Perceptions of organizational effectiveness in public hospitals: Insights from frontline healthcare workers in Ghana

Introduction

Organizational effectiveness in healthcare institutions—defined as the ability to achieve institutional goals through strong leadership, efficient systems, engaged staff, and a supportive environment that fosters high-quality, patient-centered care—is essential to ensuring that healthcare delivery meets the needs of patients, staff, and the wider community. ¹ Hospitals that demonstrate high organizational effectiveness are better positioned to manage their workforce, adapt to changes in healthcare demands, and achieve national and international health objectives, including the United Nations’ Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for all at all ages.^2,3

In low- and middle-income countries (LMICs) such as Ghana, organizational effectiveness is especially important due to resource constraints, workforce shortages, and the rising burden of communicable and noncommunicable diseases.^4,5 The performance of public hospitals, which serve the majority of the population, significantly influences public health outcomes, particularly for vulnerable groups.^4,6 However, these hospitals often face considerable barriers, including poor infrastructure, inadequate supplies, and limited training opportunities for healthcare staff, all of which can hinder the delivery of optimal care. ⁶

Research on performance improvement in Ghanaian public hospitals has highlighted several areas of concern. Studies have shown that many hospitals suffer from poor communication between management and staff, inadequate staff development programs, and a lack of clear strategic goals.^7–10 These issues contribute to inefficiencies in healthcare delivery, reduced employee morale, and, ultimately, poorer patient outcomes.^7,8

Although substantial research has been conducted on organizational efficiency in healthcare settings,^11–13 there is limited knowledge regarding the organizational effectiveness of public healthcare organizations in Ghana. While both organizational efficiency and organizational effectiveness are important in healthcare management, they focus on different aspects of performance. Organizational effectiveness emphasizes a hospital’s ability to achieve its goals—such as delivering timely, high-quality care, maintaining employee satisfaction, and optimizing resource use. ¹⁴ Effective organizations tend to have well-structured systems that promote collaboration, foster innovation, and support continuous improvement in healthcare delivery. ¹⁵ In contrast, organizational efficiency measures how well a hospital uses its resources to meet its objectives, focusing on the relationship between inputs (such as staff hours, equipment, and finances) and outputs (such as patient treatments and services delivered). Common metrics include cost per patient treated, bed occupancy rates, and turnover ratios. ¹⁶

While efficiency is necessary, healthcare managers should balance it with effectiveness to respond to environmental demands and improve overall performance.^14,16 Understanding these concepts is crucial for evaluating and improving hospital performance in the evolving healthcare landscape. This study, therefore, aims to provide a frontline perspective on the organizational effectiveness of public hospitals in Ghana. Frontline healthcare workers—including medical doctors, nurses, pharmacists, and allied health professionals—play a central role in the daily operations of healthcare organizations. Their direct interactions with patients and their involvement in managing complex operational challenges make their insights invaluable in assessing hospital performance and identifying areas for improvement. This study is particularly relevant in the context of Ghana’s healthcare system, where public hospitals serve as the primary healthcare providers, especially for low-income populations.

Materials and methods

Sample size estimation and sampling procedure

With an estimated Ghanaian public sector healthcare workforce of 122,183, ¹⁷ the sample size for the study was determined using the Taro Yamane’s formula ¹⁸ :

n = N 1 + N ( e 2 )

where n = the expected sample size, N = finite population out of which the sample size is drawn, and e = level of precision (e = 0.05).

Substituting the above figures:

n = 122 , 183 1 + 122 , 183 ( 0 . 05 ) 2 = 399

Nonresponse rate of 20% was added to give a total sample size of 479.

