Influence of Hospital Ownership and Governance structure on Maternal Delivery Services

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.