Governance as a Determinant of Service Delivery in Secondary Health Facilities: Regression Evidence from a Nigerian State Hospitals Management Board
Abstract:
Health system governance is increasingly recognized as a determinant of service delivery performance, yet quantitative regression evidence linking governance quality to service delivery within Nigerian State Hospitals Management Boards remains scarce. This study determined the effect of health system governance on service delivery in secondary health facilities under the Plateau State Hospitals Management Board (PSHMB). A cross-sectional analytical design, anchored in the Siddiqi governance assessment framework, was employed. Governance instruments were administered to PSHMB headquarters officials (n = 40) and to health workers across six secondary health facilities (n = 120). GOVERNANCE and SERVICE_DELIVERY composite indices derived from headquarters officials’ responses were analyzed using simple linear regression and analysis of variance. Governance was a strong, positive, and statistically significant predictor of service delivery, accounting for 71.2% of the variance in service delivery scores (R = .844, R² = .712, adjusted R² = .705, F(1, 38) = 94.004, p < .001). A one-unit increase in the governance composite score was associated with a 0.81-unit increase in service delivery scores (B = .810, β = .844, p < .001). Participation, strategic vision, and accountability were the most positively rated governance dimensions among both headquarters’ officials and facility-level health workers, while transparency and rule of law, particularly procurement practices, regulatory enforcement, and cost-effectiveness in resource allocation, emerged as the weakest. These findings confirm governance quality as a substantial determinant of service delivery performance and offer governing-board-level regression evidence to inform targeted governance reform in PSHMB and comparable Nigerian State Hospitals Management Boards.References:
[1]. Salarikheh E, Vahdat S,
Hesam S. Key factors influencing health system governance in Iran: a scoping
review. Evid Based Health Policy Manag Econ. 2025;9(2):130-8. Available from: https://jebhpme.ssu.ac.ir/article-1-533-fa.pdf
[2]. Kesale AM, Swai IL.
Management and governance of health facilities. In: Anasel MG, Kapologwe NA,
Kalolo A, editors. Leadership and Governance in Primary Healthcare: An Exemplar
for Practice in Resource Limited Settings. Boca Raton: CRC Press; 2023. p. 13-26.
doi: 10.1201/9781003346821-2
[3]. Siddiqi S, Masud TI,
Nishtar S, Peters DH, Sabri B, Bile KM, et al. Framework for assessing
governance of the health system in developing countries: gateway to good
governance. Health Policy. 2009;90(1):13-25. doi:
10.1016/j.healthpol.2008.08.005
[4]. Barbazza E, Tello JE. A
review of health governance: definitions, dimensions and tools to govern.
Health Policy. 2014;116(1):1-11. doi: 10.1016/j.healthpol.2014.01.007
[5]. World Health Organization.
The World Health Report 2000 - Health Systems: Improving Performance. Geneva:
WHO; 2000. Available from: https://www.who.int/publications/i/item/924156198X
[6]. Olafsdottir AE, Reidpath
DD, Pokhrel S, Allotey P. Health systems performance in sub-Saharan Africa:
governance, outcome and equity. BMC Public Health. 2011;11:237. doi:
10.1186/1471-2458-11-237
[7]. Makuta I, O'Hare B. Quality
of governance, public spending on health and health status in Sub-Saharan
Africa: a panel data regression analysis. BMC Public Health. 2015;15:932. doi:
10.1186/s12889-015-2287-z
[8]. George J, et al. Impact of
health system governance on healthcare quality in low-income and middle-income
countries: a scoping review. BMJ Open. 2023;13(11):e073669. Available from: https://bmjopen.bmj.com/content/13/12/e073669
[9]. Eboreime EA, Abimbola S,
Bozzani F, McKee M, Balabanova D. Evaluating the sub-national fidelity of
national initiatives in decentralized health systems: integrated primary health
care governance in Nigeria. BMC Health Serv Res. 2017;17:743.
[10]. Ajisegiri WS, Abimbola S,
Tesema AG, Odusanya OO, Ojji DB, et al. Aligning policymaking in decentralized
health systems: evaluation of strategies to prevent and control
non-communicable diseases in Nigeria. PLOS Glob Public Health.
