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Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in
Kenyan Na ional Re e al Hospi als
Be hwel Kipko i Che uiyo 1, S anley Ka ale2, Pamela Chebii3
1,2,3Depa men o Managemen science and en ep eneu ship School o Business and Economics, Moi Uni e si y, Kenya
ABSTRACT: Hospi al pe o mance is a key issue in esou ce cons ained en i onmen s like Kenya, whe e na ional e e al hospi als
ace eno mous challenges o clinical and ope a ional e iciency. The cu en s udy looks a he mode a ing ole played by
con empo a y leade ship in he ela ionship be ween s a egic posi ioning (emb acing cus ome se ice, con enience, cos and
quali y) and hospi al pe o mance ( ocusing on clinical e iciency (de ined as imely, e idence-based ca e) and ope a ional
e iciency (de ined as esou ce op imiza ion)). A c oss-sec ional su ey was dis ibu ed amongs 351 s a membe s wi h
leade ship esponsibili ies in h ee Kenyan na ional e e al hospi als: Kenya a Na ional Hospi al (KNH), Moi Teaching and Re e al
Hospi al (MTRH) and Kenya a Uni e si y Teaching, Re e al, and Resea ch Hospi al (KUTRRH) wi h 328 usable esponses (93 pe
cen esponse a e). Da a we e analyzed using mul iple eg ession and mode a ion analyses in he s a is ical package, S a is ical
Package and Sys ems (SPSS) e sion 29. Findings show ha s a egic posi ioning has a posi i e in luence on clinical e iciency (be a
(.312, p < .05) and ope a ional e iciency (be a (.289, p < .05). Con empo a y leade ship has a signi ican mode a ing e ec ,
inc easing he in luence on clinical e iciency (be a in e ac ion = -0.098, p < .05, del a R2 = 0.008) and on ope a ional e iciency
(be a in e ac ion = -0.085, p < .05, del a R2 = 0.007). These esul s highligh he c i ical ole o leade ship de elopmen in boos ing
e icacy o s a egic ini ia i es o o e ac ionable in o ma ion o policymake s and manage s wo king in esou ce-limi ed se ings
and con ibu e o uni e sal heal h co e age goals in Kenya.
KEYWORDS: Con empo a y leade ship, s a egic posi ioning, clinical e iciency, ope a ion e iciency, na ional e e al hospi als,
Kenya
INTRODUCTION
The ision o uni e sal heal h co e age (UHC) is a global p io i y bu an elusi e goal in esou ce-poo a eas such as sub-Saha an
A ican coun ies whe e heal h sys ems a e o e whelmed by sys emic ine iciencies (Wo ld Heal h O ganiza ion [WHO], 2021). In
Kenya, na ional e e al hospi als, such as Kenya a Na ional Hospi al (KNH), Moi Teaching and Re e al Hospi al (MTRH), and
Kenya a Uni e si y Teaching, Re e al, and Resea ch Hospi al (KUTRRH) a e key pilla s o he na ional heal h sys em, which handle
complica ed e ia y ca e cases. These ins i u ions ace signi ican challenges, including long wai ing imes o pa ien s (a e age
52 min; Mueni e al., 2019), high nosocomial in ec ion a es (4.8% a KNH; O ice o he Audi o Gene al, 2022) and clinical
ine iciencies, as demons a ed by only 20.1% o mala ia pa ien s ecei ing oxygen sa u a ion check-ups (Machini e al., 2022).
Such de iciencies weaken he scope o Kenya's Big Fou Agenda, which ocuses on a o dable heal hca e as one o he co ne s ones
o de elopmen (Macha ia, 2019).
The s udy ocused on wo key dimensions o hospi al pe o mance, clinical e iciency (a cons uc ha is ope a ionalized as he
deli e y o imely, e idence-based in e en ions ha op imize pa ien ou comes) and ope a ional e iciency (a cons uc
cha ac e ized by he op imiza ion o esou ces and p ocesses o cu ail cos s and wai ing imes) (Weimann & Weimann, 2017).