The study sample was selected using a multistage sampling approach. First, Ghana was divided into three clusters based on its ecological zones: coastal, middle belt, and northern. From these clusters, four hospitals were conveniently selected: two (Efutu Municipal Hospital, and Winneba Traum and Specialist Hospital) from the coastal belt, one (Kumasi South Hospital) from the middle belt, and one (Tamale Teaching Hospital) from the northern belt. This convenience sampling was chosen to minimize costs and logistical challenges by focusing on easily accessible hospitals. Next, we employed a proportional sampling method to draw 479 frontline healthcare workers from the four hospitals (Table 1) to participate in the study. Each hospital’s total number of frontline healthcare workers was treated as an independent subpopulation. The sample size for each hospital was determined by calculating the proportion of frontline healthcare workers at that hospital relative to the total number across all four hospitals and then multiplying this proportion by the total sample size. Finally, a consecutive sampling technique was used to select the required study participants. In this process, every eligible healthcare worker meeting the inclusion criteria was selected until the desired sample size for each hospital was reached.

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Table 1.

Estimated sample size for each of the four participating hospitals.

Name of hospital	Estimated number of frontline healthcare workers	Proportion (%)	Sample size
Kumasi South Hospital	624	10.4	50
Efutu Municipal Hospital	386	6.4	31
Tamale Teaching Hospital	4631	76.6	366
Traum and Specialist Hospital	397	6.6	32
Total	6038	100	479

Results

Out of the 479 administered questionnaires, 477 were returned, resulting in a response rate of 99.6%. The average age of the healthcare workers was 33.9 ± 6.8 years. The majority were aged 31–40 (48.4%), female (57.2%), and married (50.3%). Most identified as Christian (65.6%) and worked primarily as nurses (30.8%). In terms of work experience, the largest group had worked for 4–6 years (42.6%; Table 2).

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Table 2.

Characteristics of the study respondents.

Characteristic	Frequency	Percentage (%)
Age
<25	31	6.5
25–30	145	30.4
31–40	231	48.4
41+	70	14.7
Gender
Male	204	42.8
Female	273	57.2
Marital status
Married	240	50.3
Single	195	40.9
Cohabitating	27	5.7
Divorced	15	3.1
Religion
Christian	313	65.6
Islam	133	27.9
Traditional	31	6.5
Profession
Medical doctor	67	14
Nurse	157	30.8
Pharmacist/pharmacy technician	47	9.9
Biomedical scientist/laboratory technician	73	15.3
Health information officer	40	8.4
Nutritionist	21	4.4
Optician	35	7.3
Physiotherapist	14	2.9
X-ray technician	23	4.8
Years worked
1–3	134	28.1
4–6	203	42.6
Above 6	140	29.4

Organizational effectiveness

The healthcare professionals reported a significant disparity between their current and ideal organizational environments. On average, participants rated their current organizations notably lower (mean = 2.75 ± 0.63) than their ideal (mean = 5.20 ± 0.43), indicating widespread dissatisfaction with key organizational dimensions. This perceived gap was reflected across all fifteen items assessed (see Table 3), suggesting a systemic challenge rather than isolated issue.

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Table 3.

Comparison of organizational characteristics between current state and ideal state.

Characteristic	My organization (as is), mean (SD)	Ideal organization (should be), mean (SD)	Difference (should be—as is)	p value
The organization has a set of guiding beliefs	2.97 (0.99)	5.34 (0.65)	2.37	0.001
General objectives and values are set forth	2.99 (0.93)	5.31 (0.63)	2.33	0.001
The organization operates in a purposeful mode	3.12 (0.97)	5.42 (0.67)	2.30	0.001
Structures are designed based on work requirements	2.96 (0.88)	5.2 (0.62)	2.24	0.002
Decisions are made based on location(s) of information	2.64 (0.97)	5.09 (0.72)	2.45	0.001
Managers assume that individuals want responsibilities	2.58 (0.87)	5.1 (0.71)	2.52	<0.001
Rewards are balanced	2.61 (1.02)	5.12 (0.74)	2.51	<0.001
Communication is relatively open	2.75 (0.94)	5.12 (0.71)	2.37	0.001
Collaboration is rewarded	2.68 (1.05)	5.13 (0.74)	2.45	0.001
Conflict is managed, not suppressed or avoided	2.4 (1.08)	5.05 (0.71)	2.65	<0.001
The organization is seen as an open system	2.74 (0.97)	5.19 (0.73)	2.45	0.001
Individuality and individuals are valued	2.79 (1.01)	5.31 (0.72)	2.52	<0.001
Management respects people and treats them as adults	2.76 (0.91)	5.22 (0.79)	2.46	0.001
An effort is made to inspire people	2.74 (1.05)	5.25 (0.78)	2.51	<0.001
There is a “learning” mode of management	2.55 (0.89)	5.19 (0.77)	2.64	<0.001

