
public governance hospitals were free.
Conclusions and Recommendations: Governance structure is
associated with hospital performance as measured by MDS outcomes of
perinatal mortality. This study provides a new perspective on measuring
hospital performance (perinatal mortality), in relation to organizational
governance. No single theory alone explains hospital governance, however
stewardship theory best describes the best performing hospitals. This study
provides a fresh approach to implementing governance theories and therefore
improving accountability of hospitals. | en_US |
dc.description.department | a
Department of Psychiatry, University of Nairobi, ; bDepartment of Mental Health, School of Medicine,
Moi University, Eldoret, Kenya | |