STRATEGIES FOR ENHANCING THE FUNCTIONALITY OF HOSPITAL MANAGEMENT BOARDS IN CENTRAL HOSPITALS: EVIDENCE OF A DEVELOPING ECONOMY

How to cite this paper: B., & E. Strategies for enhancing the functionality of hospital management boards in central hospitals: Evidence of a developing economy. Journal of Governance & Regulation, 11 (3), 39–53. interviewing 12 respondents as the sample for the study selected from a target population of 66 hospital chief executive officers (CEOs) and board chairs. The 12 respondents were selected using the purposive sampling technique based on experience and knowledge as the inclusion and exclusion criteria of participants. The study revealed 6 critical strategies as gaps that hospitals need to enhance to improve on performance. These include networking, monitoring and evaluation, revenue generation, public-private partnerships (PPPs), HMB operational plan, and transparency in the selection and appointment of board members. The gaps identified required policy review to strengthen the appointment and performance of HMBs.


INTRODUCTION
Zimbabwe's public hospitals face a myriad of challenges that hinder the delivery of effective health services to ordinary citizens, and this has been worsened by the emergence of the COVID-19 pandemic which erupted when the health system throughout the country was already overstretched (Dubas-Jakóbczyk et al., 2020). The country's deteriorating economy, rising inflation levels, and policy inconsistency have been the underlying factors affecting strategies by public hospitals to ensure effective health delivery across the country.
The main concern is that the challenges negatively impact the functionality and performance of hospitals expected to provide a sustainable longterm solution in the form of strategies rather than an ad hoc and piece-meal fix. Since the year 2019, the country has witnessed one of the longest strikes by health personnel over poor working conditions, which nearly crippled all the public hospitals. Several negotiations between government and health sector employees have failed to unlock the impasse. With no clear solution in sight, a demotivated and incapacitated health workforce will continue to be a risk to the delivery of quality health care services by public hospitals. Retention of critical staff has remained a challenge given the limited fiscal space to address the needs of the health staff. This has been exacerbated by long periods of underperformance of the macroeconomy. Due to the declining economy, public hospitals are now under-budgeted and under-resourced ultimately affecting their functionality.
Developing countries, the world over continues to provide techniques and strategies to improve the functionality of public hospitals with much focus on enhancing performance. It is common knowledge that the developing world has inherited bureaucratic practices from colonial rulers which compel public organisations to follow the dictates as prescribed by the government taking away the autonomy to operate or function without interference. Following the need to improve service delivery, public hospitals have gradually been granted autonomy to operate as intuitions led by the chief executive officer (CEO) and a board of directors without strictly following the bureaucratic practices as dictated by the government. Thus, granting public hospitals autonomy is expected to strengthen functionality in the form of increased revenue generation, while gradually reducing the dependency syndrome from the central government. The new dispensation of service delivery excellence, through the establishment of hospital boards, allows public hospitals to devise alternative ways of generating revenues as opposed to waiting for government grants as well as from fee-paying patients (Võ & Löfgren, 2019). It is, however, critical to note that boards of directors also face challenges in devising effective strategies to ensure functionality and performance, a concern which many believe is caused by the extent to which the boards are granted autonomy (De Geyndt, 2017). At the moment, there seems to be a huge amount of interference from government officials by way of policy directives which tend to compel the board to make decisions they may not be comfortable with. There is, therefore, a need to further extend the HMB's autonomy so that they can freely run the hospital without government interference. Another issue of concern is the board's skill to deliver what is expected of them in terms of quality governance expertise . It is critical to note that the board of directors for state-owned enterprises serves the interests of several stakeholders, and because hospitals fall under the Ministry of Health, the appointment of the board is the responsibility of the Minister of Health. Hence the minister has control over the board to the extent of influencing the appointment of board members (Matamande, 2015). Zimbabwe's management of public hospitals falls under this predicament as stated by Matamande (2015) with responsible ministers single unilaterally making decisions on who should be appointed to chair the board. This kind of hospital governance has been going on for three decades, motivating the need to conduct a study on HMBs to introduce fresh ideas on ways to improve functionality and performance. HMBs are significant for providing oversight function as part of the hospital governance structure, but due to the ministerial interference, realising the intended goal, remains an unachievable task, and until the interference is minimised, public hospitals in the developing world will continue to face health service delivery challenges (Ngongo, Ochola, Ndegwa, & Katuse, 2019).
Corporate governance practices, involvement of stakeholders is the backbone that influences the success of the boards, and globally this has been the standard practice. For example, in Belgium, public hospitals must work with key stakeholders. Thus, hospitals that engage active stakeholders more aggressively post good results as opposed to those that engage a limited number of stakeholders (Malfait, Van Hecke, Hellings, De Bodt, & Eeckloo, 2017). In Romania, deliberate efforts were put in place to ensure that all public hospitals must be guided by a strategic board that is led by individuals with relevant experience and expertise in hospital management (Duran, Chanturidze, Gheorghe, & Moreno, 2019). It is, however, important to ensure the selection of board members should be a committee function and not a responsibility of the line minister.
Prior to refining the governance structure, Romania faced a number of similar challenges in the form of policy inconsistencies, interference by government officials, and incompetent board managers. The Romania study revealed that the bulk of the challenges was due to operational, strategic, and financial capacity by the respective hospitals. At the heart of global healthcare reforms, lie policy reforms on operational, funding, transparency, procedures, and practices. Thus, policy changes remain critical globally, in Africa and Zimbabwe, in particular (Braithwaite et al., 2017).
Coming to health leadership in Africa, studies to determine the preparedness of the public hospitals were conducted, and the findings were that Africa still needs to work harder on this aspect focusing on leadership development (Gilson & Agyepong, 2018). Thus, leadership is expected to address pertinent issues in the central hospitals such as staff incentives, key expertise, and patient treatment. In other words, Africa experiences a lack of incentives for hospital staffers, a lack of expertise in the form of medical doctors and nurses as well as related personnel to ensure effective patient treatment. It is this status quo of health leadership that ought to be transformed to ensure the effectiveness of central hospitals in terms of being more responsive to the health needs of the citizens. Key to this, leadership development is not adequate in the developing world, hence there is a need to train individuals towards organisational development.