Bo h dimensions a e aligned wi h he WHO's Pe o mance Assessmen Tool o Quali y Imp o emen in Hospi als (PATH) model
which ocuses on quan i iable imp o emen s in he deli e y o ca e and u iliza ion o esou ces (WHO, 2006). S a egic posi ioning-
dedica ed e o s o di e en ia e se ices h ough such ace s as cus ome se ice, con enience, cos and quali y-has become an
essen ial ac o in d i ing he pe o mance o hospi als wo ldwide (Po e & Teisbe g, 2006). Now, despi e nume ous e o s, gaps
in implemen a ion con inue o exis in he public sec o o Kenya, and he e a e s ill ew empi ical epo s on how such s a egic
posi ioning ma e ializes in o e ec i eness, e iciency, and conc e e gains in ope a ions (Mwangi e al., 2023).
Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in Kenyan Na ional Re e al Hospi als
JEFMS, Volume 08 Issue 10 Oc obe 2025 www.ije m.co.in Page 6609
The in luence o leade ship on heal hca e pe o mance canno be o e -emphasized. Con empo a y leade ship, which blends s yles
o ans o ma ional (inspi a ional, ision led) and adap i e ( lexible, con ex esponsi e) leade ship, is gaining inc easing
ecogni ion as a ca alys o o ganiza ional success (Bass, 1985; O' B ennan, 2023). Wi hin he amewo k o a de ol ed heal h
sys em in Kenya - a sys em ha was ounded by he Cons i u ion o Kenya (2010), leade s ace unique challenges such as
bu eauc a ic hu dles, lack o esou ces and s akeholde misalignmen (Ba asa e al., 2018; Nzinga e al., 2021). Despi e he
impo ance, he ole o con empo a y leade ship in mode a ing be ween s a egic posi ioning and e ec i eness o public hospi als
in A ica has no been o e -explo ed (Khal an e al., 2022).
The cu en esea ch in ends o answe wo main ques ions: (1) how does s a egic posi ioning a ec clinical and ope a ional
e iciency in na ional e e al hospi als in Kenya? and (2) does leade ship in con empo a y imes mode a e hese ela ionships?
Based on Donabedian's S uc u e -- P ocess -- Ou come (SPO) model (1988), b and equi y heo y (Aake , 1991) and
ans o ma ional leade ship heo y (Bass, 1985), he s udy adop s posi i is pa adigm and u ilizes a c oss-sec ional su ey and
eg ession analyses o p o ide empi ical e idence. The expec ed indings aim a policy in o ming unde Kenya's Heal h Sec o
S a egic Plan (KHSSP; Minis y o Heal h [MoH], 2023), and he b oade discou se on heal hca e managemen in low esou ce
se ings.
The impo ance o his s udy is ha i is conce ned wi h a esou ce cons ained si ua ion whe e small gains in e iciency can
p oduce la ge socie al di idends. By analyzing he mode a ing e ec o leade ship, he esea ch has implica ions o p o iding
conc e e knowledge o hospi al adminis a ion and policy make s who a e in e es ed in inc easing pe o mance and equi y in he
deli e y o heal hca e. Con empo a y endea o s, like he WHO Coun y Coope a ion S a egy 2024_wi h 2030 o Kenya,
unde sco e he impe a i e o ein o cing heal h sys ems h ough leade ship and go e nance (WHO, 2024), hus allying wi h he
cu en in es iga ion.
LITERATURE REVIEW
Hospi al Pe o mance: Clinical & Ope a ional E iciency
Hospi al pe o mance is a mul idimensional cons uc howe e , clinical and ope a ional e iciency a e pi o al o sus ainable
heal hca e deli e y (Sa o & Ve onesi, 2016). Clinical e iciency e e s o he abili y o deli e e idence-based ca e ha op imizes
pa ien ou comes whils minimizing e o s and delays. S anda d me ics a e 30-day mo ali y a e, p o ocol adhe ence and pa ien
eco e y imes (A iah e al., 2022). In e na ionally, high-pe o ming hospi als, like he Mayo Clinic, epo an acu e myoca dial
in a c ion mo ali y a e o 11.5 pe cen compa ed o a na ional a e age o 13.2 pe cen in he Uni ed S a es (Cen e s o Medica e
& Medicaid Se ices, 2024). In con as , Kenyan e e al hospi als ace signi ican challenges wi h a s udy epo ing high a es o
wo kplace iolence [91.67 (pe cen ) o s a s] ha co ela es o clinical ine iciencies wi h a sco e o 0.9012 unde he assump ion
o he a iabili y o e u ns o scale [30, 31]. These ine iciencies a ec pa ien sa e y and he quali y o ca e, which equi e speci ic
in e en ions. Recen e alua ions o coun y e e al hospi als in Kenya show ha echnical e iciency le els widely ange wi h
some acili ies unning a 70-80% capaci y due o poo human esou ce managemen (Owuo e al. 2022). The adop ion o
ISO 7101:2023 by he Minis y o Heal h aims o imp o e clinical p ocesses by s anda diza ion o isk managemen and ope a ional
excellence (MoH, 2025). Ne e heless, implemen a ion is s ill inconsis en ac oss he na ional e e al acili y, whe e complica ed
cases add o ine iciencies.
