Good Governance in Primary Health Care Centers: Real-life evidence from Iran

Good Governance in Primary Health Care Centers: Real-life evidence from Iran | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Good Governance in Primary Health Care Centers: Real-life evidence from Iran Zahra Asadi-Piri, Abbas Vosoogh Moghadam, Ebrahim Jaafaripooyan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7282495/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Primary Health Care (PHC) plays a crucial role in promoting equitable health outcomes by improving access and addressing the diverse needs of populations. Evaluating good governance at the level of primary health care center is vital to identify managerial strengths and weaknesses, thereby informing policies aimed at enhancing system performance. This study aims to assess the status of good governance in Comprehensive Health Care Centers (CHCCs) affiliated with Tehran University of Medical Sciences (TUMS) in Tehran Province. Methods This cross-sectional study was conducted between October 2024 and March 2025 across 30 CHCs. Data were collected using a researcher-developed, validated Good Governance Assessment Checklist through face-to-face interviews with key stakeholders. Stratified sampling was employed drawing on their service area and administration type to ensure proportional representation across three district health networks. In addition, documents such as organizational charts, job descriptions, and performance reports were reviewed. Quantitative data were analyzed using SPSS26 and descriptive statistics. Results The average score of 34.39 (out of 100), indicates a fairly low level for good governance in the centers. The conscience dimension scored the highest (66.00), while professional ethics and rights received the lowest score (6.66). The superior governance scores of urban–rural centers suggest that hybrid management models may better accommodate local diversity and resource variability. Moreover, the outsourced CHCCs showed better performance in key areas such as Conscience, Monitoring and Evaluation, Rule of Law, Transparency, and Strategic Planning. However, in such areas as Responsiveness, Information Management, and Service Quality, the differences were trivial or slightly favored toward non-outsourced centers. Conclusion The CHCCs affiliated to TUMS face significant governance challenges, particularly in the areas of ethics, transparency, and accountability. Despite strengths in the conscience and equity, overall governance remains weak, impeding possibly the healthcare quality and responsiveness. The higher performance of urban–rural and outsourced centers highlight the potential of flexible, community-based governance models. Strengthening governance will thus require evidence-based policy-making, professional capacity building, robust monitoring systems, inclusive participation, political commitment, and cross-sector collaboration. Good Governance Primary Health Care Comprehensive Health Care Center Iran Figures Figure 1 Figure 2 Introduction Health is a fundamental pillar of sustainable development and plays a crucial role in advancing social and economic justice ( 1 , 2 ). Accordingly, the primary goal of health systems worldwide is to improve population health and foster active participation in social and economic life ( 3 ). The “Health for All” movement, launched in the 1970s, marked a major step toward achieving Universal Health Coverage (UHC). Its principles were consolidated in the 1978 Alma-Ata Declaration, which identified Primary Health Care (PHC) as the central strategy for attaining health equity ( 4 ). As the first point of contact between individuals and the health system, PHC plays a vital role in health promotion, disease prevention, and the provision of care for diverse health needs ( 5 ). Numerous studies have demonstrated that broad access to PHC is associated with improved health outcomes, reduced inequalities, and lower healthcare costs ( 6 , 7 ). The World Health Organization (WHO), in both the Alma-Ata and Astana Declarations, has recognized PHC as the foundation for equitable and effective health services for all population groups ( 8 , 9 ). Despite this evidence, health systems worldwide face mounting challenges, including population aging, the rising burden of chronic diseases, and the growing prevalence of multimorbidity ( 10 ). These developments have increased the urgency of reforming the structures of health systems and strengthening PHC. In response, the WHO called for a global revitalization of PHC in 2008—a call reaffirmed at the 2018 Global Conference on Primary Health Care in Astana, Kazakhstan ( 11 , 12 ) In this context, health governance has emerged as a critical cross-cutting determinant of health system performance ( 13 – 15 ). Governance, in a broad sense, refers to the systems, rules, and processes through which public affairs are managed. In the health sector, it encompasses the structures, institutions, and procedures that guide decision-making, policy implementation, and accountability( 16 ). The WHO defines governance as including strategic leadership, effective oversight, transparent accountability, and efficient resource allocation. However, not all forms of governance equally enhance performance ( 17 ). However, not all forms of governance equally enhance system performance. The concept of good governance has gained prominence as a benchmark for effectiveness, fairness, and responsiveness in public institutions. Good governance in health systems ensures that policies and interventions are implemented transparently, resources are managed efficiently, and population needs are prioritized( 18 – 20 ). It also helps prevent corruption—a frequent consequence of weak governance—while strengthening public trust in the health system. According to the WHO, the key elements of good health governance include accountability, transparency, participation, rule of law, equity, efficiency, and strategic vision ( 21 ). Assessing health governance is essential for identifying strengths and weaknesses within the health system. Such assessments help monitor progress, highlight structural gaps, and inform the design of corrective interventions. Governance assessment frameworks typically include measurable dimensions such as transparency, accountability, participation, equity, efficiency, effectiveness, evidence-based decision-making, and the strategic use of information. Indeed, good governance only becomes meaningful when linked to tangible indicators at the system, organizational, and individual levels ( 22 – 25 ). In addition to good governance, the increasing complexity of health systems and the growing role of technology and data-driven decision-making have given rise to the concept of smart governance. Smart health governance incorporates digital tools, predictive analytics, and real-time monitoring systems to enhance responsiveness, coordination, and resource allocation. While still emerging, this model offers promising opportunities for improving service delivery and policy effectiveness through innovation and evidence-based management ( 26 ). At the international level, organizations such as the WHO, World Bank, and United Nations Development Programme (UNDP) have developed comprehensive frameworks for assessing health governance. These frameworks integrate technical, managerial, and participatory dimensions, and emphasize local adaptation—particularly in primary health care settings ( 24 , 25 , 27 , 28 ). In Iran, the health system is structured as a mixed model involving both public and private sectors, with a strong emphasis on equitable access to care. The public sector plays a central role through an extensive network of hospitals, clinics, and community health centers, while the Social Health Insurance Organizations provide coverage for a significant portion of the population. PHC forms the cornerstone of Iran’s health system and is delivered through a nationwide network of over 24,000 rural and urban facilities. These services are organized in a multi-tiered referral system: at the first level, rural Health Houses and urban Health Posts offer basic preventive and primary services and the Comprehensive Health Care Centers (CHCs), which provide outpatient care and oversee peripheral units; and the second and third levels consist of district specialized and provincial teaching hospitals. This hierarchical structure ensures continuity of care and facilitates appropriate referrals. Despite ongoing challenges—such as communicable and non-communicable diseases, and regional disparities—Iran’s PHC network has significantly improved health indicators, expanded access in underserved areas, and strengthened public participation in health promotion( 29 )(Fig. 1 ). Nonetheless, several studies in Iran have explored various aspects of health system governance and revealed considerable challenges, including poor intersectoral coordination, weak implementation capacity, lack of robust accountability mechanisms, and structural inefficiencies. However, existing literature predominantly focuses on high-level policy issues or hospital-based governance, with limited empirical attention to governance performance within frontline PHC facilities( 30 – 35 ). This gap highlights the need to assess good governance within CHCs, which are crucial in implementing governance principles and linking policy to practice. Evaluating governance at this level aligns with global frameworks and supports the development of context-specific strategies based on local capacities and needs. Therefore, this study aims to evaluate the status of good governance in CHCCs in Tehran University of Medical Sciences (TUMS) in Tehran Province. The findings will provide evidence-based insights to support policy reforms and improve governance performance at the frontline of primary health care delivery. Method Study Design A cross-sectional research design was employed to assess the good governance attributes in the CHCs, as a part of a big project for developing a good governance framework for PHC facilities. Study Setting This study was conducted CHCCs affiliated with Tehran University of Medical Sciences (TUMS) in Tehran Province. TUMS is one of the most prestigious and oldest medical universities in Iran and the Middle East. Founded in 1851 as part of Dar ul-Funun, TUMS has played a leading role in shaping the country’s medical education, research, and healthcare system development. It’s public health deputy covers and oversees mostly the southern parts of Tehran capital city and the districts of Rey and Eslamshahr. More than three million individuals fall under the jurisdiction of this university (Based on the population estimates for 2024). As of 2024, a total of 75 CHCCs were operational in this region. Data Collection A number of 30 CHCCs were chosen based on a stratified sampling method, which was designed to ensure proportional representation across key variables. The selection was conducted from three Health Networks—South Tehran, Rey, and Eslamshahr. Within each network, CHCCs were selected proportionally according to two main criteria: Type of service area (urban, rural, or mixed), Mode of administration (outsourced or non-outsourced). This sampling approach was based on the sample size calculation formula for descriptive studies, considering a standard deviation (S) of 42 and a relative precision (D) of 12, which resulted in a final sample of 30 centers. The stratification ensured that the selected CHCCs reflected variations in geographical context and administrative models, thus enhancing the validity and generalizability of the findings. Data were collected between October 2024 and March 2025. The main data collection tools included a customized Good Governance Assessment Checklist and a document (desktop) review. To enhance data accuracy and gain in-depth insights, the checklist was completed by the researcher through direct interviews with the managerial teams and key technical staff at each CHSC. Data Collection Instrument Due to the absence of a locally customized instrument for assessing good governance in Iranian CHCs, a tailored Good Governance Assessment Checklist was developed specifically for this study. As such, firstly, a systematic literature review was conducted using the keywords such mainly as “governance,” “stewardship,” “community health centers,” “primary care,” and “governance dimensions.” The search covered databases including Web of Science, Scopus, and PubMed from 2000 to September 2024. Additionally, grey literature was reviewed via Google Scholar and reference mining of key articles. In the document review phase, 36 articles were included. Good governance dimensions and indicators were extracted and categorized at the national and organizational levels. In addition, articles, the development process incorporated practical tools and internal assessment resources commonly used in CHCs, such as checklists, supervision records, staff evaluation forms, and standardized reporting templates. These materials were examined to ensure that the final instrument was firmly grounded in real-world operational practices while maintaining methodological rigor. Additionally, national-level documents—including health sector development national plans were reviewed to align the checklist's content with the country's strategic priorities and administrative structures. Subsequently, expert panels, including nine