In Southern African countries, the public health hospitals face similar challenges on hospital governance, however, there have been gradual developments to improve the governance structures, effectiveness, and efficiency. A study on governance structures was conducted in South Africa on several public hospitals to determine the effect of governance on the delivery of health services (Fusheini, Eyles, & Goudge, 2016). The findings revealed that besides effective governance as a key element of health service delivery, stakeholder involvement and assessment should be undertaken. In reality, effective governance, leadership, and political will within the province and nationally, infrastructure development, structural improvements, and enhancing processes are critical to hospital governance. Geared towards the improvement of public hospital service delivery, Botswana has implemented reforms to address governance by decentralising the governance strategy to encourage participatory development. However, the government seemingly retained the centralisation and coordination functions as arms of the government. Drawing from the scenario, Botswana's hospital governance is embedded in bureaucratic tendencies ultimately slowing the functionality and performance of hospital service delivery. In practice, public hospitals in Botswana are led and directed by the Ministry of Health from the head office, ultimately hindering operational autonomy (Mooketsane, Bodilenyane, & Motshekgwa, 2017).
China's public hospital management falls under an administrator while the CEO and board deal with government-led policy issues (Nong & Yao, 2019). This, therefore, means that the government, through the Minister of Health holds full responsibility and control of public hospitals with the CEO, expected to meet the set targets failure of which dismissal is proffered (Janke, Propper, & Sadun, 2019). The CEO is held accountable by the board for achieving the hospital's mission, by way of implementing operational plans (Friedman & Rabkin, 2018).
Coming to Zimbabwe, the public hospital delivery system is undergoing structural changes which have led to the appointment of health centre committees responsible for implementing rural health facilities, advisory boards for district and provincial hospitals, and hospital management boards (HMBs) for central hospitals. The common denominator across countries remains embracing good governance principles and ensuring effective processes and practices. Board performance in the middle and low-income countries inclusive of Zimbabwe faces challenges like a lack of authority by some members, a lack of skill to devise effective strategies, and poor decision-making (Sikipa et al., 2019). Drawing from a lack of skill to devise effective strategies, the study seeks to explore and devise strategies that enhance the functionality of HMBs in Zimbabwe's central hospitals to enhance performance and service delivery overall.
Zimbabwean's health service delivery is punctuated by a lack of policy on unique health set up, such as rural hospitals, provincial and central hospitals as well as a lack of procurement planning, weak selection criteria for board members and key positions (Shonhe & Bayat, 2017). This is despite the fact that there are functional hospital boards in all central hospitals (Bismark & Studdert, 2013). This study, therefore, seeks to devise strategies that enhance the functionality of public hospitals. At the time of this study, and drawing from the functionality challenge, Zimbabwe's central hospitals have reached a point where hospital boards must be enhanced to ensure effective governance. The new dispensation to ensure excellence in health service delivery calls for every central hospital to establish an effective board whose primary focus is to proffer effective governance by way of devising key strategies that enhance hospital performance (Health Service Act of 2004, Chapter 15:16).
The remainder of this paper is structured as follows. Section 2 reviews the relevant literature. Section 3 presents the methodology used to collect and analyse data, detailing research approaches, study population, study sample, and data collection tools. Section 4 provides the study results while Section 5 entails a discussion and interpretation of the study findings. Section 6 provides the conclusions of the study focusing on limitations, implications of the study as well as perspectives for future research.

Strategies that enhance transparency by hospital management boards
Transparency is when the public or citizenry is informed about the decision-making process by the government or its agencies (Greer, Wismar, Figueras, & McKee, 2016). According to the United Nations definition, transparency is the accessibility to public information that is executed appropriately and consistently to enhance decision-making and performance in the public (Armstrong, 2005). It should be noted that, in hospital governance, transparency and stakeholder participation are directly related to quality performance (Zehir, Çınar, & Şengül, 2016 (Dwyer, 2019). The establishment of effective structures in public hospitals is very critical. This is because the governance of a health system should include determination of the policymaking, strategic direction and goals, establishment of resources for strategic goals, formulation of rules and regulations. Furthermore, the government should allow for monitoring and control mechanisms for the achievement of the strategic goals of a hospital (Jafari, Hajinabi, Jahangiri, & Riahi, 2019). The strategies include the engagement of clinicians and patients, improving timeliness reporting, and improving the communication of information so that it becomes accessible and meaningful to the diverse stakeholders (Canaway, Bismark, Dunt, & Kelaher, 2018).
The government of Rwanda through the Ministry of Health engaged international accreditation experts who developed the national accreditation system. The accreditation system in Rwanda was adopted to meet the identified quality standard gaps in all its 43 district hospitals. The standards were affiliated with the national health sector priorities for assuring quality and safety. The accreditation standards focused on leadership and accountability, competence and capable employees, the safe operating environment for staff and clients, clinical care of patients, and the improvement of quality and safety (Binagwaho et al., 2019).
The health services of Victoria, Australia were studied, to explore the impact of organisational quality systems on quality care. The study discovered that health service boards were inadequately meeting their governance mandate to guarantee high-quality care. Additionally, the study revealed some clinical governance gaps between the specified board and executive ambitions on quality and safety indicators. Confusion on the quality system, limited staff engagement, and over-reliance on compliance without innovation exacerbated the existing gaps in clinical governance. The five modalities were suggested to assist boards to close the governance gaps. The strategic modalities were holding CEOs accountable for pursuing consistently high-quality care, ensuring board accountability on the provision of high-quality care, developing an implementable and measurable strategy to actively pursue high-quality care, actively monitoring and responding proactively to quality strategy implementation, and ensuring effective quality system and appropriate culture to support strategy implementation (Leggat & Balding, 2019). Other aspects proffered for improvement were the implementation of a transparent system of recruitment, reasonable assessment, salary and incentive modalities, to ensure segregation of duties for management and operation and strengthening of market competition (Xiong, Su, Zhang, & Lyu, 2018).