Ope a ional e iciency on he o he hand is conce ned wi h op imizing esou ces, including human esou ces, inancial esou ces,
and in as uc u al esou ces, o s eamline se ice deli e y and o cu down cos s (Kohl e al., 2019). Key indica o s include: bed
occupancy a es, a e age leng h o s ay (ALOS) and cos pe pa ien . Fo ins ance, Samsung Medical Cen e , Sou h Ko ea, has an
ALOS o 4.3 days which is lowe han he na ional benchma k o 4.7 days (Heal h Insu ance Re iew & Assessmen Se ice [HIRA],
2024). In Kenya, he ope a ional issues a e e iden , whe e KNH epo ed he nosocomial in ec ion a e o be 4.8% and MTRH a
86% bed occupancy, which shows he s ain in esou ces (Na ional T easu y, 2025; O ice o he Audi o Gene al, 2022). These
ine iciencies hampe he KHSSP's goal o equi able and e icien heal hca e deli e y (MoH, 2023).c
The balance be ween clinical and ope a ional e iciency is c i ical. Clinical p ocesses (e.g., diagnos ic es ing) a e delayed,
ope a ional esou ces a e s ained (i.e., ALOS inc eased); i ope a ional bo lenecks (e.g., limi ed bed a ailabili y) delay clinical
in e en ions, pa ien ou comes a e comp omised (Weimann & Weimann, 2017). A s udy on he e e al sys em a KNH showed
ha he compliance in e e al be o e he in e en ion was only 45% he eby causing o e loading o he ope a ion; a e he
in e en ion, he e iciency imp o ed by 25% due o en o cemen o he guidelines (Omondi, 2023). Simila ly, he s a e o Kenya's
heal h e e al sys em shows gaps in seconda y o e ia y ansi ion ha con ibu es o 30% unnecessa y e e als (MEASURE
E alua ion, 2018).
Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in Kenyan Na ional Re e al Hospi als
JEFMS, Volume 08 Issue 10 Oc obe 2025 www.ije m.co.in Page 6610
S a egic Posi ioning in Heal h Ca e
S a egic posi ioning is he p ocess o de eloping a dis inc i e ma ke iden i y o inc ease i s compe i i eness and pa ien
sa is ac ion (Po e & Teisbe g, 2006). In heal hca e, i has ou dimensions:
Cus ome Se ice: Pa ien -cen e ed ca e which ocuses on empa hy, communica ion and sa is ac ion (Boamah, 2019). E ec i e
cus ome se ice can con ibu e o he imp o emen o clinical esul s by enhancing pa ien compliance in he ea men plan
(Eps ein & S ee , 2007). In he A ican con ex , cus ome -se ice posi ioning has been co ela ed wi h inc eased e en ion in
p i a e hospi als (Abekah-Nk umah e al., 2021).
Con enience: A ailabili y and ease o se ice p o ision, e.g. ia elemedicine o sho e wai ing imes [Gup a e al., 2022].
Con enience has been ound o diminish ALOS and inc ease pa ien sa is ac ion (K use e al., 2017). In Kenya, he adop ion o
elemedicine in e e al hospi als has yielded a 15% imp o emen in ope a ional e iciency in he ime o he Co id-19 pandemic
(Tebeje & Klein, 2021).
Cos : Low cos wi h no comp omise on quali y, which is o en ealized wi h he help o lean managemen p ac ices (Saqib, 2021).
Cos posi ioning is c i ical in esou ce limi ed en i onmen s, whe e access is limi ed by inancial cons ain s (Robinson e al., 2020).
A s udy unde aken on p i a e hospi als in Kisii Coun y ound ha cos leade ship s a egies imp o ed pe o mance by 22 pe cen
(Mu hu i & Ouma, 2017).