practitioners and professionals working in the public and primary healthcare delivery, health management and policymaking, were conducted to identify and refine the key dimensions of good governance, as well as to generate relevant items and questions tailored to the context of PHC facilities and practices. Furthermore, the panel played a crucial role in reviewing, validating, and finalizing the preliminary conceptual framework, initially developed (Fig. 2 ). These dimensions collectively describe effective health center management: strong management and leadership ensures clear structure, capable leaders, and crisis readiness; participation, collaboration, and consensus involve inclusive planning, stakeholder engagement, and shared decision-making; conscientiousness refers to the dedication and responsibility of staff in performing their duties accurately and reliably, ensuring that work is aligned with regulations, protocols, and organizational standards, and that health outcomes are systematically monitored and improved. accountability and transparency promote feedback, complaint handling, and public access to information; legal compliance and professional ethics maintain adherence to laws and ethical standards; human resource management covers workforce planning, training, performance, and motivation; information and evidence management integrates data collection and research into planning; monitoring and evaluation guide performance and resource allocation; equity, responsiveness, efficiency, quality, and effectiveness ensure fair, timely, cost-effective, high-quality, and goal-oriented health services for all populations. The final conceptual framework represents good governance in PHC system at three interconnected logical levels: Foundational Dimensions, Intermediate Attributes, and Final Outcomes. At the first level, core elements such as management and leadership, strategic and operational planning, participation and consensus building and information and evidence management serve as the drivers but do not necessarily lead to final outcomes (i.e. effectiveness) unless the intermediate attributes (eg. equity, transparency and conscientiousness) have already existing in the organizations. The third group including quality, effectiveness, and efficiency are as understood, only achievable when intermediate attributes are successfully established through continuous monitoring and evaluation mechanisms. The framework further situates the good governance within the broader context of economic, political, technological, and societal factors, emphasizing that success is shaped both by internal reforms and external systemic factors. The questions, constructing an initial assessment checklist, underwent validation during which the Content Validity Ratio (CVR = 0.61) and Content Validity Index (CVI = 0.73) were calculated. Items with acceptable validity scores were retained in the final version. The reliability of the tool was assessed using Cronbach’s alpha, which yielded a score of 0.87, indicating satisfactory internal consistency. The final checklist consisted of 116 items, scored using a three-point Likert scale (no-partially-yes). Scores for each dimension of good governance were converted to a 0–100 scale. Desktop (Document) Review Documents reviewed included organizational charts of the centers, job descriptions of personnel (physicians, health workers, and center managers), internal regulations, results of patient and staff satisfaction surveys, operational PHC plans, health center performance-evaluation checklists, and other documentation demonstrating the implementation of good governance practices. Data Analysis Quantitative data were analyzed using SPSS software version 26.0. Descriptive statistics such as means, standard deviations, frequencies, and percentages were used to summarize the data. A descriptive-exploratory design was employed for the qualitative phase of the study. Results An analysis of the various dimensions of good governance across 30 CHCCs revealed an overall average governance score of 34.39 ± 7.10, indicating a generally low-to-moderate level of governance performance in the studied centers. Among the governance dimensions assessed, Conscientiousness received the highest average score (66.00 ± 15.44), followed by Equity (59.58 ± 13.40). In contrast, the lowest score was observed in the dimension of Professional Ethics and Human Rights, with an average of 6.66 ± 10.35, indicating a critical gap in ethical and rights-based practices. Other underperforming areas included Strategic and Operational Planning (12.50 ± 6.14) and Accountability (30.00 ± 17.17), both of which fell significantly below desirable thresholds (Table 1 ). A comparative analysis of governance scores across different types of CHCs—urban, rural, and urban–rural—showed notable variations in implementation. Urban–rural centers consistently achieved higher scores across most governance dimensions, particularly in Supervision, Effectiveness, and Equity. Urban centers demonstrated moderate performance in some areas, whereas rural centers generally scored the lowest across multiple governance components (Table 2 ). In addition, the comparison between outsourced and non-outsourced CHCCs revealed clear performance disparities. Outsourced centers scored higher across most governance dimensions, with especially strong results in Conscientiousness, Monitoring and Evaluation, Rule of Law, Transparency, Strategic and Operational Planning, and Effectiveness (Table 3 ). However, for certain dimensions—including Responsiveness, Information and Evidence Management, and Quality and Safety of Services—performance differences were minimal or slightly favored non-outsourced centers. It is noteworthy that the Professional Ethics and Human Rights dimension remained consistently low in both groups, highlighting a system-wide deficiency in this critical area. Table 1 Mean (%) and SD of the overall GG score in the CHCCs (N = 30) Governance Dimensions Maximum Minimum Mean ± Std. Dev. Management & Leadership 12.50 68.75 43.54 ± 17.40 Strategic and Operational Planning 6.25 25.00 12.50 ± 6.14 Participation, Collaboration, and Consensus Building 14.29 50.00 29.52 ± 8.54 Conscientiousness 40.00 90.00 66.00 ± 15.44 Accountability .00 50.00 30.00 ± 17.17 Legal and Regulatory Compliance 12.50 62.50 39.37 ± 15.49 Information and Evidence Management 33.33 58.33 40.83 ± 7.99 Human Resource Management 12.50 50.00 32.91 ± 9.41 Professional Ethics and Rights .00 33.33 6.66 ± 10.35 Monitoring and Evaluation (M&E) 28.57 64.29 44.28 ± 12.06 Equity 37.50 87.50 59.58 ± 13.40 Responsiveness 40.00 80.00 49.00 ± 13.48 Transparency 12.50 50.00 32.08 ± 10.21 Efficiency 14.29 42.86 29.76 ± 9.94 Quality and Safety 7.69 50.00 32.30 ± 12.95 Effectiveness 15.63 59.38 46.04 ± 12.03 Good Governance/Overall 16.67 44.05 34.39 ± 7.10 Table 2 Total good governance (CG) scores and its dimensions by type of CHCs CG Dimension Urban Rural Urban–Rural Minimum Maximum Mean ± Std. Minimum Maximum Mean ± Std. Minimum Maximum Mean ± Std. Management& Leadership 12.50 68.75 44.56 ± 16.46 12.50 68.75 34.37 ± 25.25 31.25 62.50 47.91 ± 15.72 Strategic and Operational Planning 6.25 25.00 12.50 ± 6.25 6.25 12.50 9.37 ± 3.60 12.50 25.00 16.66 ± 7.21 Participation, Collaboration, and Consensus Building 14.29 50.00 30.74 ± 7.89 14.29 28.57 19.64 ± 6.83 28.57 42.86 33.33 ± 8.24 Conscientiousness 40.00 90.00 66.95 ± 14.90 40.00 90.00 57.50 ± 22.17 60.00 80.00 70.00 ± 10.00 Accountability .00 50.00 31.15 ± 16.89 .00 33.33 16.66 ± 13.60 16.67 50.00 38.88 ± 19.24 Legal and Regulatory Compliance 12.50 62.50 40.21 ± 15.17 12.50 37.50 25.00 ± 11.41 43.75 62.50 52.08 ± 9.54 Information and Evidence Management 33.33 58.33 41.30 ± 7.73 33.33 41.67 35.41 ± 4.16 33.33 58.33 44.44 ± 12.72 Human Resource Management 12.50 50.00 33.96 ± 8.80 12.50 31.25 23.43 ± 7.86 31.25 50.00 37.50 ± 10.82 Professional Ethics and Rights .00 33.33 7.24 ± 11.03 .00 16.67 4.16 ± 8.33 .00 16.67 5.55 ± 9.62 Monitoring and Evaluation (M&E) 28.57 64.29 45.03 ± 11.68 28.57 35.71 32.14 ± 4.12 42.86 64.29 54.76 ± 10.91 Equity 37.50 87.50 62.50 ± 13.05 37.50 62.50 46.87 ± 11.96 50.00 62.50 54.16 ± 7.21 Responsiveness 40.00 80.00 48.69 ± 13.58 40.00 50.00 45.00 ± 5.77 40.00 80.00 56.66 ± 20.81 Transparency 12.50 50.00 33.15 ± 10.56 18.75 31.25 23.43 ± 5.98 31.25 43.75 35.41 ± 7.21 Efficiency 14.29 42.86 29.50 ± 10.17 21.43 28.57 23.21 ± 3.57 35.71 42.86 40.47 ± 4.12 Quality and Safety 7.69 50.00 33.94 ± 11.80 7.69 38.46 18.26 ± 13.82 26.92 50.00 38.46 ± 11.53 Effectiveness 15.63 59.38 48.50 ± 10.05 15.63 53.13 30.46 ± 16.01 40.63 53.13 47.91 ± 6.50 Good Governance 44.05 16.67 35.40 ± 6.19 16.67 33.33 25.00 ± 6.81 36.11 44.05 39.15 ± 4.28 Table 3 Good Governance (CG) scores and its dimensions by type of management of CHCs CG Dimension Governmental Outsourced Minimum Maximum Mean ± Std. Minimum Maximum Mean ± Std. Management& Leadership 12.50 68.75 43.75 ± 17.86 25.00 62.50 42.50 ± 16.77 Strategic and Operational Planning 6.25 25.00 12.00 ± 5.38 6.25 25.00 15.00 ± 9.47 Participation, Collaboration, and Consensus Building 14.29 50.00 29.14± 28.57 42.86 31.42 ± 6.38 Conscientiousness 40.00 90.00 65.6000 60.00 80.00 68.00 ± 8.36 Accountability .00 50.00 28.6667 16.67 50.00 36.66 ± 18.25 Legal and Regulatory Compliance 12.50 62.50 38.2500 37.50 62.50 45.00 ± 10.26 Information and Evidence Management 33.33 58.33 40.6667 33.33 58.33 41.66 ± 10.20 Human Resource Management 12.50 50.00 32.2500 31.25 43.75 36.25 ± 6.84 Professional Ethics and Rights .00 33.33 6.6667 .00 16.67 6.66 ± 9.12 Monitoring and Evaluation (M&E) 28.57 64.29 42.8571 35.71 64.29 51.42 ± 14.63 Equity 37.50 87.50 58.5000 50.00 75.00 65.00 ± 10.45 Responsiveness 40.00 80.00 49.2000 40.00 80.00 48.00 ± 17.88 Transparency 12.50 50.00 31.2500 31.25 43.75 36.25 ± 6.84 Efficiency 14.29 42.86 29.1429 21.43 42.86 32.85 ± 10.83 Quality and Safety 7.69 50.00 32.4615 26.92 50.00 31.53 ± 10.32 Effectiveness 15.63 59.38 44.8750 50.00 53.13 51.87 ± 1.71 Good Governance 16.67 44.05 33.8571 33.33 44.05 37.06 ± 4.37 Discussion In recent years, good governance has emerged as a central pillar in enhancing the quality, effectiveness, and efficiency of health systems( 36 , 37 ). Governance indicators not only serve as mechanisms to promote transparency, accountability, and organizational responsibility, but also play a critical role in health policy-making and evidence-based decision-making( 38 ). Assessing these indicators, particularly within primary healthcare delivery systems, can uncover structural shortcomings, managerial deficiencies, and limited stakeholder engagement, thus creating a foundation for effective reform-oriented interventions. The findings of this study, which assessed governance in CHCs across Iran, highlight substantial gaps in the application of good governance principles. With an average score of 34.39 out of 100, the results point to poor-to-moderate overall performance. This reflects significant structural and operational weaknesses that hinder the effective functioning of primary healthcare centers and, in turn, impact service quality and health equity. When viewed in a global context, these findings align with governance challenges reported in other low- and middle-income countries. For example, a 2018 study in Kenya revealed that only 10% of participants perceived governance practices as satisfactory, with systemic issues such as corruption, political interference, and inequitable resource distribution impeding progress( 39 ). In contrast, a study from Zambia reported far more favorable evaluations of governance, likely due to greater institutional autonomy and a decentralized governance structure(40). This stark difference may be explained by variations in organizational infrastructure, cultural norms, and the degree of institutional autonomy granted to health authorities. Zambia’s relatively decentralized governance structure and enhanced local accountability mechanisms might contribute to the more favorable outcomes reported. Within Iran, the governance challenges identified in CHCCs are not isolated incidents but are consistent with findings from several national-level studies. Rahimi et al. highlighted fundamental problems in areas such as planning, organizational alignment, intersectoral coordination, and performance evaluation. Their research indicated that inefficiencies in these domains significantly limit the overall effectiveness of health governance( 41 ). Similarly, a systematic review by Behzadi-Fard and colleagues emphasized the widespread difficulty in implementing clinical governance elements within Iran’s health system( 35 ). Their study identified inadequate infrastructure and insufficient stakeholder engagement as major impediments to policy execution. They stressed that without supportive systems and active collaboration from relevant actors; even well-designed policies are unlikely to achieve their intended impact. These national findings align closely with broader observations from the World Health Organization, which has documented several structural barriers to effective health governance in low- and middle-income countries. Common issues include limited stakeholder participation, the absence of robust monitoring and evaluation systems, and policymaking processes that are not sufficiently grounded in evidence( 42 ). These challenges diminish the capacity of health systems to respond efficiently to public health needs and allocate resources