The stakeholder interaction can be in the form of general meetings, comprehensive annual reports, and clarification on critical employees. Hence, HMBs ought to routinely engage citizens in order to gain media coverage. A study was conducted in three Flemish hospitals to evaluate the involvement of stakeholder committees in the internal decisionmaking processes for hospitals (Malfait et al., 2017). The stakeholder committee discussed 15 themes and 11 resulted in a considerable change. This implies that in a bid to inspire public answerability effectively, stakeholder involvement in hospitals' decision-making process is vital. Consequently, it should be noted that public payers could be the most important players in a world of comparative effectiveness. This is because of the large population covered and the amount of money spent (Rossiter, 2017). Moreover, it can be argued that public payers frequently set the payment rules for other private payers to follow. Therefore, the model of stakeholder committee is very vital in both the operational level and decision-making process.

Strategies that enhance accountability by hospital management boards
Given the general understanding that accountability is a social relationship where parties concerned hold each answerable for their respective actions on a subject matter of common interest (Greer, Wismar, Figueras, & McKee, 2016;Stewart, 1984). Therefore, to improve accountability strategies should focus on clarifications on stakeholder expectations and provide open lines of communication to report progress.
Greer, Wismar, Figueras, and McKee (2016) posit that standards and codes of conduct are concerned with the acceptable and intolerable behaviour within an organisation. Therefore, the established behaviors and expectations should be publicised in order to make deviant behaviour more apparent and easier to address. The code of conduct provides the standards of conduct, principles of expressing responsibilities, and the rules that apply to certain professions (Pozgar, 2019). Therefore, the standards and codes of conduct are there to reinforce constructive behaviours and outline expectations that are relevant to members of staff in health institutions (Hardy, 2016).
The reviewing of the conflict of interest policies should be done periodically in order to conceal all significant interests that can impede the individual or professional judgement. Generally, conflict of interest is understood to mean a scenario where an individual or organisational decision-making function might provide an unfair advantage or improperly benefit from decisions that are made. The benefit could be financial or non-financial (Besley et al., 2017). In this era, conflicts of interest are endemic and sometimes unavoidable because of the increasing social and economic challenges that affect many people in society. Against this backdrop, it can be argued that whilst they are problematic situations, they do not automatically constitute misconduct or breach of integrity. The conflict of interest in organisations should be managed through disclosure, education of staff, preventive measures, and independent reviews. Therefore, it is important to manage conflict of interest in order to enhance the professional ethics and personal integrity of health experts. This can be achieved through the implementation of practical institutional governance mechanisms (Bélisle-Pipon, Ringuette, & Williams-Jones, 2017). In North America, many medical faculties have initiated the introduction of strict conflict of interest policies from the year 2010 onwards. This was in response to the 2009-2010 drug safety scandal that had been experienced. On this aspect, a study conducted in the French medical faculties which focused on 37 medical faculties found out that only 2 out of 37 had a conflict of interest policies in their respective institutions. Furthermore, the 2 medical faculties had neither written documents nor publication on the medical faculties' websites. The delay in the establishment of the conflict of interest policies might be due to a lack of action by the government or other bodies (Scheffer et al., 2017). This finding buttresses the notion that HMBs in public hospitals should come up with conflict of interest policies in their respective institutions. The conflict of interest policies should be both in written and electronic form and all board members should be aware of the policy. It is actually encouraged that the organisational conflict of interest policies be uploaded onto the institutional website for the benefit of internal and external stakeholders.
Competitive bidding is done to enhance competition among providers of goods or services, hence this can lead to lowering of costs and quality service. The competitive bidding process should have checks and balances or segregation of duties at all stages. The evaluation of tender documents should be conducted objectively before the development of a contractual agreement to finalize the relationship ( which can be implemented by the procuring entities are stated in Section 30 of the Act, thus competitive bidding, restricted bidding, direct procurement, request for quotations, and request for proposals. The terms and conditions for the competitive bidding method are as stated in Section 31 of the Act. The bidding document is published or circulated in the widely read newspaper, Internet, or institutional website. Furthermore, all suitable bidders are acceptable regardless of any segregation modalities on the submission of bids, hence the assessment is done per the set criteria. It should be noted that the bidding period, bidding documents, opening of bids, the consideration of opened bids, the evaluation of tenders, and the contract award should follow provisions of the Act. On the notion of bidding, a study was conducted in Kenya to ascertain the impact of procurement procedures on the performance of public hospitals. From the study results, it was recommended that the public hospitals should adopt best procurement practices by public health care entities for the enhancement of their performance. The study further revealed that hospitals review their procurement policies on supplier selection frequently which ensures the quality of supplies (Oloo, Atambo, & Muturi, 2017). It is against this background that, the implementation of better procurement practices in public hospitals would lead to improved quality of health service provision to members of the public who form the bulk of taxpayers. Thus, it can be seen that HMBs should put in place mechanisms that strengthen the procurement process in their respective institutions as a governance effort to minimise fraud, corruption, and other procurement malpractices.
In Lebanon, the Ministry of Public Health pursued modifications in hospitals' contracting systems to encourage stakeholder involvement and participative governance in policymaking. The contracting reform system adopted three committees, which are the Utilization Review Committee, the Admission Criteria Committee, and the Performance Contracting Committee. On another dimension, privatisation or corporatisation is another approach that might be adopted to strengthen efficiency in the public health sector. The concept of privatisation is concerned with the limitation, reduction of direct government economic activities and functions (Ulusoy & Oflaz, 2016). The notion of privatisation or corporatisation of public enterprises to enhance organisational performance is an essential tenet of the new public management concept or administration (Lindlbauer, Winter, & Schreyögg, 2015). Another study to evaluate privatisation was conducted in Pakistan, which is in the category of developing countries with over-reliance on private sponsors, non-governmental benefactors, and international donors for its health services delivery (Reading, 2010). The results indicated that while privatisation serves its citizens, it has some shortfalls. It was argued that the privatisation model should take into consideration greater government involvement, and therefore the healthcare provision in developing countries should be pursued cautiously. In the case of central hospitals, HMBs can do partial privatisation of some departments, services, patient wards, or cubicles.