Quali y: P o ision o e idence-based ca e ha is o clinical s anda d and leads o be e ou comes (Twahi & Ki i e, 2017). Good
quali y s eng hens hospi al's image and pa ien 's us (D e s e al., 2014). In sub-Saha an A ica, good posi ioning is associa ed
wi h good go e nance and o e all sys em pe o mance (Amoako e al., 2011).
The e is some empi ical e idence o he ela ionship be ween s a egic posi ioning and hospi al pe o mance. Fo example, in a
s udy o E hiopian hospi als, quali y posi ion o ien a ion was ound o enhance clinical ou comes by 15% (Endeshaw 2021).
Muhimbili Na ional Hospi al in Tanzania saw ha hei cos s a egies made se ices mo e a o dable bu also caused quali y ade-
o s (Joseph, 2020). In Kenya, s a egic posi ioning e o s ha e shown p omise bu a e acing implemen a ion challenges, such as
inadequa e in as uc u e and s a ing sho ages (Mwangi e al., 2023; Ndinda, 2019). Recen esea ch on ocus s a egies in le el
4 public hospi als shows ha ocused posi ioning leads o an imp o emen in ope a ional measu es o 18 pe cen (Kamau e al.,
2024). P oac i e s a egic sou cing has been ecognized as a game change o public hospi al pe o mance - i has he po en ial
o dec ease he cos o p ocu emen by 12 pe cen (Ochieng 2024).
Con empo a y Leade ship as a Mode a o
Con empo a y leade ship inco po a es ans o ma ional and adap i e s yles o adap o complex o ganiza ional en i onmen s
(Bass, 1985; O'B ien, 2023). T ans o ma ional leade ship d i es change h ough inspi a ion, mo i a ion, and in ellec ual
s imula ion, whe eas adap i e leade ship emphasizes lexibili y and esponsi eness o con ex ual challenges. (Ali e al., 2023). In
he case o heal hca e, hese s yles a e impo an o econcile s a egic ini ia i es and ope a ional eali ies. Fo example, he
clinician-led model o he Cle eland Clinic, using ans o ma ional leade ship echniques, has achie ed a pa ien sa is ac ion a ing
o 98% (S olle , 2023) and he Ne ca e G oup o Sou h A ica, h ough he use o adap i e leade ship, has led he way in
elemedicine adop ion wi h a 20% educ ion in consul a ion imes (Ne ca e G oup, 2023).
In Kenya, ecen ini ia i es highligh he ole o leade ship. The WHO Coun y Coope a ion S a egy 2024-2030 ocuses on
leade ship in heal h sys em s eng hening (WHO, 2024). The Kenya Communi y Heal h S a egy 2020 - 2025 emphasizes p inciples
on in eg a ed leade ship (MoH, 2021). A scoping e iew on leade ship in e en ions in Kenyan coun ies e ealed ha ained
eams boos ed pe o mance by 28 pe cen (Mbindyo e al., 2024). The AMPATH Women in Leade ship P og am (2025) Posi ioning
women o global heal h change (AMPATH, 2025). The Ko i Annan Global Heal h Leade ship P og amme de elops A ican public
heal h leade s (A ica CDC, 2024): The IWD 2025 Nai obi Con e ence empowe ed 200+ women leade s (KHF, 2025). ACQUIRE's
2025 Theo y Leade ship Cou se is aimed a C- Sui e execu i es (ACQUIRE, 2025). The heme o he ans o ma i e leade ship
con e ence is Kenya Medical Associa ion 2025.
Mode a ion heo y p oposes ha leade ship could imp o e he ela ion o s a egy and pe o mance would educe he ba ie s
and he esou ces (Ba on & Kenny, 1986). In heal hca e, mode n leade ship is used o s eng hen clinical ou comes, h ough a
cul u e o inno a ion (Asamani e al., 2023) and also ope a ional e iciency, h ough op imal esou ce alloca ion (Galpin e al.,
2012). In Kenya, howe e , leade ship gaps (including he lack o aining and bu eauc acy) hampe pe o mance (O ieno & Ouma,
2023). S udies call o he use o adap i e leade ship in add essing some o he de olu ion- ela ed challenges ha include unding
delays, policy misalignmen (Kinyua, 2024). A complexi y heo y lens on clinical leade ship in Kenyan Hospi als: Re ealing con ex
d i en p ac ices, Nzinga e al. (2021).
Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in Kenyan Na ional Re e al Hospi als
JEFMS, Volume 08 Issue 10 Oc obe 2025 www.ije m.co.in Page 6611
Resea ch Gap and Resea ch Concep ual F amewo k
While he s a egic posi ioning has been demons a ed o be a known d i e o hospi al e iciency (Smi h e al., 2022), he
mode a ing ole o con empo a y leade ship in public A ican hospi als has been unde explo ed (Khal an e al., 2022; No onha
e al., 2023). This s udy add esses his gap by s udying he media ing e ec o leade ship on he e ec s o s a egic posi ioning on
clinical and ope a ional e iciency in Kenyan e e al hospi als. The concep ual model (Figu e 1) a gues ha s a egic posi ioning
a ec s e iciency and mode n leade ship enhances hese ela ionships.
Hypo heses De elopmen
H01: The e is no s a is ically signi ican ela ionship be ween S a egic posi ioning and clinical e iciency in Kenyan na ional
e e al hospi als.
H02: The e is no s a is ically signi ican ela ionship be ween S a egic posi ioning and ope a ional e iciency in Kenyan
na ional e e al hospi als.
H03: Con empo a y leade ship does no signi ican ly mode a e he ela ionship be ween s a egic posi ioning and clinical
e iciency aspec o hospi al pe o mance
H04: Con empo a y leade ship does no signi ican ly mode a e he ela ionship be ween s a egic posi ioning and
ope a ional e iciency aspec o hospi al pe o mance
These hypo heses a e an ex ension o Donabedian's SPO model whe e leade ship was added as a p ocess enhancing beha io and
he e o e b ough s a egic inpu s and pe o mance ou comes oge he (Donabedian, 1988; Sha ew e al., 2020). Fu he mo e,
he p oposi ions a e based on b and equi y heo y (Aake , 1991) o concep ualizing he concep o posi ioning as a alue-c ea ing
mechanism and ans o ma ional leade ship heo y (Bass, 1985) o concep ualizing he concep o leade ship as a mode a o .
METHODOLOGY
Design o Resea ch and Pa adigm
This in es iga ion employed a c oss-sec ional desc ip i e design, which was loca ed unde a posi i is pa adigm, and he emphasis
was gi en o objec i e measu emen and hypo hesis es ing (Pa k e al., 2020). Da a we e collec ed om Ap il o May 2025 in
h ee Kenyan na ional e e al hospi als, Kenya a Na ional Hospi al (KNH; 6,100 s a ), Moi Teaching and Re e al Hospi al (MTRH;
3,820 s a ), and Kenya a Uni e si y Teaching and Re e al Hospi al (KUTRRH; 1,404 s a ). The a ge popula ion included 2,820
s a membe s wi h leade ship esponsibili ies such as depa men heads, senio clinicians and adminis a o s. Using Yamane's
o mula (n = N / [1 + N(e)^2], e = .05) he sample size was calcula ed as n = 351.
Measu es
The s udy used alida ed scales o measu e cons uc s, all employing 5-poin Like scales (1 = S ongly Disag ee, 5 = S ongly
Ag ee):
1. S a egic Posi ioning: A Twen y 20-i em scale (α = .89) adap ed om Ko le e al. (2008), wi h subscales o cus ome
se ice (5 i ems, e.g., “Pe sonalized ca e plans enhance pa ien sa is ac ion”), con enience (5 i ems, e.g., “Telemedicine
educes pa ien wai imes”), cos (5 i ems, e.g., “Lean p ac ices lowe ope a ional expenses”), and quali y (5 i ems, e.g.,
“E idence-based p o ocols imp o e pa ien ou comes”).
2. Con empo a y Leade ship: A Fi e 5-i em scale (α = .92) adap ed om Bass (1985), measu ing ans o ma ional and
adap i e leade ship (e.g., “Leade s inspi e inno a ion and adap abili y”).
3. Clinical E iciency: A Fi e 5-i em scale (α = .87) based on WHO PATH (2006), assessing imely and e idence-based ca e
(e.g., “Adhe ence o p o ocols educes mo ali y a es”).
4. Ope a ional E iciency: A Fi e 5-i em scale (α = .85) based on WHO PATH (2006), e alua ing esou ce op imiza ion (e.g.,
“E icien esou ce use minimizes ope a ional was e”).
All scales we e p e- es ed o eliabili y and alidi y in a pilo s udy wi h 30 esponden s, ensu ing cul u al and con ex ual
ele ance.