in a manner that maximizes health outcomes. Importantly, governance functions not only as a determinant of health system efficiency but also as a critical mediator between the allocation of resources and the realization of improved health outcomes at the population level. Weaknesses in governance structures can result in mismanagement, inefficiency, and resource wastage, thereby undermining the effectiveness of public health interventions. As such, strengthening governance should be prioritized as a foundational strategy for improving primary healthcare services, ensuring equity, and advancing overall health system performance. Conscience scored highest among governance components, indicating a relatively strong commitment by staff to their responsibilities. However, achieving comprehensive Conscience is not feasible in isolation—it requires the simultaneous realization of interconnected governance elements such as transparency, equity, adherence to the rule of law, and public participation. Among the measured components, Conscience received the highest score, suggesting that staff in these centers show a relative level of commitment to their responsibilities and are, relatively, answerable for their actions. However, achieving comprehensive Conscience is not feasible in isolation—it requires the simultaneous realization of interconnected governance elements such as transparency, equity, adherence to the rule of law, and public participation. Conscientiousness gains meaning only in systems where decision-making is transparent, complaints are systematically addressed, and public oversight is embedded ( 43 ). In this context, experiences from countries like Indonesia illustrate that raising public awareness about individual rights and responsibilities not only enhance civic engagement but also establishes the foundation for sustained and effective governance through social responsibility mechanisms ( 44 ). becomes meaningful only when decision-making processes are transparent, mechanisms for registering and addressing complaints exist, and public oversight is institutionalized( 43 ). In this context, experiences from countries like Indonesia illustrate that raising public awareness about individual rights and responsibilities not only enhances civic engagement but also establishes the foundation for sustained and effective governance through social responsibility mechanisms( 44 ). Equity also emerged as a relatively strong component. In this study, equity was defined as the provision of standardized and comprehensive service packages to different demographic groups—including gender, age, and geographical distribution—along with fair treatment of staff and patients. Such a comprehensive definition underscores the importance of equal access to health services at all levels. International comparisons reveal significant variation in how equity is implemented. In Canada, for example, financial incentives and performance-based reporting mechanisms are integrated into physician contracts, promoting both equitable access and service motivation( 45 ). In contrast, studies from Kenya show that equity in healthcare is not adequately observed, largely due to structural and administrative limitations( 39 ). A study conducted in Egypt reported a notable divergence in the perception of equity: while providers and administrators gave relatively moderate scores, users perceived a much higher level of fairness—highlighting the subjective nature of equity as experienced by different stakeholder groups( 46 ). A particularly concerning finding in this study relates to professional ethics and human rights, which received the lowest score among the governance components. This indicates a severe weakness in this area, likely stemming from a lack of sustained training in medical ethics, the absence of performance evaluation systems grounded in ethical standards, and the lack of clearly defined mechanisms for protecting patient rights. Comparative studies support these findings. For example, in Jordan, the absence of formal legal frameworks has led to widespread violations of patients’ rights( 47 ),while in Norway, systemic barriers such as limited resources, insufficient professional training, and ethical decision-making difficulties have been reported at the organizational level( 48 ). National research, including the work of Monaafi et al. (2018), emphasizes the critical role of ethical principles in resource allocation decisions—particularly in environments where resources are constrained( 49 ). Likewise, a systematic review by Rastegari-Mehr et al. (2025) underscores the necessity of continual monitoring of both patient and employee rights as key indicators in accrediting primary care centers, which also directly contribute to improved service quality, patient trust, and staff satisfaction( 50 ). Another important dimension revealed by the findings relates to the structural composition of the health centers. Centers operating under urban–rural hybrid models demonstrated stronger performance across most governance indicators compared to centers located exclusively in urban or rural areas. This strength may be attributed to a broader population base, more diverse resources, and greater managerial flexibility, allowing services to be better tailored to local and cultural contexts. Studies from China and Bangladesh corroborate these results, indicating that although urban areas generally offer better infrastructure and service quality, community health centers in rural areas—when adequately funded and well-organized—can also deliver effective care( 51 , 52 ). In the United States, rural health centers that operate under community-based governance structures have been more successful in building public trust and responding to local needs( 53 ). However, these models are not without challenges, particularly the difficulty in conducting objective performance assessments due to the lack of anonymity and standardized evaluation tools. The study further found that outsourced CHCs outperformed non-outsourced centers in key governance areas such as planning, monitoring, transparency, and overall effectiveness. This suggests that transferring certain managerial responsibilities to non-governmental actors can enhance organizational flexibility and service quality. Supporting evidence from New Zealand shows that non-profit and community-led centers are more likely to have documented policies for quality assurance, complaint handling, and emergency response, and they tend to be more active in community needs assessments and service planning( 54 , 55 ). This shift away from traditional state-led models toward community-driven and non-profit management approaches not only promotes transparency but also enables stronger stakeholder participation and responsiveness. Nonetheless, public ownership retains strategic value, particularly in mitigating some of the pitfalls associated with for-profit private models, such as reduced accountability and limited control over strategic assets. However, publicly owned models may still fall short in responding to the unique needs of marginalized or minority communities, especially if decision-making is dominated by narrow interest groups. In such contexts, community-managed non-profit organizations serve as vital intermediaries for advancing local autonomy, addressing the needs of minority populations, and piloting innovative policy interventions. Finally, the study emphasizes the importance of public–private partnerships (PPPs) in enhancing governance within urban health systems. Findings from a 2019 study confirm that stronger collaboration between public and private sectors improves access to healthcare services( 56 ). These results are consistent with broader reviews of primary healthcare (PHC) delivery, which affirm that—despite inherent challenges—well-structured PPPs can facilitate access, especially in underserved and remote regions( 57 ). Long-term planning and context-sensitive policymaking are essential to the successful development of PPPs. A noteworthy example is Brazil, where the government addressed workforce shortages by contracting primary care services through non-governmental organizations. This model significantly improved the quality of care and exemplifies the transformative role of NGOs in strengthening health system governance( 58 ). This study has several limitations that should be acknowledged. First, the cross-sectional design restricts causal interpretations between governance dimensions and performance outcomes. Additionally, the use of self-reported data and face-to-face interviews could also introduce social desirability bias, particularly in responses related to accountability or ethics. Moreover, the assessment tool, while contextually validated, lacks direct comparability with internationally standardized governance frameworks. Despite these limitations, the study offers valuable empirical insight into frontline governance in Iran's primary healthcare system and lays the groundwork for further research and policy reform. Conclusion The findings of this study reveal significant structural and operational deficiencies in the governance of Iran’s CHCs. While certain dimensions such as Conscience and Equity show relative strength, consistently low scores in Ethics, Transparency, and Accountability highlight a fragmented and underperforming governance framework. These deficiencies directly impact the quality and equity of primary healthcare services. Encouragingly, the better performance observed in urban–rural hybrid and outsourced centers suggests that flexible, community-driven management models may offer a viable path forward. To realize such improvements more broadly, systemic reform is essential. This includes evidence-based policymaking, capacity building, enhanced monitoring, and inclusive stakeholder engagement. Ultimately, strengthening governance is not merely a technical adjustment—it is a foundational strategy to foster public trust, ensure fair resource distribution, and improve health outcomes. Achieving this vision requires sustained political will, institutional commitment, and collaborative action across public and non-governmental sectors. Abbreviations PHC Primary Health Care CHCC S Comprehensive Health Care Centers TUMS Tehran University of Medical Sciences CG Good Governance UHC Universal Health Coverage WHO World Health Organization UNDP United Nations Development Programme CVR Content Validity Ratio CVI Content Validity Index Declarations Ethics approval and consent to participate: Ethical approval for this study was obtained from the Ethics Committee of TUMS [The Code of Ethics: IR.TUMS.SPH.REC.1402.011]. Informed consent to participate was obtained from all participants before data collection. Participants were informed about the study's purpose and their rights, including the right to withdraw at any time without consequences. verbal consent was obtained from all participants in accordance with ethical guidelines. This study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable. Availability of Data, Tools and Materials: The datasets comprise the quantitative assessment results and internal organizational documents from CHCCs affiliated with TUMS. In line with the confidentiality agreements made with the participating centers, these datasets are not publicly available. However, anonymized and aggregated data supporting the study findings may be obtained from the corresponding author upon request. Checklist will also be provided upon request. Competing interests : The authors declare no competing interests. Funding: The present study is part of a PhD thesis conducted in TUMS. Authors' Contributions ZAP contributed to the conceptualization and design of the study, conducted the literature search and data extraction, and drafted the manuscript. AVM contributed to the study design, provided critical input on governance frameworks, and reviewed the manuscript for intellectual content. EJP led the overall study supervision, critically revised the manuscript, and approved the final version for submission. All authors read and approved the final manuscript. References Newman LA. The health care system as a social determinant of health: qualitative insights from South Australian maternity consumers. Aust Health Rev. 2009;33(1):62–71. Raminashvili D, Gvanceladze T, Kajrishvili M, Zarnadze I, Sh Z. Social environment, bases social markers and health care system in Shida Kartli region. Georgian Med News. 2009(175):68–70. Franken M, Koolman X. Health system goals: a discrete choice experiment to obtain societal valuations. Health Policy. 2013;112(1–2):28–34. Organization WH, editor. Primary health care: report of the International Conference on primary health care, Alma-Ata, USSR, 6–12 September 1978/jointly sponsored by the world Health organization and the United nations children's fund. : report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978/jointly sponsored by the World Health Organization and the United Nations Children's Fund; 1978. Kreindler SA, Metge C, Struthers A, Harlos K, Charette C, Bapuji S, et al. Primary care reform in Manitoba, Canada, 2011–15: balancing accountability and acceptability. Health Policy. 2019;123(6):532–7. Chang C-H, Stukel TA, Flood AB, Goodman DC. Primary care physician workforce and Medicare beneficiaries' health outcomes. JAMA. 2011;305(20):2096–104. Thomas SL, Wakerman J, Humphreys JS. Ensuring equity of access to primary health care in rural and remote Australia-what core services should be locally available? Int J Equity Health. 