The performance-based financing has been implemented successfully in a number of countries to transform the health system and improve maternal and child health (Shen et al., 2017). On another dimension, the financial mechanism is a model of pay-for-performance or performancebased payment system which is adopted by government institutions through contracting third parties. The payment is done based on meeting the agreed targets (Greer, Wismar, Figueras, & McKee, 2016). In order to buttress the effect of performance-based financing, another study was conducted in Cambodia to examine the utilisation of the performance-based financing model in an endeavor to address primary health employees' job satisfaction. The study results revealed that there was high job motivation and the promotion of a capability, offering community service, and creation of job worthiness (Khim, 2016). In another study that was conducted in Burkina Faso to explore healthcare employees' preferences for performancebased incentives, the study results suggested that the majority of health workers preferred both financial incentives and team-based incentives. This finding suggests that it is ideal that health workers and other relevant authorities ensure involvement in the designing of an appropriate incentive arrangement (Ye et al., 2016). To support the notion that performance-based financing is key in meeting the set targets in the health sector programmes, Zimbabwe implemented the model with the intention of staff retention of low-paid health care employees through the voluntary medical male circumcision programme. From the study findings, it can be seen that the performance-based financing increased motivation among the voluntary medical male circumcision teams and improved service provision at the facilities where the services were provided. The performance-based financing model enabled the rapid increase in programme scale-up and achievement of set targets (Feldacker et al., 2017).
The organisational separation as part of an internal control system is designed as a system of financial controls and other management controls which strengthen the conduct of business desirably and efficiently. This helps to ensure adherence to management policies, safeguard the assets, and secure the completeness and accuracy of the records (Iyinomen & Nkechi, 2016). Hospital management boards have the responsibility of enhancing departmental performance through the creation of competition. This can be achieved through the offering of awards to the best-performing departments and other staff incentives. Furthermore, it might be prudent to create platforms for exchange programmes with other bestperforming departments in other institutions as part of continuous learning, continuous quality improvement, and best practices. Healthcare providers, governments, and professional bodies can make use of quality improvement strategies to enhance the quality and safety of health care (Brennan et al., 2017). In healthcare management, quality improvement outcomes to both health workers and leadership are a result of the use of regulatory and performance methods. This can be achieved through the conduct of staff meetings at regular intervals to expose possible challenges, constant reviews of performance, and supporting the concept of continuous quality development (Silver et al., 2016).

Strategies that enhance stakeholder participation
In terms of the participation concept, those affected by the policies made should have access to the decision-making process and feel empowered to have their voice heard. The empowerment drive might involve directly reaching out to the citizenry, establishing representative groups to convey the feedback, and collaborating with other entities that offer services to similar clientele (Greer, Wismar, Figueras, & McKee, 2016). According to the Ministry of Health and Child Care (MoHCC) Patient's Charter of Zimbabwe, it is the right of patients to partake in the decision-making and have adequate information and consent on issues that affect their health. Therefore, HMBs should foster strategies or mechanisms that bolster stakeholder participation at various levels.
The patient satisfaction survey plays a significant part in the aspects of healing and emotional well-being of patients (Marama, Bayu, Merga, & Binu, 2018). Furthermore, surveys on client satisfaction are important in evaluating the quality of the healthcare processes and assist hospital management to improve service delivery through the development of appropriate strategies (Shumba et al., 2017). The client survey is an evaluation tool to obtain feedback from the constituents who are involved in or affected by government decisions or policy changes. The surveys can be developed in-house or an organisation can engage the services of a management consultancy firm for client survey assistance.
The quality of care is anchored on patient experience, clinical effectiveness, and patient safety. A study conducted in Pakistan on the client satisfaction survey discovered that the overall satisfaction survey was 77%, dissatisfied client's rate was 13% whilst those who were uncertain was 10%. The study results revealed a positive correlation between value, honour, and quality care given to a patient and the satisfaction derived by a patient (Hussain, Hussain, & Hamid, 2017). This is a forum that is designed to obtain feedback or to interface with stakeholders who have a stake or vested interests in the organisation's programmes and policies. The decision-making process should involve stakeholder engagement, with a focus on ensuring effectiveness, multidirectional, meaningful, and equity for both stakeholders and guideline developers (Petkovic et al., 2020). The effectiveness and performance of a business leader are measured or identified through the ability to satisfy the needs and wants of its divergent and conflicting interested parties, on a sustainable basis (Ehlers, Lazenby, Cronjé, & Maritz, 2010).
Furthermore, in the case of HMBs, there is a need to establish various board committees which would focus on the needs and expectations of the hospital stakeholders like patients, government, community leadership, representatives from relevant professional bodies, and others. However, it should be noted that the advisory boards have no legal oversight responsibility for financial and other corporate operations. They are established to provide input on patient and community relations (Johnson & Calderwood, 2016). Large not-for-profit organisations like central hospitals should establish advisory boards which would offer advice to both the management and fiduciary board of the respective hospital. In the long run, this would strengthen the performance of hospital management boards since they are kept abreast with the needs and expectations of their important stakeholders.
The public-private partnership (PPP) is a model used in alleviating the risk of investment in the health sector. The successful implementation of the PPP enhances the achievement of higher efficiency levels and harnesses the skills and experiences of the private sector for quality improvement (Barzegar, Tabibi, Maleki, & Nasiripour, 2016). The involvement of consumers in the delivery of health services is highly encouraged in many countries. In fact, studies have shown that consumer partnerships bring benefits like service planning, innovation, and quality improvement (Farmer et al., 2018). It was further revealed that for PPPs to be successful in Poland, there was a need for stable legal and economic conditions, allocation of risk, enough experience from both partners, use of reputable and competent private partners, sufficient initial capital, and consistency in contract terms (Kosycarz, Nowakowska, & Mikołajczyk, 2019). In an effort to enhance the provision of health to individuals, communities, employers, and policymakers, the United States of America government has adopted the strategy of cross-sector collaboration through the involvement of community members, businesses, the education sector, human service organisations, social services and public health specialists (Lyda-McDonald, 2019). Hospital management boards should strive to network with various stakeholders who would offer assistance or partnership of any form to strengthen the health service delivery.