Da a Collec ion and Analysis
A o al o 351 pa icipan s we e handed sel -adminis e ed ques ionnai es, and 328 alid esponses ( esponse a e o 93%) we e
ob ained. The da a was cleaned o emo e incomple e da a, and no mali y was checked (skewness < 2, ku osis < 7; Ghasemi &
Zahediasl, 2012). Analyses we e pe o med wi h he aid o he s a is ical package (SPSS Ve sion 29) .
Da a Collec ion and Analysis
Adminis e ed ques ionnai es we e dis ibu ed o 351 pa icipan s, yielding 328 alid esponses (93% esponse a e). Da a we e
cleaned o emo e incomple e en ies, and no mali y was con i med (skewness < 2, ku osis < 7; Ghasemi & Zahediasl, 2012).
Analysis was conduc ed using SPSS Ve sion 29, wi h he ollowing s eps:
Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in Kenyan Na ional Re e al Hospi als
JEFMS, Volume 08 Issue 10 Oc obe 2025 www.ije m.co.in Page 6612
1. Desc ip i e S a is ics: Means, s anda d de ia ions, and co ela ions o summa ize da a.
2. Hie a chical Mul iple Reg ession: Tes ed di ec e ec s o s a egic posi ioning on e iciency (H1, H2).
3. Mode a ion Analysis: Followed Hayes (2018), wi h h ee s eps: (a) con ols (age, gende , expe ience), (b) main e ec s
(posi ioning, leade ship), and (c) in e ac ion e m (posi ioning × leade ship) o es H3 and H4.
Mul icollinea i y was absen (VIF < 5), and he e oscedas ici y was no de ec ed (B eusch-Pagan es , p > .05). E hical app o al was
ob ained om Moi Uni e si y’s Ins i u ional Re iew Boa d and he Na ional Commission o Science, Technology, and Inno a ion
(NACOSTI). In o med consen was secu ed, ensu ing pa icipan con iden iali y and olun a y pa icipa ion.
RESULTS
Desc ip i e S a is ics
The mean age o he sample was 42 yea s (SD = 8.2), and 58% o he pa icipan s we e male wi h 62% ha ing deg ees and
pos g adua e quali ica ions and 45% ha ing mo e han 10 yea s o expe ience. The ollowing means we e a iable: s a egic
posi ioning (M = 3.92, SD = .67), con empo a y leade ship (M = 4.01, SD = .58), clinical e iciency (M = 3.78, SD = .72) and
ope a ional e iciency (M = 3.65, SD = .69). Subg oup analysis by ins i u ion showed some small di e ences: KNH (clinical M =
3.85), MTRH (ope a ional M = 3.72), KUTRRH (leade ship M = 4.10).
Table 1: Desc ip i e S a is ics and Co ela ions
Va iable
M
SD
1
2
3
4
1. S a egic Posi ioning
3.92
.67
—
.62**
.58**
.54**
2. Con empo a y Leade ship
4.01
.58
.62**
—
.55**
.51**
3. Clinical E iciency
3.78
.72
.58**
.55**
—
.67**
4. Ope a ional E iciency
3.65
.69
.54**
.51**
.67**
—
No e. N = 328. **p < .01.
Co ela ions indica e s ong posi i e ela ionships among a iables, suppo ing he heo e ical amewo k. Fo ins ance, s a egic
posi ioning and clinical e iciency ( = .58, p < .01) sugges a obus link, consis en wi h p io s udies (Gup a e al., 2022). Subg oup
co ela ions by expe ience le el (>10 yea s: =.65 o posi ioning-e iciency) highligh s onge e ec s among e e ans.
Table 2: Subg oup Analysis: Means by Hospi al
Hospi al
S a egic Posi ioning
Leade ship
Clinical E .
Ope a ional E .
KNH
3.90 (.68)
3.98 (.59)
3.85 (.70)
3.62 (.71)
MTRH
3.95 (.66)
4.05 (.57)
3.75 (.73)
3.72 (.67)
KUTRRH
3.92 (.67)
4.10 (.56)
3.74 (.73)
3.60 (.70)
No e. N=328. S anda d de ia ions in pa en heses.
REGRESSION RESULTS
Hie a chical eg ession esul s a e p esen ed in Table 2. Fo H01, s a egic posi ioning signi ican ly p edic ed clinical e iciency (β =
.312, p < .001, R² = .194), explaining 19.4% o he a iance. Cus ome se ice (β=.145) and quali y (β=.112) subscales con ibu ed
mos . Fo H02, s a egic posi ioning p edic ed ope a ional e iciency (β = .289, p < .001, R² = .167), explaining 16.7% o he a iance,
wi h cos (β=.130) and con enience (β=.108) p ominen .