2015;14:1–8. Hone T, Macinko J, Millett C. 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Health Policy Plann. 2014;29(6):685–93. Savedoff WD. Governance in the health sector: a strategy for measuring determinants and performance. World Bank policy research working paper. 2011(5655). Mooketsane KS, Phirinyane MB. Health governance in sub-Saharan Africa. Global social policy. 2015;15(3):345–8. Organization WH. Global tuberculosis report 2013: World health organization; 2013. Lewis M, Pettersson Gelander G. Governance in health care delivery: raising performance. World Bank Policy Research Working Paper. 2009(5074). Savedoff WD, Smith PC. Measuring governance: accountability, management and research. Strength Health Syst Gov. 2016:85. Gurung G, Derrett S, Hill PC, Gauld R. Governance challenges in the Nepalese primary health care system: time to focus on greater community engagement? Int J Health Plann Manag. 2016;31(2):167–74. Gray JM. The shift to personalised and population medicine. Lancet. 2013;382(9888):200–1. Gilson L, Lehmann U, Schneider H. Practicing governance towards equity in health systems: LMIC perspectives and experience. Springer; 2017. pp. 1–5. Gilson L, Doherty J, Lowenson R, Francis V. Challenging inequity through health systems. Final report. Knowledge Network on Health Systems. 2007. Mikkelsen-Lopez I, Wyss K, De Savigny D. An approach to addressing governance from a health system framework perspective. BMC Int health Hum rights. 2011;11:1–11. Siddiqi S, Masud TI, Nishtar S, Peters DH, Sabri B, Bile KM, et al. Framework for assessing governance of the health system in developing countries: gateway to good governance. Health Policy. 2009;90(1):13–25. Kickbusch I, Gleicher D. Smart governance for health and well-being: the evidence. Smart governance for health and well-being: the evidence2014. Taylor L. The world bank and the environment: the world development report 1992. World Dev. 1993;21(5):869–81. Pyone T, Smith H, van den Broek N. Frameworks to assess health systems governance: a systematic review. Health Policy Plann. 2017;32(5):710–22. Aboutorabi A, Teli BD, Rezapour A, Ehsanzadeh SJ, Martini M, Behzadifar M. History of primary health care in Iran. J Prev Med Hyg. 2023;64(3):E367. Khodayari-Zarnaq R, Mobasseri K, Ghasemyani S, Sadeghi-Ghyassi F, Naghshi M, Kabiri N. Challenges and Weaknesses of Leadership and Governance-related Health Policies in Iran: A Systematic Review. Arch Iran Med. 2024;27(9):508. Dehnavieh R, Ebrahimipour H, Jafari Zadeh M, Dianat M, Noori Hekmat S, Mehrolhassani MH. Clinical governance: The challenges of implementation in Iran. Int J Hosp Res. 2013;2(1):1–10. Tabrizi JS, Pourasghar F, Nikjoo RG. Governance of iranian primary Health Care System: perceptions of experts. Iran J Public Health. 2019;48(3):541. Hooshmand E, Tourani S, Ravaghi H, Ebrahimipour H. Challenges in evaluating clinical governance systems in Iran: a qualitative study. Iran Red Crescent Med J. 2014;16(4):e13421. Aboulhallaj M, Mousavi SM, Jafari M, Vosoogh-Moghaddam A, Bahariniya S, Ghasemyani S, et al. Challenges and executive requirements of advanced health system governance based on general health policies in Iran: qualitative research. BMC Health Serv Res. 2024;24(1):1517. Behzadifar M, Bragazzi NL, Arab-Zozani M, Bakhtiari A, Behzadifar M, Beyranvand T, et al. The challenges of implementation of clinical governance in Iran: a meta-synthesis of qualitative studies. Health Res policy Syst. 2019;17:1–14. Safaei J. Is democracy good for health? Int J Health Serv. 2006;36(4):767–86. Navarro V, Muntaner C. Political and economic determinants of population health and well-being: controversies and developments. Baywood Amityville, NY; 2004. Greer S, Wismar M, Figueras J. Strengthening health system governance: better policies, stronger performance. McGraw-Hill Education (UK); 2015. Sitienei J, Nangami M, Manderson L. The Implementation of Governance Attributes in Health in Uasin Gishu County, Kenya. East Afr Health Res J. 2018;2(2):91. Mutale W, Mwanamwenge MT, Balabanova D, Spicer N, Ayles H. Measuring governance at health facility level: developing and validation of simple governance tool in Zambia. BMC Int health Hum rights. 2013;13:1–9. Rahimi H, Haghdoost A, Noorihekmat S. A qualitative study of challenges affecting the primary care system performance: Learning from Iran's experience. Health Sci Rep. 2022;5(2):e568. WHO. Primary health care on the road to universal health coverage: 2019 monitoring report. Switzerland: WHO Geneva; 2019. Abbasi M, Rezaee R, Dehghani G. Concept and situation of the right to health in Iran legal system. Med Law J. 2014;8(30):183–99. Hasanbasri M, Maula AW, Wiratama BS, Espressivo A, Marthias T. Analyzing Primary Healthcare Governance in Indonesia: Perspectives of Community Health Workers. Cureus. 2024;16(3). Mukhi S, Barnsley J, Deber RB. Accountability and primary healthcare. Healthc Policy. 2014;10(SP):90. Fatah AE, Ali TA, Elazazy NA, Dowidar EM, Abd Elgalil NL, Mohamed HM. Assessment of clinical governance in primary health care services: a case study on Dakahlia governorate, Egypt. Egypt J Hosp Med. 2019;76(1):3355–65. Jabbour S. Public health in the Arab World: at a crossroads. J Public Health Policy. 2013;34:356–60. Lillemoen L, Pedersen R. Ethical challenges and how to develop ethics support in primary health care. Nurs Ethics. 2013;20(1):96–108. Manafi F, Takian AH, Sari AA. Assessing the governance of human resources for health in Iran: A qualitative study. J Educ health promotion. 2019;8(1):97. Rastegarimehr B, Teymourlouy AA, Gorji HA. Accreditation of primary health care services: A systematic review. J Educ Health Promotion. 2025;14(1):15. Shi L, Lee D-C, Liang H, Zhang L, Makinen M, Blanchet N, et al. Community health centers and primary care access and quality for chronically-ill patients–a case-comparison study of urban Guangdong Province, China. Int J Equity Health. 2015;14:1–17. Albis MLF, Bhadra SK, Chin B. Impact evaluation of contracting primary health care services in urban Bangladesh. BMC Health Serv Res. 2019;19:1–12. Wright B. Rural-urban differences in consumer governance at community health centers. J Rural Health. 2013;29(2):125–31. Crampton P, Starfield B. A case for government ownership of primary care services in New Zealand: weighing the arguments. Int J Health Serv. 2004;34(4):709–27. Crampton P, Davis P, Lay-Yee R, Raymont A, Forrest CB, Starfield B. Does community-governed nonprofit primary care improve access to services? Cross-sectional survey of practice characteristics. Int J Health Serv. 2005;35(3):465–78. Obosi JO. Decentralized governance in the management of urban health care systems in developing countries. Open J Political Sci. 2019;9(01):189. Joudyian N, Doshmangir L, Mahdavi M, Tabrizi JS, Gordeev VS. Public-private partnerships in primary health care: a scoping review. BMC Health Serv Res. 2021;21:1–18. Ireland M, Cavalini L, Girardi S, Araujo EC, Lindelow M. Expanding the primary health care workforce through contracting with nongovernmental entities: the cases of Bahia and Rio de Janeiro. Hum Resour health. 2016;14:1–11. Additional Declarations No competing interests reported. Supplementary Files chechlist3.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7282495","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502913457,"identity":"873e04b4-6ffd-48a4-b533-69d623a15b1f","order_by":0,"name":"Zahra Asadi-Piri","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Asadi-Piri","suffix":""},{"id":502913458,"identity":"291871b0-b19b-4122-8cad-c8354a5b7fa7","order_by":1,"name":"Abbas Vosoogh Moghadam","email":"","orcid":"","institution":"National Institute for Health Research, Tehran University of Medical Sciences (TUMS)","correspondingAuthor":false,"prefix":"","firstName":"Abbas","middleName":"Vosoogh","lastName":"Moghadam","suffix":""},{"id":502913459,"identity":"85b5bcd6-81c7-4fae-8059-9adb91b96c61","order_by":2,"name":"Ebrahim Jaafaripooyan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYBACxgYGhg8MDBJQbgVcQgKrcqgWxhkIBWcMCGsB6ZqBYLYZ4FEIBczthx82/NxjkcfP3mP4uXDen8S1/QcYP/xgsMjHaUVPmmFjzzOJYsmeM8bSM7cZJG67kcAs2cMgYdmA0y8J5g94DkgkbriRYyDNC9bCwCAN9AtOJzL2P//Y+Aeixfg37xyglvMHmH/j1TIjx7AZaouZNG8DUMuBBDb8tsx4U9gscwDkl2Nl1jzHjI233Uhss+wxwK3FsD99Y+ObA3XAEGvefJunRk522/nDh2/8qKjDraUBQicwMHDAFIFSBJ74kWeAa2F/gFvZKBgFo2AUjGgAAIl9WKdxQSADAAAAAElFTkSuQmCC","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Ebrahim","middleName":"","lastName":"Jaafaripooyan","suffix":""}],"badges":[],"createdAt":"2025-08-03 09:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7282495/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7282495/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89698438,"identity":"8dec58c3-f464-4661-8051-d4a0d6443336","added_by":"auto","created_at":"2025-08-22 18:56:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":82523,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePHC structure at the provincial level in Iran\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7282495/v1/8cf74a074264e9c4b29451a5.jpg"},{"id":89698443,"identity":"c9f74ede-133c-458f-8065-c404a7c415d1","added_by":"auto","created_at":"2025-08-22 18:56:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":493455,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConceptual framework of good governance in CHCs\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7282495/v1/6811278b9dcbc1f8d13478e8.jpg"},{"id":89790193,"identity":"f6e7bd91-4bb5-420c-91ee-43a0e08b33a3","added_by":"auto","created_at":"2025-08-25 05:32:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1827037,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7282495/v1/e3b818cf-c96c-4b08-85e3-803cd4112540.pdf"},{"id":89698440,"identity":"ac19485b-9e26-483c-90ef-13340d0dd73c","added_by":"auto","created_at":"2025-08-22 18:56:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":275369,"visible":true,"origin":"","legend":"","description":"","filename":"chechlist3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7282495/v1/f238185b4849d9808a14852d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Good Governance in Primary Health Care Centers: Real-life evidence from Iran","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth is a fundamental pillar of sustainable development and plays a crucial role in advancing social and economic justice (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Accordingly, the primary goal of health systems worldwide is to improve population health and foster active participation in social and economic life (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The \u0026ldquo;Health for All\u0026rdquo; movement, launched in the 1970s, marked a major step toward achieving Universal Health Coverage (UHC). Its principles were consolidated in the 1978 Alma-Ata Declaration, which identified Primary Health Care (PHC) as the central strategy for attaining health equity (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As the first point of contact between individuals and the health system, PHC plays a vital role in health promotion, disease prevention, and the provision of care for diverse health needs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Numerous studies have demonstrated that broad access to PHC is associated with improved health outcomes, reduced inequalities, and lower healthcare costs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The World Health Organization (WHO), in both the Alma-Ata and Astana Declarations, has recognized PHC as the foundation for equitable and effective health services for all population groups (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite this evidence, health systems worldwide face mounting challenges, including population aging, the rising burden of chronic diseases, and the growing prevalence of multimorbidity (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These developments have increased the urgency of reforming the structures of health systems and strengthening PHC. In response, the WHO called for a global revitalization of PHC in 2008\u0026mdash;a call reaffirmed at the 2018 Global Conference on Primary Health Care in Astana, Kazakhstan (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) In this context, health governance has emerged as a critical cross-cutting determinant of health system performance (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eGovernance, in a broad sense, refers to the systems, rules, and processes through which public affairs are managed. In the health sector, it encompasses the structures, institutions, and procedures that guide decision-making, policy implementation, and accountability(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The WHO defines governance as including strategic leadership, effective oversight, transparent accountability, and efficient resource allocation. However, not all forms of governance equally enhance performance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, not all forms of governance equally enhance system performance. The concept of good governance has gained prominence as a benchmark for effectiveness, fairness, and responsiveness in public institutions. Good governance in health systems ensures that policies and interventions are implemented transparently, resources are managed efficiently, and population needs are