Strategies that enhance the integrity of hospital management boards
The creation of reasonable expectations about the roles and responsibilities of an organisation brings about its integrity to society. The integrity of an organisation is built through the strengthening of policies on financial, personnel, and administrative issues. On the other hand, integrity may fail or get damaged due to engagement in irrelevant activities, the sudden ending of certain programmes, or policy inconsistencies (Greer, Wismar, Figueras, & McKee, 2016). Therefore, HMBs should engage in activities or programmes that assist in building the reputation or integrity of their respective institutions.
The public sector hospitals should enhance risk assurance through various mechanisms such as periodic managerial and board committee reports, external and internal audits. The internal audits of clinical areas should be conducted by independent internal auditors and the findings reported to the internal audit committee (Brown, Santilli, & Scott, 2015). Fundamentally, HMBs should ensure routine conduct of internal audits. This ultimately assists an organisation to better understand the status of an organisation in terms of financial management, operations, programme implementation, human resources management, and other mechanisms that have an effect on hospital operations. The internal audits should follow a sequence that involves the preparation, execution, reporting, developing, and implementing an improvement plan and then follow or track the audit findings. In addition, sufficient tools should be provided to perform issues raised by the audit, the hospital board should ensure compliance with improvement measures, and ensure that audit contributes to quality improvement of health care services (Hanskamp-Sebregts, Robben, Wollersheim, & Zegers, 2020). The internal audits further assist hospital boards with structured, standardised, formal, and periodic reviews of quality and safety problems (Van Gelderen et al., 2017). So strategically, hospital boards use matters raised in internal audits to improve the health care service provision.
Budgeting is a critical exercise, hence every hospital regardless of size and complexity relies on budgeting to forecast and establish predetermined goals, report on actual performance, and evaluate performance. In order to buttress the importance of budgeting in the performance of an organisation, a study was conducted at Kenyatta National Hospital in Kenya to assess the effect of the budgetary process on-budget performance. The study results revealed that budgetary participation, budgetary control, and budgetary reports positively affect the budget performance of the hospital. Therefore, it was against this background that a recommendation was proffered in that, staff engagement is key during the crafting of the budget for the hospital. Furthermore, budget reports should be periodically prepared to strengthen clear communication channels on-budget performance (Kamau, Rotich, & Anyango, 2017). The financial audits in a hospital are conducted routinely to convey an independent judgement on the organisation's financial statements. The audit ought to establish if the financial documents are prepared in compliance with the professional rules and the generally accepted accounting policies and standards (Raymond & Désiré, 2019). The financial audits of an organisation should be conducted by an independent audit firm, to review all the organisation's revenues, expenditures, equipment, and financial investments.

Strategies that enhance policy capacity for hospital management boards
Policy capacity is a key determinant of the extent to which policy actors are capable of addressing public problems (Wu, Ramesh, & Howlett, 2015). Lawrence, Fierlbeck, McGrath, and Curran (2020), buttressed the definition of policy capacity as ability of policy makers to achieve quality work, which ultimately leads to effective policies. From this definition, it is clear that setting strategic directions and allocating scarce resources to fulfill public demands is a key function of policies in an organisation.
Forecasting is an effective tool that can be used to decide future demand, schedule of staff in tandem with the future workload, and stocking of inventory required for future stock requirements. Hence, forecasting is key in the achievement of effective and efficient planning of an organisation. The forecast can be short-term, medium-term, and long-term (Hyndman & Athanasopoulos, 2018). Therefore, hospital managers and leaders can use forecasting to predict the future as accurately as possible, through the use of available information. The information that aid forecasting includes data from past events and intelligence on any future undertakings that might impact the projections. Hospital management should gather intelligence on performance, thus the identification of possible challenges and opportunities and the consequences associated. The intelligence gathering and analysis assist hospital management and leadership to forecast costs and benefits that an organisation is likely to face and this enables it to be prepared to devise counter-strategies.
The concept of recruitment is concerned with the attraction and selection of staff to an organisation or role, whilst retention is the length of time between commencement and termination of employment.
Therefore, in practice, good recruitment procedures are a pre-requisite for the retention of staff ( In an effort to develop research capacity, health care systems need to invest and plan strategies that foster research in their respective institutions. In the UK, research is considered as a core function that is planned through research and development strategies. The initiatives in the UK health service organisations are aimed at promoting research activity and research capacity development for sustainable improvement of health care services (Gee & Cooke, 2018). Fundamentally, with a sustained research culture and practice, the organisation is able to generate new knowledge and opportunities whose evidence for decision-making or policymaking. In this regard, a systematic review of frameworks for capacity building on all health professions was conducted. The study results revealed that in order to achieve research capacity and analysis in hospitals, there is a need to support clinicians or health professionals in research, working together as a team in research, and value research for excellence (Matus, Walker, & Mickan, 2018).
The other strategy to enhance board effectiveness and performance is through decentralisation. In order to enhance the quality and efficiency of hospitals in low-income countries, the adoption of the decentralisation approach through the launch of hospital governing boards has been considered desirable (McNatt et al., 2014). A study was conducted in Kenya to examine the association between hospital board functioning and hospital performance. The results revealed that hospitals with greater management standards met had governing boards that paid members and reviewed performance periodically. Furthermore, new revenue-generating models were developed, subcontracting of services, reviewing of patients' complaints and expert members in both business and financial management are some of the positives witnessed in certain hospitals. In particular, results proffered that the hospital performance might be boosted due to the strengthening of governing boards to perform essential financial and operational functions. However, to some extent decentralisation face some limitations in its implementation. This was highlighted in the case when operations to control tropical diseases were decentralised in Tanzania (Mubyazi, Kamugisha, Mushi, & Blas, 2004). Whenever reforms are undertaken, politicians and policymakers have argued that the new system remedies have fundamental flaws in the old, but sometimes the reforms appear to introduce further unintended consequences that they require remedy (Martin & Carter, 2017).