2021;1(11):e0000050. doi: 10.1371/journal.pgph.0000050
[11]. Abimbola S, Olanipekun T,
Igbokwe U, Negin J, Jan S, Martiniuk A, et al. How decentralization influences
the retention of primary health care workers in rural Nigeria. Glob Health
Action. 2015;8:26616. doi: 10.3402/gha.v8.26616
[12]. Lewis TP, McConnell M,
Aryal A, Irimu G, Mehata S, Mrisho M, et al. Health service quality in 2929
facilities in six low-income and middle-income countries: a positive deviance
analysis. Lancet Glob Health. 2023;11(6):e862-70. doi: 10.1016/S2214-109X(23)00163-8
[13]. Davwar PP, Adelaiye PO,
Nathan N. Efficiency in health care delivery: a DEA analysis of hospitals at
the secondary health care level in Plateau State, Nigeria. J Phys Sci Innov.
2010. Available from: https://www.researchgate.net/publication/355198888
[14]. Plateau State Gazette.
Plateau State Hospitals Management Board Edict (Cap. 78). Jos: Plateau State
Government; 1989.
[15]. Sheikh K, Abimbola S.
Learning Health Systems: Pathways to Progress. Flagship report of the Alliance
for Health Policy and Systems Research. Geneva: World Health Organization;
2021. Available from: https://iris.who.int/server/api/core/bitstreams/fb94ab60-d3b2-45fe-b0a2-3dec77febfe9/content
[16]. Bigdeli M, Rouffy B, Lane
BD, Schmets G, Soucat A, The Bellagio Group. Health systems governance: the
missing links. BMJ Glob Health. 2020;5:e002533. doi: 10.1136/bmjgh-2020-002533
[17]. Brinkhoff T. Thomas
Brinkhoff's “City Population” database [Internet]. 2024. Available from: https://citypopulation.de/en/nigeria/admin/NGA032__plateau/
[18]. Plateau State Government.
Official website of Plateau State [Internet]. [cited 2026 Jul 23]. Available
from: https://www.plateaustate.gov.ng/
[19]. Mutale W, Bond V,
Mwanamwenge MT, Mlewa S, Balabanova D, Spicer N, et al. Measuring governance at
health facility level: developing and validation of simple governance tool in
Zambia. BMC Health Serv Res. 2013;13:34. doi: 10.1186/1472-698X-13-34
[20]. Ochola S, Mwimali J, Wekesa
S, Omondi M. Governance of county revenue, leadership and delivery of health
services in Kenya's level 5 public hospitals. Int J Leadersh Gov.
2026;6(1):1-18. doi: 10.47604/ijlg.3645
[21]. Tamayo JMD. The role of
health information system, service innovation, and data governance in enhancing
hospital quality standards in University of Perpetual Help Dr. Jose G. Tamayo
Medical Center. Int J Multidiscip Res. 2026;8(3). doi: 10.36948/ijfmr.2026.v08i03.78613
[22]. Shiyanbade BW.
Administrative structures sustainability and secondary health care
administration in Lagos, Nigeria. Glob J Soc Sci. 2024;23:57-71. doi:
10.4314/gjss.v23i1.5
[23]. Brinkerhoff DW, Bossert TJ.
Health governance: principal-agent linkages and health system strengthening.
Health Policy Plan. 2014;29(6):685-93. doi: 10.1093/heapol/czs132
[24]. Ezenwaka U, Onyemaechi S.
Analyzing governance of a sub-national health insurance scheme for providing
universal health care and better social health protection performance through
the lenses of the principal-agent theory in Anambra state. BMC Health Serv Res.
2026;26(1):747. doi: 10.1186/s12913-026-14563-6
[25]. Naher N, Hoque R, Hassan
MS, Balabanova D, Adams AM, Ahmed SM. The influence of corruption and
governance in the delivery of frontline health care services in the public
sector: a scoping review of current and future prospects in low and
middle-income countries of south and south-east Asia. BMC Public Health.
2020;20(1):880. doi: 10.1186/s12889-020-08975-0
[26]. Saltman RB,
Ferroussier-Davis O. The concept of stewardship in health policy. Bull World
Health Organ. 2000;78(6):732-9.
[27]. Savedoff WD. Governance in
the Health Sector: A Strategy for Measuring Determinants and Performance.
Policy Research Working Paper No. WPS 5655. Washington DC: World Bank; 2011.
doi: 10.1596/1813-9450-5655
[28]. Lewis M, Pettersson G.
Governance in Health Care Delivery: Raising Performance. Policy Research
Working Paper 5074. Washington DC: World Bank; 2009. Available from: https://documents1.worldbank.org/curated/en/792741468330936271/pdf/WPS5074.pdf
[29]. Spector PE. Method variance in organizational research: truth or urban legend? Organ Res Methods. 2006;9(2):221-32. doi: 10.1177/1094428105284955