prioritized(\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It also helps prevent corruption\u0026mdash;a frequent consequence of weak governance\u0026mdash;while strengthening public trust in the health system. According to the WHO, the key elements of good health governance include accountability, transparency, participation, rule of law, equity, efficiency, and strategic vision (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Assessing health governance is essential for identifying strengths and weaknesses within the health system. Such assessments help monitor progress, highlight structural gaps, and inform the design of corrective interventions. Governance assessment frameworks typically include measurable dimensions such as transparency, accountability, participation, equity, efficiency, effectiveness, evidence-based decision-making, and the strategic use of information. Indeed, good governance only becomes meaningful when linked to tangible indicators at the system, organizational, and individual levels (\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition to good governance, the increasing complexity of health systems and the growing role of technology and data-driven decision-making have given rise to the concept of smart governance. Smart health governance incorporates digital tools, predictive analytics, and real-time monitoring systems to enhance responsiveness, coordination, and resource allocation. While still emerging, this model offers promising opportunities for improving service delivery and policy effectiveness through innovation and evidence-based management (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). At the international level, organizations such as the WHO, World Bank, and United Nations Development Programme (UNDP) have developed comprehensive frameworks for assessing health governance. These frameworks integrate technical, managerial, and participatory dimensions, and emphasize local adaptation\u0026mdash;particularly in primary health care settings (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Iran, the health system is structured as a mixed model involving both public and private sectors, with a strong emphasis on equitable access to care. The public sector plays a central role through an extensive network of hospitals, clinics, and community health centers, while the Social Health Insurance Organizations provide coverage for a significant portion of the population. PHC forms the cornerstone of Iran\u0026rsquo;s health system and is delivered through a nationwide network of over 24,000 rural and urban facilities. These services are organized in a multi-tiered referral system: at the first level, rural Health Houses and urban Health Posts offer basic preventive and primary services and the Comprehensive Health Care Centers (CHCs), which provide outpatient care and oversee peripheral units; and the second and third levels consist of district specialized and provincial teaching hospitals. This hierarchical structure ensures continuity of care and facilitates appropriate referrals. Despite ongoing challenges\u0026mdash;such as communicable and non-communicable diseases, and regional disparities\u0026mdash;Iran\u0026rsquo;s PHC network has significantly improved health indicators, expanded access in underserved areas, and strengthened public participation in health promotion(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNonetheless, several studies in Iran have explored various aspects of health system governance and revealed considerable challenges, including poor intersectoral coordination, weak implementation capacity, lack of robust accountability mechanisms, and structural inefficiencies. However, existing literature predominantly focuses on high-level policy issues or hospital-based governance, with limited empirical attention to governance performance within frontline PHC facilities(\u003cspan additionalcitationids=\"CR31 CR32 CR33 CR34\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This gap highlights the need to assess good governance within CHCs, which are crucial in implementing governance principles and linking policy to practice. Evaluating governance at this level aligns with global frameworks and supports the development of context-specific strategies based on local capacities and needs. Therefore, this study aims to evaluate the status of good governance in CHCCs in Tehran University of Medical Sciences (TUMS) in Tehran Province. The findings will provide evidence-based insights to support policy reforms and improve governance performance at the frontline of primary health care delivery.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eA cross-sectional research design was employed to assess the good governance attributes in the CHCs, as a part of a big project for developing a good governance framework for PHC facilities.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted CHCCs affiliated with Tehran University of Medical Sciences (TUMS) in Tehran Province. TUMS is one of the most prestigious and oldest medical universities in Iran and the Middle East. Founded in 1851 as part of Dar ul-Funun, TUMS has played a leading role in shaping the country\u0026rsquo;s medical education, research, and healthcare system development. It\u0026rsquo;s public health deputy covers and oversees mostly the southern parts of Tehran capital city and the districts of Rey and Eslamshahr. More than three million individuals fall under the jurisdiction of this university (Based on the population estimates for 2024). As of 2024, a total of 75 CHCCs were operational in this region.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eA number of 30 CHCCs were chosen based on a stratified sampling method, which was designed to ensure proportional representation across key variables. The selection was conducted from three Health Networks\u0026mdash;South Tehran, Rey, and Eslamshahr. Within each network, CHCCs were selected proportionally according to two main criteria: Type of service area (urban, rural, or mixed), Mode of administration (outsourced or non-outsourced).\u003c/p\u003e\u003cp\u003eThis sampling approach was based on the sample size calculation formula for descriptive studies, considering a standard deviation (S) of 42 and a relative precision (D) of 12, which resulted in a final sample of 30 centers. The stratification ensured that the selected CHCCs reflected variations in geographical context and administrative models, thus enhancing the validity and generalizability of the findings.\u003c/p\u003e\u003cp\u003eData were collected between October 2024 and March 2025. The main data collection tools included a customized \u003cem\u003eGood Governance Assessment Checklist\u003c/em\u003e and a document (desktop) review. To enhance data accuracy and gain in-depth insights, the checklist was completed by the researcher through direct interviews with the managerial teams and key technical staff at each CHSC.\u003c/p\u003e\n\u003ch3\u003eData Collection Instrument\u003c/h3\u003e\n\u003cp\u003eDue to the absence of a locally customized instrument for assessing good governance in Iranian CHCs, a tailored Good Governance Assessment Checklist was developed specifically for this study. As such, firstly, a systematic literature review was conducted using the keywords such mainly as \u0026ldquo;governance,\u0026rdquo; \u0026ldquo;stewardship,\u0026rdquo; \u0026ldquo;community health centers,\u0026rdquo; \u0026ldquo;primary care,\u0026rdquo; and \u0026ldquo;governance dimensions.\u0026rdquo; The search covered databases including Web of Science, Scopus, and PubMed from 2000 to September 2024. Additionally, grey literature was reviewed via Google Scholar and reference mining of key articles. In the document review phase, 36 articles were included. Good governance dimensions and indicators were extracted and categorized at the national and organizational levels.\u003c/p\u003e\u003cp\u003eIn addition, articles, the development process incorporated practical tools and internal assessment resources commonly used in CHCs, such as checklists, supervision records, staff evaluation forms, and standardized reporting templates. These materials were examined to ensure that the final instrument was firmly grounded in real-world operational practices while maintaining methodological rigor. Additionally, national-level documents\u0026mdash;including health sector development national plans were reviewed to align the checklist's content with the country's strategic priorities and administrative structures.\u003c/p\u003e\u003cp\u003eSubsequently, expert panels, including nine practitioners and professionals working in the public and primary healthcare delivery, health management and policymaking, were conducted to identify and refine the key dimensions of good governance, as well as to generate relevant items and questions tailored to the context of PHC facilities and practices. Furthermore, the panel played a crucial role in reviewing, validating, and finalizing the preliminary conceptual framework, initially developed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These dimensions collectively describe effective health center management: strong management and leadership ensures clear structure, capable leaders, and crisis readiness; participation, collaboration, and consensus involve inclusive planning, stakeholder engagement, and shared decision-making; conscientiousness refers to the dedication and responsibility of staff in performing their duties accurately and reliably, ensuring that work is aligned with regulations, protocols, and organizational standards, and that health outcomes are systematically monitored and improved. accountability and transparency promote feedback, complaint handling, and public access to information; legal compliance and professional ethics maintain adherence to laws and ethical standards; human resource management covers workforce planning, training, performance, and motivation; information and evidence management integrates data collection and research into planning; monitoring and evaluation guide performance and resource allocation; equity, responsiveness, efficiency, quality, and effectiveness ensure fair, timely, cost-effective, high-quality, and goal-oriented health services for all populations.\u003c/p\u003e\u003cp\u003eThe final conceptual framework represents good governance in PHC system at three interconnected logical levels: Foundational Dimensions, Intermediate Attributes, and Final Outcomes. At the first level, core elements such as management and leadership, strategic and operational planning, participation and consensus building and information and evidence management serve as the drivers but do not necessarily lead to final outcomes (i.e. effectiveness) unless the intermediate attributes (eg. equity, transparency and conscientiousness) have already existing in the organizations. The third group including quality, effectiveness, and efficiency are as understood, only achievable when intermediate attributes are successfully established through continuous monitoring and evaluation mechanisms.\u003c/p\u003e\u003cp\u003eThe framework further situates the good governance within the broader context of economic, political, technological, and societal factors, emphasizing that success is shaped both by internal reforms and external systemic factors.\u003c/p\u003e\u003cp\u003eThe questions, constructing an initial assessment checklist, underwent validation during which the Content Validity Ratio (CVR\u0026thinsp;=\u0026thinsp;0.61) and Content Validity Index (CVI\u0026thinsp;=\u0026thinsp;0.73) were calculated. Items with acceptable validity scores were retained in the final version. The reliability of the tool was assessed using Cronbach\u0026rsquo;s alpha, which yielded a score of 0.87, indicating satisfactory internal consistency.\u003c/p\u003e\u003cp\u003eThe final checklist consisted of 116 items, scored using a three-point Likert scale (no-partially-yes). Scores for each dimension of good governance were converted to a 0\u0026ndash;100 scale.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eDesktop (Document) Review\u003c/h3\u003e\n\u003cp\u003eDocuments reviewed included organizational charts of the centers, job descriptions of personnel (physicians, health workers, and center managers), internal regulations, results of patient and staff satisfaction surveys, operational PHC plans, health center performance-evaluation checklists, and other documentation demonstrating the implementation of good governance practices.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eQuantitative data were analyzed using SPSS software version 26.0. Descriptive statistics such as means, standard deviations, frequencies, and percentages were used to summarize the data. A descriptive-exploratory design was employed for the qualitative phase of the study.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAn analysis of the various dimensions of good governance across 30 CHCCs revealed an overall average governance score of 34.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.10, indicating a generally low-to-moderate level of governance performance in the studied centers.