In a bid to achieve a thriving and sustainable health

Research design
This study is an exploratory and qualitative approach from a phenomenological paradigm, with the purpose of identifying and proposing strategies for enhancing the functionality of hospital boards in Zimbabwe. A data collection technique used in this study was open-ended interviews, which refers to a social interaction between interviewer and respondent, where both parties have an opportunity to clarify questions and responses (Chambliss & Schutt, 2012). The respondence interviewed were based on their experiences, insights, and opinions in the governance of hospital boards. Interviews enabled the researcher the flexibility to ask openended questions, have control over the order in which questions are asked and answered; and provide participants with an opportunity to clarify interpretations of questions.

Study population and data source
A research population is defined as an aggregation of study elements (such as individuals, artifacts, events, or organisations) from which data will be collected providing the basis of analysis (Burns & Grove, 2004;Babbie & Mouton, 2009). For this study, the population consisted of 6 central hospital management boards with each comprising 7 nonexecutive and 4 executive board members. In other words, 42 and 24 non-executive and executive board members, respectively constituted the population at the central hospital level, this being 66 study contributors. The common aspect of the study participants in this category is that they are responsible for ensuring good governance practice in their respective central hospitals in the country.

Sampling technique and sample size
Sampling refers to a process of selecting the sample, for the actual participation in the study, from the target population using specific non-probability sampling techniques (Babbie & Mouton, 2009). There are various non-probability sampling techniques available, with the most common being: convenience sampling, snowball sampling, quota sampling, and purposive sampling (Collis & Hussey, 2003;Babbie & Mouton, 2009;Kolb, 2008). A purposive sampling technique was used to select participants for the study. In purposive sampling, the researcher selects participants subjectively and deliberately based on a predefined set of characteristics. Exploratory qualitative research is only effective if the right participants are selected (Kolb, 2008). To achieve this desired effectiveness, this study used a purposive sampling technique, intending to enable the researcher to involve only -information-rich‖ participants with significant insight, detailed knowledge, or direct experience in public hospital governance.
In purposeful sampling, the sample size varies depending on the breadth and complexity of the study, although samples are generally smaller than those used in quantitative studies and are studied intensively (Curry, Nembhard, & Bradley, 2009). In this study, 6 CEOs and 6 board chairs were selected using a minimum of a 5-year board experience as the inclusion and exclusion criteria (Creswell, 2014). Characteristics of a sample should be relevant for the study. A purposive sample was considered based on the assumption that the board chairs represent the interests of external stakeholders, whilst the CEOs represent the internal clients (Andrade, 2021). The external stakeholders include independent non-executive directors, patients, the government, business, and donor community, whilst internal stakeholders include executive directors, line managers, and staff at lower levels.

The interview
Descriptive qualitative data was collected from interviews. A non-quantifying approach was taken in analysing this data and no statistical analysis was considered relevant (Collis & Hussey, 2003). In particular, the data analysis method used in this study was thematic analysis, which enabled the researcher to move the analysis from a broad reading of the data collected from interviews towards discovering patterns and developing themes (Harvard, 2008). Thematic analysis, while it minimally organises and describes data set in rich detail, is also relatively easy to conduct without prior detailed theoretical and technical knowledge of the method, which was of great benefit to the researcher (Braun & Clarke, 2006).
The use of purposive sampling in this study allowed data review and analysis to be done in conjunction with data collection (Collis & Hussey, 2003;Babbie & Mouton, 2009). Data analysis was therefore in continuous iterations of note compilations based on thoughts and reflections of the researcher, data reduction of interview notes, as well as categorising the data from all interviews and linking it to other data sources literature. Once, data was categorised and themes were identified, the next step was to display the data in a tabular format as reflected in Table 1 which shows the themes from the interview narratives. A theme reflects a pattern, or meaning, that emerges from the research data set, which embodies critical aspects responding to a research question. (Braun & Clarke, 2006).

RESULTS
Thematic analysis was used to analyse data collected from the interviews conducted. Data was coded and entered to come up with themes that assist in the analysis and interpretation. Table 1 shows the 6 themes which emerged from thematic analysis depicting the strategies that could be used to strengthen the performance of hospital management boards. The strategies include resource strategy, fundraising, monitoring and evaluation, networking strategy, community support, and entering into PPPs. Stakeholder engagement is very key in the enhancement of HMBs' performance. Board chair 1 suggested, "I think more interaction between the boards and the government so that the vision of government is fully realized. More stakeholder involvement through workshops is encouraged". The concept of community engagement or networking was buttressed by board chair 4 who proffered, -So their prime responsibility is to pick concerns of society or community and bring them to the notice of the hospital management and as well as the board. We could do better in terms of community outreach and interactions with the community. We need to have good systems that continually make it possible for communities and societies to say this is what we are experiencing at the hospital. That is not being done because in other countries and jurisdictions that have become a very important part of management". This highlights the importance of community outreach as a way of building the institutional image and stakeholder interface. The citizenry in various capacities needs to be engaged in order to foster close interaction.
Monitoring and evaluation mechanisms should be put in place to enhance the performance of hospital management boards. The concept of monitoring and evaluation of hospital boards is very critical in that the approved plans should be closely and regularly monitored to boost accountability and transparency by board members. Board chair 1 provided, "On the ministerial side, I suppose we do get to interact quite a bit with our minister. Put in place more constant monitoring and evaluation mechanisms so that boards account more. But in terms of the powers of the hospital management boards, the Health Service Act is very clear so the more evaluation that takes place and how far we have achieved as a board is it in line with the government expectations and our appointing authority".
