Healthcare financing governance and patient outcome quality in public hospitals: Evidence from Nigeria, Kenya, and Rwanda under universal health coverage frameworks.

Background: Healthcare financing governance encompasses the institutional structures, accountability mechanisms, and resource allocation processes through which public health systems manage funding streams to achieve universal health coverage objectives. In Sub-Saharan Africa, governance deficits and fiduciary weaknesses continue to limit the translation of financing investments into improved patient outcomes.

Aim: This study examined how healthcare financing governance quality influences patient outcome indicators in public hospitals across Nigeria, Kenya, and Rwanda, with accountability mechanisms as a mediating variable.

Methodology: A mixed-methods design combined panel data from 180 public hospitals for 2014 to 2024 with qualitative interviews from 42 hospital administrators and health officials. Governance quality was assessed through a structured index. Mediation was tested using the Hayes PROCESS framework adapted for panel settings.

Findings: Governance quality showed significant negative associations with maternal mortality and positive associations with treatment success rates. Accountability mechanisms mediated 47 percent of the total governance effect. Rwanda demonstrated the strongest governance-outcome effects.

Contributions: The study advances health governance literature by establishing accountability mechanisms as a critical mediating pathway and documenting cross-country heterogeneity in UHC governance effectiveness.