\u003c/p\u003e\u003cp\u003eAmong the governance dimensions assessed, Conscientiousness received the highest average score (66.00\u0026thinsp;\u0026plusmn;\u0026thinsp;15.44), followed by Equity (59.58\u0026thinsp;\u0026plusmn;\u0026thinsp;13.40). In contrast, the lowest score was observed in the dimension of Professional Ethics and Human Rights, with an average of 6.66\u0026thinsp;\u0026plusmn;\u0026thinsp;10.35, indicating a critical gap in ethical and rights-based practices. Other underperforming areas included Strategic and Operational Planning (12.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.14) and Accountability (30.00\u0026thinsp;\u0026plusmn;\u0026thinsp;17.17), both of which fell significantly below desirable thresholds (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA comparative analysis of governance scores across different types of CHCs\u0026mdash;urban, rural, and urban\u0026ndash;rural\u0026mdash;showed notable variations in implementation. Urban\u0026ndash;rural centers consistently achieved higher scores across most governance dimensions, particularly in Supervision, Effectiveness, and Equity. Urban centers demonstrated moderate performance in some areas, whereas rural centers generally scored the lowest across multiple governance components (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, the comparison between outsourced and non-outsourced CHCCs revealed clear performance disparities. Outsourced centers scored higher across most governance dimensions, with especially strong results in Conscientiousness, Monitoring and Evaluation, Rule of Law, Transparency, Strategic and Operational Planning, and Effectiveness (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, for certain dimensions\u0026mdash;including Responsiveness, Information and Evidence Management, and Quality and Safety of Services\u0026mdash;performance differences were minimal or slightly favored non-outsourced centers. It is noteworthy that the Professional Ethics and Human Rights dimension remained consistently low in both groups, highlighting a system-wide deficiency in this critical area.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMean (%) and SD of the overall GG score in the CHCCs (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernance Dimensions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Std. Dev.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eManagement \u0026amp; Leadership\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e43.54\u0026thinsp;\u0026plusmn;\u0026thinsp;17.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStrategic and Operational Planning\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e12.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipation, Collaboration, and Consensus Building\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e29.52\u0026thinsp;\u0026plusmn;\u0026thinsp;8.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConscientiousness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e66.00\u0026thinsp;\u0026plusmn;\u0026thinsp;15.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAccountability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e30.00\u0026thinsp;\u0026plusmn;\u0026thinsp;17.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLegal and Regulatory Compliance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e39.37\u0026thinsp;\u0026plusmn;\u0026thinsp;15.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInformation and Evidence Management\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e40.83\u0026thinsp;\u0026plusmn;\u0026thinsp;7.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHuman Resource Management\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e32.91\u0026thinsp;\u0026plusmn;\u0026thinsp;9.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional Ethics and Rights\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e6.66\u0026thinsp;\u0026plusmn;\u0026thinsp;10.35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonitoring and Evaluation (M\u0026amp;E)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e44.28\u0026thinsp;\u0026plusmn;\u0026thinsp;12.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEquity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e59.58\u0026thinsp;\u0026plusmn;\u0026thinsp;13.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResponsiveness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e49.00\u0026thinsp;\u0026plusmn;\u0026thinsp;13.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTransparency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e32.08\u0026thinsp;\u0026plusmn;\u0026thinsp;10.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEfficiency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e29.76\u0026thinsp;\u0026plusmn;\u0026thinsp;9.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQuality and Safety\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e32.30\u0026thinsp;\u0026plusmn;\u0026thinsp;12.95\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEffectiveness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e46.04\u0026thinsp;\u0026plusmn;\u0026thinsp;12.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGood Governance/Overall\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e34.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTotal good governance (CG) scores and its dimensions by type of CHCs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCG Dimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u003cp\u003eUrban\u0026ndash;Rural\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Std.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Std.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Std.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eManagement\u0026amp; Leadership\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e44.56\u0026thinsp;\u0026plusmn;\u0026thinsp;16.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e68.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e34.37\u0026thinsp;\u0026plusmn;\u0026thinsp;25.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e31.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e47.91\u0026thinsp;\u0026plusmn;\u0026thinsp;15.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStrategic and Operational Planning\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e12.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e9.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e25.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e16.66\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipation, Collaboration, and Consensus Building\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e30.74\u0026thinsp;\u0026plusmn;\u0026thinsp;7.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e19.64\u0026thinsp;\u0026plusmn;\u0026thinsp;6.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e33.33\u0026thinsp;\u0026plusmn;\u0026thinsp;8.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConscientiousness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e66.95\u0026thinsp;\u0026plusmn;\u0026thinsp;14.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e90.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e57.50\u0026thinsp;\u0026plusmn;\u0026thinsp;22.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e60.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e70.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAccountability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e31.15\u0026thinsp;\u0026plusmn;\u0026thinsp;16.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e16.66\u0026thinsp;\u0026plusmn;\u0026thinsp;13.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e38.88\u0026thinsp;\u0026plusmn;\u0026thinsp;19.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLegal and Regulatory Compliance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e40.21\u0026thinsp;\u0026plusmn;\u0026thinsp;15.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e37.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e25.00\u0026thinsp;\u0026plusmn;\u0026thinsp;11.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e43.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e52.08\u0026thinsp;\u0026plusmn;\u0026thinsp;9.54\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInformation and Evidence Management\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e41.30\u0026thinsp;\u0026plusmn;\u0026thinsp;7.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e41.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e35.41\u0026thinsp;\u0026plusmn;\u0026thinsp;4.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e58.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e44.44\u0026thinsp;\u0026plusmn;\u0026thinsp;12.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHuman Resource Management\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e33.96\u0026thinsp;\u0026plusmn;\u0026thinsp;8.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e31.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e23.43\u0026thinsp;\u0026plusmn;\u0026thinsp;7.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e31.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e37.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional Ethics and Rights\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.24\u0026thinsp;\u0026plusmn;\u0026thinsp;11.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e4.16\u0026thinsp;\u0026plusmn;\u0026thinsp;8.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e5.55\u0026thinsp;\u0026plusmn;\u0026thinsp;9.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMonitoring and Evaluation (M\u0026amp;E)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e45.03\u0026thinsp;\u0026plusmn;\u0026thinsp;11.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e35.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e32.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e64.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e54.76\u0026thinsp;\u0026plusmn;\u0026thinsp;10.91\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEquity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e62.50\u0026thinsp;\u0026plusmn;\u0026thinsp;13.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e37.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e46.87\u0026thinsp;\u0026plusmn;\u0026thinsp;11.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e54.16\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eResponsiveness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e48.69\u0026thinsp;\u0026plusmn;\u0026thinsp;13.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e45.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e56.66\u0026thinsp;\u0026plusmn;\u0026thinsp;20.81\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTransparency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e33.15\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e18.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e31.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e23.43\u0026thinsp;\u0026plusmn;\u0026thinsp;5.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e31.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e43.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e35.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEfficiency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e29.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e23.21\u0026thinsp;\u0026plusmn;\u0026thinsp;3.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e35.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e40.47\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQuality and Safety\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e33.94\u0026thinsp;\u0026plusmn;\u0026thinsp;11.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e38.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e18.26\u0026thinsp;\u0026plusmn;\u0026thinsp;13.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e26.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e38.46\u0026thinsp;\u0026plusmn;\u0026thinsp;11.53\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEffectiveness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e48.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e53.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e30.46\u0026thinsp;\u0026plusmn;\u0026thinsp;16.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e40.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e53.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e47.91\u0026thinsp;\u0026plusmn;\u0026thinsp;6.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGood Governance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e44.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e35.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e25.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e36.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e44.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c10\"\u003e\u003cp\u003e39.15\u0026thinsp;\u0026plusmn;\u0026thinsp;4.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGood Governance (CG) scores and its dimensions by type of management of CHCs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCG Dimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eGovernmental\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eOutsourced\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Std.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Std.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eManagement\u0026amp; Leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.75\u0026thinsp;\u0026plusmn;\u0026thinsp;17.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e25.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e42.50\u0026thinsp;\u0026plusmn;\u0026thinsp;16.