When comparing specific organizational characteristics, the characteristics with the highest differences were “Conflict is managed, not suppressed or avoided,” “There is a learning mode of management,” “Managers assume that individuals want responsibilities,” and “Individuality and individuals are valued.” Conversely, the characteristics with the lowest differences were “Structures are designed based on work requirements,” “The organization operates in a purposeful mode,” “General objectives and values are set forth,” and “Communication is relatively open” (see Table 3 and Figure 1).

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Figure 1.

Difference in mean scores between the “as is” and the “should be” modes of organizational effectiveness.

A comparison between the hard and soft elements revealed that participants rated the hard elements slightly more favorably, with an average score of 2.83 compared to 2.71 for the soft elements. Although the difference in mean scores was relatively small (0.012), it was statistically significant (t(476) = 5.681, p = 0.013).

Finally, the overall perception of organizational effectiveness was notably low. Fewer than one in ten respondents (8.4%) considered their hospital to be “one of the best, extremely effective.” The majority, however, offered more reserved or critical assessments. Approximately 31% felt that their organization was effective in certain areas but required significant improvements in others, while nearly 10% viewed their hospital as only “marginally effective” (see Figure 2).

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Figure 2.

Overall rating of organizational effectiveness.

Overall mean score for ideal organization = 5.20 ± 0.43; current organization (my organization as is) mean score = 2.75 ± 0.63; difference between ideal and current mean score = 2.45 ± 0.58. This difference was statistically significant, t(476) = 91.640, p = 0.001; 95% CI: 2.40–2.50.

Discussion

The findings from this study highlight the disparity between the current state of the assessed organizations and the workers’ ideal expectations. The overall perception of organizational effectiveness was low, with a substantial gap identified between the healthcare workers’ ratings of their current organization and their ideal organization. Importantly, this gap was consistently observed across all 15 organizational items assessed, reinforcing the need for urgent reforms in hospital management and operational practices.

Among the specific organizational characteristics evaluated, the highest perceived gaps were related to conflict management, managerial responsibilities, and valuing individuality. These characteristics are integral to fostering a positive organizational culture that promotes teamwork, personal growth, and efficient conflict resolution. For instance, the largest gap (2.65) was found in the item “Conflict is managed, not suppressed or avoided.” This suggests that workers perceive a lack of effective conflict resolution mechanisms, which may lead to unresolved tensions, decreased morale, and lower overall effectiveness. Similarly, a gap of 2.64 was identified for “There is a learning mode of management,” indicating dissatisfaction with management’s support for continuous learning and professional development. Earlier studies^8,21 have identified inadequate staff development programs as a major concern in Ghanaian public hospitals, emphasizing the need for improving training and learning initiatives in these healthcare organizations.

In contrast, characteristics with the lowest differences, such as “Structures are designed based on work requirements” (gap = 2.24) and “The organization operates in a purposeful mode” (gap = 2.30), suggest that while there are still significant gaps, certain structural aspects of the organization may be relatively better aligned with workers’ expectations. However, these smaller differences should not detract from the overall message that substantial improvements are needed across all organizational dimensions.

