Feasibility of Good Governance at Health Facilities: A Proposed Framework and its Application Using Empirical Insights From Kenya

Background: Governance is a social phenomenon which permeates throughout systemic, organisational and individual levels. Studies of health systems governance traditionally assessed performance of systems or organisations against principles of good governance. However, understanding key pre-conditions to embed good governance required for healthcare organisations is limited. We explore the feasibility of embedding good governance at healthcare facilities in Kenya. Methods: Our conceptualisation of organisational readiness for embedding good governance stems from a theory of institutional analysis and frameworks for understanding organisational readiness for change. Four inter-related constructs underpin to embed good governance: (i) individual motivations, determined by (ii) mechanisms for encouraging adherence to good governance through (iii) organisation’s institutional arrangements, all within (iv) a wider context. We propose a framework, validated through qualitative methods and collected through 39 semi-structured interviews with healthcare providers, county and national-level policy-makers in Kenya. Data was analysed using framework approach, guided by the four constructs of the theoretical framework. We explored each construct in relation to three key principles of good governance: accountability, participation and transparency of information. Results: Embedding good governance in healthcare organisations in Kenya is influenced by political and socio-cultural contexts. Individual motivations were a critical element of self-enforcement to embed principles of good governance by healthcare providers within their facilities. Healthcare providers possess strong moral incentives to self-enforce accountability to local populations, but their participation in decision-making was limited. Health facilities lacked effective mechanisms for enforcing good governance such as combating corruption, which led to a proliferation of informal institutional arrangements. Conclusion: Organisational readiness for good governance is context-specific so future work should recognise different interpretations of acceptable degrees of transparency, accountability and participation. While good governance involves collective social action, organisational readiness relies on individual choices and decisions within the context of organisational rules and cultural and historical environments.