The notion of monitoring and evaluation of hospital board performance including the CEOs was reinforced by board chair 4 who echoed, -There is no tangible effort for assessing the performance of the CEO and its left to the permanent secretary. The bottom line is that there is no tangible process for assessing the CEO and thus a problem". It is important to regularly monitor and evaluate the performance of the CEOs as well since they are part of the executive management. The duty of the hospital management board includes the monitoring and evaluation of the CEO.
Resource mobilisation is another strategy that was suggested by both board chairs and CEOs. CEO 1 suggested, "What the management board should do is to create a vision and resource mobilisation. The board has come up with business models. So one of the strategies that the hospital management boards can come up with is resource mobilization for government to be sustainable and for hospital management boards to generate revenue streams to complement what they get from the national fiscus". The strategy of resource mobilisation was supported by CEO 2 who suggested, "Resource mobilisation concept should be effective through fundraising". The strategy should involve the harnessing of resources from diverse revenue streams available, for example, income-generating projects like farming and musical concerts. CEO 1 propped, "Therefore, the hospital management board has come up with a model which says that we should not be basket cases, we should not be beggars who will be going to donors. These business models started in 2018. The institution ventured into horticulture such that most of the vegetables that patients eat come from the project. The horticulture is not done commercially as yet but at subsistence level on 7 hectares of land. There is also a dry land plot where maize is grown, which produced in excess of 30 tonnes in 2018, which is used to feed patients. The institution also has 4 hectares of beans which are produced at a subsistence level". The resource mobilisation strategy is key in assisting to meet the financial demands for hospitals since funding from the treasury might be inadequate.
Boosting revenue generation is another strategy that can strengthen the performance of hospital management boards. Board chair 2 buoyed, "Most of the revenue-generating ventures commenced in 2018. The ventures include farming specializing in horticulture, maize and beans". In buttressing the concept of boosting revenue generation in health institutions, board chair 4 was quoted saying, "For instance in finance, there is need for somebody to test them to say how do you maximise revenue, how do you make sure the financial system that helps in the revenue generation is in place, cost controls…". In supporting the concept of revenue generation in hospitals CEO 5 suggested, -Since funds from the treasury are inadequate, the hospital board should implement other revenue generation projects for example boosting farming production on the already existing hospital farm. The increase in farming production can be achieved through joint ventures with reputable private farmers who have the necessary inputs like farming equipment, expertise, and adequate funding".
Capacity building is another strategy that was proffered by hospital board members in a bid to enhance the performance of hospital management boards. Board chair 3 suggested, "From inception, hospital management boards should attend some training courses or induction in order to standardise things. If appointed board members should know what is expected of them. We are coming from different backgrounds so there is a need for team building or capacity-building exercises. They were being done before but maybe they were discontinued due to certain problems. I am urging the new minister and the new permanent secretary so that people are trained on how to look after a hospital. It is necessary for people to be properly aligned and trained by whoever people from the public or private". In support of training and induction of board members board chair 4 suggested, "So there is need to come up with training program for hospital management boards. Not every board member is a good manager. They need to be taught what is it like to run a hospital". Training can be conducted either when commencing duties or during the board's term of office in an effort to sharpen the managerial skills and close the knowledge gap for non-health professionals as well as some board members drawn from other sectors.
The suggestion for in-house training was propped by CEO 5 as quoted, "Offer in-house trainings for board members to enhance their knowledge on health service delivery". The notion of in-house training is very critical, especially considering that the operating environment in the health sector continuously changes due to changes in trends related to disease burden. Even policies at the national level can be changed or modified hence the need for board members to be offered in-house training.
Board chair 4 suggested the holding of meetings as a strategy to enhance the performance of hospital management boards as quoted, "As far as the management of the hospital is concerned, the management board meets regularly to discuss during the board meetings and during management meetings". Holding regular meetings is another strategy that can enhance the performance of hospital management boards in that board members will be kept updated on the new developments in the health sector and solving challenges that might be encountered due to the continuously changing operating environment.
The process of identification and appointment of hospital management board members should be strengthened taking into consideration the good corporate governance best practices. Board chair 4 echoed proffered, "The appointment of board members should be a public event where the minister places an advert in the newspaper. Those names should come from the community not from the Ministry of Health officials and not from the HSB". The strengthening of identification and appointment of board members was reinforced by CEO 4 who was quoted saying, "One of the strategies that may work is to strengthen the process of identifying and appointing board members. When you appoint board members while there is this principle that if you want your job done don't pick somebody who is less busy or who is idle because he will be idle forever. If you want your job done pick somebody who is busy but sometimes board members may also be so busy that they then don't pay attention to important details and that sometimes you may miss the purpose of some board members". In support of competent board members for hospitals, CEO 2 propped, "The hospital should have board members who do understand the health systems and the involvement of other executive directors in hospital management boards". It is therefore critical to strengthen the appointment process for board members to attract competent and effective board members who can bring the intended benefits to the diverse stakeholders.
The concept of PPPs is a strategy that can assist in the enhancement of resource mobilisation for central hospitals. CEO 5 proffered, "There is a need to strengthen the public-private partnerships through the engagement of the business community on the financing of health services. This can be achieved through the provision of medical equipment, medicines, surgical and other critical requirements". Board chair 4 buttressed the importance of PPPs as quoted, "The concept of public-private partnerships has become very important in the sense that government alone are not in a position to finance health services including hospitals. There is a need to reach out to the private sector to support some of the activities. We have had a lot of support in the purchase of fairly expensive medical equipment. So you need a very good program for resource mobilization from the private sector". In support of partnering with the private sector, CEO 1 suggested, "The board has moved a gear up to go commercial and the institution applied for a licence from the Bulawayo City Council to do pan fattening. A plot has been established to do a horticulture project commercially which will be funded by donors. Furthermore, the institution is in negotiations with Agribank to secure a loan to start a poultry project. The board is also in talks with the Infrastructure Development Bank of Zimbabwe so that some of the lands can be used to build accommodation both for staff and the public". The relevant authorities should come up with a standard operating manual for HMBs to strengthen and standardise their functionality. Board chair 4 was quoted saying, "There is great need to develop of an operational manual for hospital management boards. The concept of management boards is something that evolved from the past so there is a need to modify and modernize. Even now there is a lack of clarity between the role of minister, ministry and the HSB".