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStrategic and Operational Planning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e25.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e15.00\u0026thinsp;\u0026plusmn;\u0026thinsp;9.47\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipation, Collaboration, and Consensus Building\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.14\u0026plusmn;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e31.42\u0026thinsp;\u0026plusmn;\u0026thinsp;6.38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConscientiousness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65.6000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e60.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e68.00\u0026thinsp;\u0026plusmn;\u0026thinsp;8.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccountability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.6667\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e36.66\u0026thinsp;\u0026plusmn;\u0026thinsp;18.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLegal and Regulatory Compliance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.2500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e37.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e62.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e45.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformation and Evidence Management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.6667\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e58.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e41.66\u0026thinsp;\u0026plusmn;\u0026thinsp;10.20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHuman Resource Management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.2500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e43.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e36.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProfessional Ethics and Rights\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.6667\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e6.66\u0026thinsp;\u0026plusmn;\u0026thinsp;9.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonitoring and Evaluation (M\u0026amp;E)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42.8571\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e35.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e64.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e51.42\u0026thinsp;\u0026plusmn;\u0026thinsp;14.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEquity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58.5000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e75.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e65.00\u0026thinsp;\u0026plusmn;\u0026thinsp;10.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResponsiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49.2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e40.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e80.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e48.00\u0026thinsp;\u0026plusmn;\u0026thinsp;17.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransparency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.2500\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e31.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e43.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e36.25\u0026thinsp;\u0026plusmn;\u0026thinsp;6.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEfficiency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29.1429\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e42.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e32.85\u0026thinsp;\u0026plusmn;\u0026thinsp;10.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality and Safety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32.4615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e26.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e31.53\u0026thinsp;\u0026plusmn;\u0026thinsp;10.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e59.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44.8750\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e53.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e51.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood Governance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.8571\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e44.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c7\"\u003e\u003cp\u003e37.06\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn recent years, good governance has emerged as a central pillar in enhancing the quality, effectiveness, and efficiency of health systems(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Governance indicators not only serve as mechanisms to promote transparency, accountability, and organizational responsibility, but also play a critical role in health policy-making and evidence-based decision-making(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Assessing these indicators, particularly within primary healthcare delivery systems, can uncover structural shortcomings, managerial deficiencies, and limited stakeholder engagement, thus creating a foundation for effective reform-oriented interventions.\u003c/p\u003e\u003cp\u003eThe findings of this study, which assessed governance in CHCs across Iran, highlight substantial gaps in the application of good governance principles. With an average score of 34.39 out of 100, the results point to poor-to-moderate overall performance. This reflects significant structural and operational weaknesses that hinder the effective functioning of primary healthcare centers and, in turn, impact service quality and health equity.\u003c/p\u003e\u003cp\u003eWhen viewed in a global context, these findings align with governance challenges reported in other low- and middle-income countries. For example, a 2018 study in Kenya revealed that only 10% of participants perceived governance practices as satisfactory, with systemic issues such as corruption, political interference, and inequitable resource distribution impeding progress(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In contrast, a study from Zambia reported far more favorable evaluations of governance, likely due to greater institutional autonomy and a decentralized governance structure(40). This stark difference may be explained by variations in organizational infrastructure, cultural norms, and the degree of institutional autonomy granted to health authorities. Zambia\u0026rsquo;s relatively decentralized governance structure and enhanced local accountability mechanisms might contribute to the more favorable outcomes reported.\u003c/p\u003e\u003cp\u003eWithin Iran, the governance challenges identified in CHCCs are not isolated incidents but are consistent with findings from several national-level studies. Rahimi et al. highlighted fundamental problems in areas such as planning, organizational alignment, intersectoral coordination, and performance evaluation. Their research indicated that inefficiencies in these domains significantly limit the overall effectiveness of health governance(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Similarly, a systematic review by Behzadi-Fard and colleagues emphasized the widespread difficulty in implementing clinical governance elements within Iran\u0026rsquo;s health system(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Their study identified inadequate infrastructure and insufficient stakeholder engagement as major impediments to policy execution. They stressed that without supportive systems and active collaboration from relevant actors; even well-designed policies are unlikely to achieve their intended impact. These national findings align closely with broader observations from the World Health Organization, which has documented several structural barriers to effective health governance in low- and middle-income countries. Common issues include limited stakeholder participation, the absence of robust monitoring and evaluation systems, and policymaking processes that are not sufficiently grounded in evidence(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). These challenges diminish the capacity of health systems to respond efficiently to public health needs and allocate resources in a manner that maximizes health outcomes.\u003c/p\u003e\u003cp\u003eImportantly, governance functions not only as a determinant of health system efficiency but also as a critical mediator between the allocation of resources and the realization of improved health outcomes at the population level. Weaknesses in governance structures can result in mismanagement, inefficiency, and resource wastage, thereby undermining the effectiveness of public health interventions. As such, strengthening governance should be prioritized as a foundational strategy for improving primary healthcare services, ensuring equity, and advancing overall health system performance.\u003c/p\u003e\u003cp\u003eConscience scored highest among governance components, indicating a relatively strong commitment by staff to their responsibilities. However, achieving comprehensive Conscience is not feasible in isolation\u0026mdash;it requires the simultaneous realization of interconnected governance elements such as transparency, equity, adherence to the rule of law, and public participation. Among the measured components, Conscience received the highest score, suggesting that staff in these centers show a relative level of commitment to their responsibilities and are, relatively, answerable for their actions. However, achieving comprehensive Conscience is not feasible in isolation\u0026mdash;it requires the simultaneous realization of interconnected governance elements such as transparency, equity, adherence to the rule of law, and public participation. Conscientiousness gains meaning only in systems where decision-making is transparent, complaints are systematically addressed, and public oversight is embedded (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). In this context, experiences from countries like Indonesia illustrate that raising public awareness about individual rights and responsibilities not only enhance civic engagement but also establishes the foundation for sustained and effective governance through social responsibility mechanisms (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). becomes meaningful only when decision-making processes are transparent, mechanisms for registering and addressing complaints exist, and public oversight is institutionalized(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). In this context, experiences from countries like Indonesia illustrate that raising public awareness about individual rights and responsibilities not only enhances civic engagement but also establishes the foundation for sustained and effective governance through social responsibility mechanisms(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEquity also emerged as a relatively strong component. In this study, equity was defined as the provision of standardized and comprehensive service packages to different demographic groups\u0026mdash;including gender, age, and geographical distribution\u0026mdash;along with fair treatment of staff and patients. Such a comprehensive definition underscores the importance of equal access to health services at all levels. International comparisons reveal significant variation in how equity is implemented. In Canada, for example, financial incentives and performance-based reporting mechanisms are integrated into physician contracts, promoting both equitable access and service motivation(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). In contrast, studies from Kenya show that equity in healthcare is not adequately observed, largely due to structural and administrative limitations(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). A study conducted in Egypt reported a notable divergence in the perception of equity: while providers and administrators gave relatively moderate scores, users perceived a much higher level of fairness\u0026mdash;highlighting the subjective nature of equity as experienced by different stakeholder groups(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA particularly concerning finding in this study relates to professional ethics and human rights, which received the lowest score among the governance components. This indicates a severe weakness in this area, likely stemming from a lack of sustained training in medical ethics, the absence of performance evaluation systems grounded in ethical standards, and the lack of clearly defined mechanisms for protecting patient rights. Comparative studies support these findings. For example, in Jordan, the absence of formal legal frameworks has led to widespread violations of patients\u0026rsquo; rights(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e),while in Norway, systemic barriers such as limited resources, insufficient professional training, and ethical decision-making difficulties have been reported at the organizational level(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). National research, including the work of Monaafi et al. (2018), emphasizes the critical role of ethical principles in resource allocation decisions\u0026mdash;particularly in environments where resources are constrained(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Likewise, a systematic review by Rastegari-Mehr et al. (2025) underscores the necessity of continual monitoring of both patient and employee rights as key indicators in accrediting primary care centers, which also directly contribute to improved service quality, patient trust, and staff satisfaction(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAnother important dimension revealed by the findings relates to the structural composition of the health centers. Centers operating under urban\u0026ndash;rural hybrid models demonstrated stronger performance across most governance indicators compared to centers located exclusively in urban or rural areas. This strength may be attributed to a broader population base, more diverse resources, and greater managerial flexibility, allowing services to be better tailored to local and cultural contexts. Studies from China and Bangladesh corroborate these results, indicating that although urban areas generally offer better infrastructure and service quality, community health centers in rural areas\u0026mdash;when adequately funded and well-organized\u0026mdash;can also deliver effective care(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). In the United States, rural health centers that operate under community-based governance structures have been more successful in building public trust and responding to local needs(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). However, these models are not without challenges, particularly the difficulty in conducting objective performance assessments due to the lack of anonymity and standardized evaluation tools.