The finding that hard elements received a slightly higher mean score than soft elements, despite a small but statistically significant difference, aligns with a similar study conducted in Poland. ²² In that study, soft aspects had significantly lower scores (p < 0.05), with a mean of 2.58 (95% CI: 2.43–2.73), compared to the hard aspects, which had a mean score of 2.80 (95% CI: 2.66–2.94). These observations suggest that healthcare workers perceive the structural and operational frameworks within their organizations to be relatively better than the intangible, interpersonal aspects. This implies that the foundational systems—such as policies, procedures, and technological resources—are more developed or functional compared to the softer aspects such as leadership and communication. It must be noted however that in this study, both hard and soft elements still received low scores, reflecting an overall perception of inadequacy in both areas.

The results of this study have significant implications for healthcare policy and practice in Ghana, particularly regarding workforce management and hospital operations. Policymakers and healthcare managers must prioritize strategies that address the substantial gaps between current organizational conditions and the expectations of healthcare workers. A critical area of focus should be the development and implementation of policies that enhance conflict resolution mechanisms within hospitals, as conflicts—whether relational, task-related, or process-related—are inherent in the healthcare environment.^23,24 The effectiveness of organizations largely depends on how these conflicts are managed.^25,26 It may, therefore, be beneficial for policymakers to promote training programs and systems that empower staff and management to address conflicts proactively and constructively.

For healthcare managers, the findings underscore the need to actively address conflicts in a transparent and fair manner. Suppressing or avoiding conflicts, as perceived by the workers, can have detrimental effects on team cohesion and morale. Managers should foster open communication channels that allow for constructive dialogue and mediation when conflicts arise. Additionally, policy interventions should aim to foster a culture of continuous learning and professional development within healthcare organizations. The gap in the perception of a “learning mode of management” suggests that workers feel unsupported in their professional growth, which can lead to disengagement and reduced job satisfaction. Policymakers should advocate for resources and programs that encourage lifelong learning, skills enhancement, and leadership development for healthcare professionals.

The gap in valuing individuality and assuming individuals want responsibilities suggests that hospitals need to empower their staff by providing more opportunities for autonomy and professional growth. Managers should strive to recognize and reward individual contributions, as well as delegate meaningful responsibilities that align with workers’ skills and interests. This would not only improve job satisfaction but also enhance organizational effectiveness by capitalizing on the diverse talents and motivations of the workforce. ²⁷ The findings also point to a need for policies that better align the structure of healthcare organizations with their operational goals. While the gaps in structural elements were smaller than in other areas, they indicate that healthcare workers feel that the current organizational designs do not fully meet their needs or the demands of the job. By ensuring that hospital structures are adaptable and responsive to frontline workers’ feedback, policymakers can contribute to more effective and efficient healthcare delivery.

This study opens several avenues for further research. First, future studies should investigate the underlying factors contributing to the large gaps in specific organizational characteristics, such as conflict management and learning modes of management. In particular, qualitative research is recommended to explore the root causes of these gaps, as it would provide in-depth insights that complement the current quantitative findings. By understanding the contextual and systemic factors driving these issues, researchers can propose more targeted and contextually relevant interventions. Additionally, comparative research across different regions or healthcare systems could shed light on whether the gaps observed in this study are unique to Ghana or indicative of broader trends in healthcare organizations in LMICs. Such research would be invaluable for informing global health policy and improving organizational effectiveness in diverse healthcare settings. Furthermore, it would be valuable for future studies to explore how individual characteristics—such as sex, education, and years of experience—relate to overall effectiveness ratings. This line of inquiry could offer additional explanatory power and refine strategies for workforce development and organizational improvement.

Conclusion

The evaluation of organizational effectiveness in public hospitals in Ghana, as perceived by frontline healthcare workers, revealed significant gaps between the current organizational environment and workers’ ideal expectation. These gaps were particularly pronounced in areas such as conflict management, managerial responsibilities, and valuing individuality. The findings have far-reaching implications for policy, practice, and research, underscoring the need for interventions that enhance conflict resolution, support continuous learning, and align organizational structures with operational goals. By addressing these issues, policymakers and healthcare managers can improve the effectiveness of public hospitals, ultimately leading to better healthcare outcomes for the population.

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