DISCUSSION
It is evident from the findings that 6 dimensions emerged as strategies for enhancing the functionality of hospital management boards. These include 1) networking; 2) monitoring and evaluation; 3) revenue generation; 4) public-private partnerships; 5) hospital management board operational plan; 6) transparency in the selection and appointment of board members. Each one of these is discussed in the next sections respectively.
Although some of the strategies are not directly linked to the governance practice, the study results indicated that they can strengthen the performance of hospital management boards. However, hospital management boards significantly interface with the corporate world, hence the success in hospital service delivery should be attributed to the board as well.
Networking is vital in hospital management boards, thus stakeholder interface role, for example, more interaction between the board's various stakeholders such as the community, business people, the government, donors, and partners so that the vision is fully realised. Working with other organisations or hospitals is a key strategy that allows interfacing with the external environment of business. A strategy should be devised in a bid to harness and manage resources from the external environment (Scherer, 2019). Board chair 1 suggested more stakeholder involvement through workshops.
Therefore, the HMB's prime responsibility should be that of gathering concerns of society or community and bringing them to the notice of the hospital management. The study findings have shown an imperative need to do more in terms of community outreach and interaction. Stakeholder involvement or buy-in is quite key in unlocking the much-needed support in terms of resources like finances, material, and other essentials. Board members are drawn from different backgrounds and there is a need to tap into their professional and social networks. This emphasises the need for hospital boards to interact or network with stakeholders within Zimbabwe and even abroad.
Monitoring and evaluation of the performance of hospital management boards should be strengthened, through relevant policy formulation (Ahenkan & Aduo-Adjei, 2017). The study revealed the absence of a clear policy on the evaluation of performance for hospital boards and even the CEO. The CEO and the board itself should be monitored and evaluated continuously, to identify any gaps or shortfalls in their implementation process. Hence, the need to come up with a policy to assist in monitoring and evaluating board performance, putting into consideration their visions, missions, and values is vital.
The study results have revealed hospital management boards have fundraising committees; hence, more emphasis should be put on revenue generation. Fundraising has remained a key strategy for every organisation that seeks to enhance its performance (Mubyazi et al., 2004), the reason being funding is the main driver of organisational performance across organisations including hospitals (Public Finance Management Act No. 11/2009, Chapter 22:19). Hospitals should come up with business ventures or models that would sustain hospital operations and not rely solely on resources from the government. The government policy is -Zimbabwe is open for business‖ which means that hospital management boards should tap into the vast business opportunities available. A good example is that of Ingutsheni central hospital which has come up with business models to generate revenue in the form of farming specialising in horticulture, maize, and beans.
The strengthening of the PPPs is another way of strengthening the performance of hospital management boards. Of late state, organisations have realised that working in partnership with the private sector improves organisational cohesion, efficiency, and the quality of service to stakeholders (Greer, Wismar, Figueras, & McKee, 2016). A good example is that of Ingutsheni central hospital board which has approached the Infrastructure Development Bank of Zimbabwe with a view to source funds to finance the provision of accommodation for staff. Furthermore, Mpilo central hospital has approached the Bulawayo Residents Association with a view to finance the construction of a perimeter wall at the institution, and was successfully conducted. These projects can only be a success if HMBs are able to interface with key stakeholders. At Harare central hospital, the National Social Security Authority is one organisation that has adopted one of the wards and Mimosa mine which painted the nursing rooms. This is evident that HMBs should strengthen the interface with the business community in order to harness the much-needed opportunities and resources.
The development of an HMB operational manual would be a commendable initiative towards strengthening the performance of the boards. The key point raised by the finding is that there is a need to enhance the performance of board members so that they become effective in every aspect of their key result area (Lannon, 2018). As they discharge their duties, board members must thrive achieve the organisational vision (Preston & Brown, 2004). From inception, HMBs should attend some training courses or induction in order to standardise operations. Regardless of their backgrounds, the appointed members of the board should have acumen in running a hospital. In practice board members come from different backgrounds, hence there is a need for team building or capacity building exercise to bring them to a common agenda in line with the goals and aspirations of the specific health institution. To ensure that the organisation takes the right steps and direction, board members should be guided by policy (Green & Griesinger, 1996).
Transparency in the recruitment and selection of board members is another strategy that should be strengthened in achieving the best out of hospital boards. The appointment of board members ought to be a public event where the relevant authorities place adverts in the relevant media (Peggy et al., 2016). The names of prospective board members should come from the community, not from the Ministry of Health officials or the HSB. The concept of HMBs is something that evolved from the past, hence there is a need to modify and modernize it.

CONCLUSION
Although some of the strategies are not directly linked to the governance practice, the study results indicated that they can strengthen the performance of hospital management boards. However, HMBs significantly interface with the corporate world, hence the success in hospital service delivery should be attributed to the board as well. The viable strategies include networking, resource mobilisation, transparency, strengthening PPPs, HMBs' operational manuals, monitoring, and evaluation.
The study gathered data from both executive and non-executive board members, hence certain limitations were encountered during the process. Financial resources were required for transport and accommodation, as well as time constraints due to the board members' tight schedules and the sample profile only considered board chairs and CEOs who ultimately represent the interests of external and internal stakeholders respectively. Purposive sampling was employed on the 12 research participants instead of the whole population of 66 board members. The study results have implications on the healthcare governance policy and practice, for example, the ultimate influence on the development of a standard hospital board operational manual and strengthening of publicprivate partnerships. The paper provides strategies that are of relevance to public hospitals in both developed and developing countries. Failure to implement viable strategies leads to systems decay in public hospitals, hence collapsing health systems to unprecedented levels. Furthermore, this paper acts as a springboard for future research in that, the strategies highlighted have to be independently explored further, in a bid to determine their effectiveness on healthcare service provision.