Tracking Institutional Governance Evolution in a Nigerian Sub-National Hospital Management Board: A 35-Year Document-Based Evaluation
Abstract
This study examines the 35-year governance evolution (1989–2025) of the Plateau State Hospitals Management Board (PSHMB), a subnational secondary healthcare authority in north-central Nigeria, addressing the gap in longitudinal governance research in low-and middle-income countries. Using a retrospective, document-based evaluation design built on an adapted WHO Document Review Protocol, the study analyzed three governance instruments: the establishing 1989 Edict, the 2010–2015 Strategic Health Development Plan, and the 2025 Annual Operational Plan. Eleven indicators across three governance pillars; structures, processes, and outcomes were scored on a four-point maturity scale by two independent reviewers, with disagreements resolved by consensus, yielding a Combined Governance Index (CGI) at each time point. Results show the CGI rose substantially over the period: from 33.3% at PSHMB's establishment to 69.7% during the mid-period strategic-planning phase and 84.8% by the most recent operational cycle. Growth was uneven across pillars; structures were strong from inception and improved only modestly (66.7% to 83.3%), while processes rose sharply (25.0% to 91.7%) and outcomes moved from complete absence to 77.8%. Financial risk-protection integration and drug-logistics governance remained consistently underdeveloped. Findings demonstrate that legal establishment and functional governance maturity are distinct phenomena, and that meaningful governance reform requires sustained investment in process and outcome infrastructure well beyond initial establishment legislation. This research provides one of the first longitudinal, document-anchored governance trajectories for a Nigerian State Hospitals Management Board, and offers a replicable, low-cost methodology for subnational health authorities to generate their own governance evidence that directly supports Sustainable Development Goal 16