A Qualitative Analysis of Governance and Management Practices of Faith-Based Health Providers and their Implications for Public Financial Management and Service Delivery in Malawi in the Context of Direct Facility Financing

A Qualitative Analysis of Governance and Management Practices of Faith-Based Health Providers and their Implications for Public Financial Management and Service Delivery in Malawi in the Context of Direct Facility Financing | 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 A Qualitative Analysis of Governance and Management Practices of Faith-Based Health Providers and their Implications for Public Financial Management and Service Delivery in Malawi in the Context of Direct Facility Financing Pemphero Norah Mphamba, Joe Maganga Zonda, Precious Chibwe, Celia Woodfill, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9097987/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Faith-based healthcare providers (FBHPs) play a crucial role in advancing Universal Health Coverage goals (UHC) in Malawi. As the government scales up the Direct Facility Financing (DFF) reform, understanding governance and public financial management (PFM) practices within FBHPs is critical for informing effective policy and institutional reforms. This study examines how governance structures influence PFM performance and operational responsiveness in Christian Health Association of Malawi and Islamic Health Association of Malawi (CHAM/IHAM) facilities, to improve the effectiveness and sustainability of healthcare services under the DFF strategy. Methods An exploratory qualitative design was employed across 40 CHAM/IHAM facilities in 16 districts. Data was collected through semi-structured key informant interviews and focus group discussions involving 17 proprietors, representatives of 5 facility boards, 3 staff from CHAM/IHAM secretariats, 113 Health Center Management Committee (HCMC) members, and 40 facility in-charges ( \(\:N=178\) ). Guided by the PFM theory of change, centering the PFM cycle and provider management as pathways to UHC service delivery goals and impacts, data were analyzed thematically to examine governance oversight during budget formulation, execution, and evaluation. Results Governance structures were closely associated with variations in PFM performance and financial autonomy. Facilities governed by dedicated, functional boards exhibited stronger PFM practices, including participatory budgeting, strategic oversight, routine board-led budget reviews, and greater discretion over fund utilization. These facilities also demonstrated improved operational responsiveness; managers were able to reallocate resources quickly and address service delivery challenges. In contrast, facilities overseen by centralized governance structures relied on distant hierarchical approvals and strict compliance mechanisms, which often constrained managerial discretion and slowed decision-making. Overall, proximity of governance to service delivery point and clarity of delegation of authority emerged as key enablers of operational responsiveness and accountability. The study found limited community oversight across all stages of the PFM cycle. Conclusion Facility-level governance is crucial for shaping PFM performance and service delivery among FBHPs. Dedicated proximate oversight structures, appear essential for balancing accountability and managerial autonomy under devolved financing. These insights provide evidence to guide the design of fit-for-purpose governance models for DFF implementation in varied primary health care systems. Primary Healthcare Universal Health Coverage Faith-based Health Providers Healthcare Governance Direct Facility Financing Public Financial Management Malawi Low- and Middle-Income Countries Full Text Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 12 May, 2026 Editor invited by journal 16 Apr, 2026 Editor assigned by journal 21 Mar, 2026 Submission checks completed at journal 20 Mar, 2026 First submitted to journal 20 Mar, 2026 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-9097987","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":639260737,"identity":"a9f78fec-6f40-41e9-971d-41d99c2438d0","order_by":0,"name":"Pemphero Norah 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Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary Healthcare, Universal Health Coverage, Faith-based Health Providers, Healthcare Governance, Direct Facility Financing, Public Financial Management, Malawi, Low- and Middle-Income Countries","lastPublishedDoi":"10.21203/rs.3.rs-9097987/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9097987/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFaith-based healthcare providers (FBHPs) play a crucial role in advancing Universal Health Coverage goals (UHC) in Malawi. As the government scales up the Direct Facility Financing (DFF) reform, understanding governance and public financial management (PFM) practices within FBHPs is critical for informing effective policy and institutional reforms. This study examines how governance structures influence PFM performance and operational responsiveness in Christian Health Association of Malawi and Islamic Health Association of Malawi (CHAM/IHAM) facilities, to improve the effectiveness and sustainability of healthcare services under the DFF strategy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAn exploratory qualitative design was employed across 40 CHAM/IHAM facilities in 16 districts. Data was collected through semi-structured key informant interviews and focus group discussions involving 17 proprietors, representatives of 5 facility boards, 3 staff from CHAM/IHAM secretariats, 113 Health Center Management Committee (HCMC) members, and 40 facility in-charges (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:N=178\\)\u003c/span\u003e\u003c/span\u003e). Guided by the PFM theory of change, centering the PFM cycle and provider management as pathways to UHC service delivery goals and impacts, data were analyzed thematically to examine governance oversight during budget formulation, execution, and evaluation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGovernance structures were closely associated with variations in PFM performance and financial autonomy. Facilities governed by dedicated, functional boards exhibited stronger PFM practices, including participatory budgeting, strategic oversight, routine board-led budget reviews, and greater discretion over fund utilization. These facilities also demonstrated improved operational responsiveness; managers were able to reallocate resources quickly and address service delivery challenges. In contrast, facilities overseen by centralized governance structures relied on distant hierarchical approvals and strict compliance mechanisms, which often constrained managerial discretion and slowed decision-making. Overall, proximity of governance to service delivery point and clarity of delegation of authority emerged as key enablers of operational responsiveness and accountability. The study found limited community oversight across all stages of the PFM cycle.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFacility-level governance is crucial for shaping PFM performance and service delivery among FBHPs. Dedicated proximate oversight structures, appear essential for balancing accountability and managerial autonomy under devolved financing. These insights provide evidence to guide the design of fit-for-purpose governance models for DFF implementation in varied primary health care systems.\u003c/p\u003e","manuscriptTitle":"A Qualitative Analysis of Governance and Management Practices of Faith-Based Health Providers and their Implications for Public Financial Management and Service Delivery in Malawi in the Context of Direct Facility Financing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-13 09:58:30","doi":"10.21203/rs.3.rs-9097987/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-05-12T11:18:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-16T18:12:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-21T22:52:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-20T08:16:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Health Systems","date":"2026-03-20T08:07:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dihs","sideBox":"Learn more about [Discover Health Systems](https://www.springer.com/44250)","snPcode":"44250","submissionUrl":"https://submission.nature.com/new-submission/44250/3","title":"Discover Health Systems","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ffd57c22-9bb1-4a21-8997-2e69feee645b","owner":[],"postedDate":"May 13th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"15","date":"2026-05-12T11:18:04+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T09:58:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-13 09:58:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9097987","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9097987","identity":"rs-9097987","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}