\u003c/p\u003e\u003cp\u003eThe study further found that outsourced CHCs outperformed non-outsourced centers in key governance areas such as planning, monitoring, transparency, and overall effectiveness. This suggests that transferring certain managerial responsibilities to non-governmental actors can enhance organizational flexibility and service quality. Supporting evidence from New Zealand shows that non-profit and community-led centers are more likely to have documented policies for quality assurance, complaint handling, and emergency response, and they tend to be more active in community needs assessments and service planning(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). This shift away from traditional state-led models toward community-driven and non-profit management approaches not only promotes transparency but also enables stronger stakeholder participation and responsiveness.\u003c/p\u003e\u003cp\u003eNonetheless, public ownership retains strategic value, particularly in mitigating some of the pitfalls associated with for-profit private models, such as reduced accountability and limited control over strategic assets. However, publicly owned models may still fall short in responding to the unique needs of marginalized or minority communities, especially if decision-making is dominated by narrow interest groups. In such contexts, community-managed non-profit organizations serve as vital intermediaries for advancing local autonomy, addressing the needs of minority populations, and piloting innovative policy interventions.\u003c/p\u003e\u003cp\u003eFinally, the study emphasizes the importance of public\u0026ndash;private partnerships (PPPs) in enhancing governance within urban health systems. Findings from a 2019 study confirm that stronger collaboration between public and private sectors improves access to healthcare services(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). These results are consistent with broader reviews of primary healthcare (PHC) delivery, which affirm that\u0026mdash;despite inherent challenges\u0026mdash;well-structured PPPs can facilitate access, especially in underserved and remote regions(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). Long-term planning and context-sensitive policymaking are essential to the successful development of PPPs. A noteworthy example is Brazil, where the government addressed workforce shortages by contracting primary care services through non-governmental organizations. This model significantly improved the quality of care and exemplifies the transformative role of NGOs in strengthening health system governance(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study has several limitations that should be acknowledged. First, the cross-sectional design restricts causal interpretations between governance dimensions and performance outcomes. Additionally, the use of self-reported data and face-to-face interviews could also introduce social desirability bias, particularly in responses related to accountability or ethics. Moreover, the assessment tool, while contextually validated, lacks direct comparability with internationally standardized governance frameworks. Despite these limitations, the study offers valuable empirical insight into frontline governance in Iran's primary healthcare system and lays the groundwork for further research and policy reform.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study reveal significant structural and operational deficiencies in the governance of Iran\u0026rsquo;s CHCs. While certain dimensions such as Conscience and Equity show relative strength, consistently low scores in Ethics, Transparency, and Accountability highlight a fragmented and underperforming governance framework. These deficiencies directly impact the quality and equity of primary healthcare services.\u003c/p\u003e\u003cp\u003eEncouragingly, the better performance observed in urban\u0026ndash;rural hybrid and outsourced centers suggests that flexible, community-driven management models may offer a viable path forward. To realize such improvements more broadly, systemic reform is essential. This includes evidence-based policymaking, capacity building, enhanced monitoring, and inclusive stakeholder engagement. Ultimately, strengthening governance is not merely a technical adjustment\u0026mdash;it is a foundational strategy to foster public trust, ensure fair resource distribution, and improve health outcomes. Achieving this vision requires sustained political will, institutional commitment, and collaborative action across public and non-governmental sectors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary Health Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHCC\u003csub\u003eS\u003c/sub\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComprehensive Health Care Centers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTUMS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTehran University of Medical Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGood Governance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUniversal Health Coverage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUNDP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Nations Development Programme\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCVR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eContent Validity Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCVI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eContent Validity Index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Ethical approval for this study was obtained from the Ethics Committee of TUMS [The Code of Ethics: IR.TUMS.SPH.REC.1402.011].\u0026nbsp;Informed consent to participate was obtained from all participants before data collection. Participants were informed about the study's purpose and their rights, including the right to withdraw at any time without consequences.\u0026nbsp;verbal consent was obtained from all participants in accordance with ethical guidelines. This study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data, Tools and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets comprise the quantitative assessment results and internal organizational documents from CHCCs\u0026nbsp;affiliated with TUMS. In line with the confidentiality agreements made with the participating centers, these datasets are not publicly available. However, anonymized and aggregated data supporting the study findings may be obtained from the corresponding author upon request. Checklist will also be provided upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe present study is part of a PhD thesis conducted in TUMS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZAP contributed to the conceptualization and design of the study, conducted the literature search and data extraction, and drafted the manuscript. AVM contributed to the study design, provided critical input on governance frameworks, and reviewed the manuscript for intellectual content. EJP led the overall study supervision, critically revised the manuscript, and approved the final version for submission. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNewman LA. The health care system as a social determinant of health: qualitative insights from South Australian maternity consumers. Aust Health Rev. 2009;33(1):62\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRaminashvili D, Gvanceladze T, Kajrishvili M, Zarnadze I, Sh Z. Social environment, bases social markers and health care system in Shida Kartli region. Georgian Med News. 2009(175):68\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFranken M, Koolman X. Health system goals: a discrete choice experiment to obtain societal valuations. Health Policy. 2013;112(1\u0026ndash;2):28\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOrganization WH, editor. 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Public-private partnerships in primary health care: a scoping review. BMC Health Serv Res. 2021;21:1\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIreland M, Cavalini L, Girardi S, Araujo EC, Lindelow M. Expanding the primary health care workforce through contracting with nongovernmental entities: the cases of Bahia and Rio de Janeiro. Hum Resour health. 2016;14:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Good Governance, Primary Health Care, Comprehensive Health Care Center, Iran","lastPublishedDoi":"10.21203/rs.3.rs-7282495/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7282495/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003ePrimary Health Care (PHC) plays a crucial role in promoting equitable health outcomes by improving access and addressing the diverse needs of populations. Evaluating good governance at the level of primary health care center is vital to identify managerial strengths and weaknesses, thereby informing policies aimed at enhancing system performance. This study aims to assess the status of good governance in Comprehensive Health Care Centers (CHCCs) affiliated with Tehran University of Medical Sciences (TUMS) in Tehran Province.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis cross-sectional study was conducted between October 2024 and March 2025 across 30 CHCs. Data were collected using a researcher-developed, validated Good Governance Assessment Checklist through face-to-face interviews with key stakeholders. Stratified sampling was employed drawing on their service area and administration type to ensure proportional representation across three district health networks. In addition, documents such as organizational charts, job descriptions, and performance reports were reviewed. Quantitative data were analyzed using SPSS26 and descriptive statistics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe average score of 34.39 (out of 100), indicates a fairly low level for good governance in the centers. The conscience dimension scored the highest (66.00), while professional ethics and rights received the lowest score (6.66). The superior governance scores of urban\u0026ndash;rural centers suggest that hybrid management models may better accommodate local diversity and resource variability. Moreover, the outsourced CHCCs showed better performance in key areas such as Conscience, Monitoring and Evaluation, Rule of Law, Transparency, and Strategic Planning. However, in such areas as Responsiveness, Information Management, and Service Quality, the differences were trivial or slightly favored toward non-outsourced centers.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe CHCCs affiliated to TUMS face significant governance challenges, particularly in the areas of ethics, transparency, and accountability. Despite strengths in the conscience and equity, overall governance remains weak, impeding possibly the healthcare quality and responsiveness. The higher performance of urban\u0026ndash;rural and outsourced centers highlight the potential of flexible, community-based governance models. Strengthening governance will thus require evidence-based policy-making, professional capacity building, robust monitoring systems, inclusive participation, political commitment, and cross-sector collaboration.\u003c/p\u003e","manuscriptTitle":"Good Governance in Primary Health Care Centers: Real-life evidence from Iran","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 18:56:45","doi":"10.21203/rs.3.rs-7282495/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f601ded-75d4-41d6-a3cc-b5bf6202e142","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T05:24:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-22 18:56:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7282495","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7282495","identity":"rs-7282495","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}