Fo mode a ion (H03, H04), he in e ac ion e m (posi ioning × leade ship) was signi ican o bo h clinical e iciency (β = -.098, p <
.05, ΔR² = .008) and ope a ional e iciency (β = -.085, p < .05, ΔR² = .007). The nega i e be a coe icien s sugges ha leade ship
supp esses ad e se in luences, s eng hening he posi i e e ec s o posi ioning. The in e ac ion e ms added small bu signi ican
a iance (0.8% o clinical, 0.7% o ope a ional), suppo ing H3 and H4. Subg oup mode a ion by hospi al showed s onge e ec s
a MTRH (ΔR²=.012 o clinical).
Table 3: Hie a chical Reg ession o Mode a ion
P edic o
Clinical E iciency
Ope a ional E iciency
β (SE)
β (SE)
S ep 1: Con ols
Age
.08 (.02)
.06 (.02)
Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in Kenyan Na ional Re e al Hospi als
JEFMS, Volume 08 Issue 10 Oc obe 2025 www.ije m.co.in Page 6613
Gende
.05 (.11)
.04 (.10)
Expe ience
.12* (.03)
.10 (.03)
R²
.045
.038
S ep 2: Main E ec s
S a egic Posi ioning
.312*** (.05)
.289*** (.05)
Con empo a y Leade ship
.210** (.06)
.195** (.06)
ΔR²
.194***
.167***
S ep 3: In e ac ion
Posi ioning × Leade ship
-.098* (.04)
-.085* (.04)
ΔR²
.008*
.007*
To al R²
.247***
.212***
No e. N = 328. *p < .05. **p < .01. ***p < .001.
Figu e 1: In e ac ion Plo : S a egic Posi ioning and Ope a ional E iciency Mode a ed by Con empo a y Leade ship
A g aph showing he ela ionship be ween s a egic posi ioning and ope a ional e iciency a low, medium, and high le els o
con empo a y leade ship. The slope s eepens wi h highe leade ship, indica ing a s onge e ec .
Table 4: Subscale Con ibu ions o E iciency
Subscale
Clinical β
Ope a ional β
Cus ome Se ice
.145***
.092**
Con enience
.098**
.108**
Cos
.057*
.130***
Quali y
.112**
.059*
No e. *p<.05. **p<.01. ***p<.001.
DISCUSSION
Theo e ical Implica ions
The empi ical e idence suppo s he p oposi ion ha he s a egic posi ioning signi ican ly augmen s he clinical and ope a ional
e iciency wi hin he Kenyan e e al hospi als which is consonan wi h he global schola ship (Gup a e al., 2022; Po e & Lee,
2013). Dimensions o cus ome se ice and quali y ha e been ound o be pi o al d i e s o clinical e icacy as hey inc ease pa ien
adhe ence and ou comes (Eps ein & S ee , 2007) while cos and con enience ini ia i es op imize ope a ional p ocesses by
educing was e and delays (K use e al., 2017; Robinson e al., 2020). These indings ex end Endeshaw's (2021) conclusions o he
se ing o public hospi als, hus highligh ing he gene alizabili y o s a egic posi ioning in esou ce - cons ained en i onmen s.
Subscale analyses, mo eo e , show a disp opo iona ely la ge impac o cus ome se ice on clinical gains, which is consis en
wi h A ican s udies on pa ien -cen ed ca e (Abekah-Nk umah e al., 2021).
1
1.5
2
2.5
3
3.5
4
4.5
5
Low CP High CP
Ope a ional E iciency
Low CL
High CL
Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in Kenyan Na ional Re e al Hospi als
JEFMS, Volume 08 Issue 10 Oc obe 2025 www.ije m.co.in Page 6614
The mode a ing unc ion o con empo a y leade ship is a new con ibu ion o he li e a u e. Signi ican in e ac ion e ec s
be ween ans o ma ional and adap i e leade ship sugges ha he impac o s a egic posi ioning is inc eased, which is consis en
wi h Bass's (1985) heo e ical amewo k. The nega i e in e ac ion coe icien s sugges leade ship helps o sol e ba ie s like lack
o esou ces o bu eauc acy delays, which help mi iga e he dilu ion o s a egic ini ia i es (Nzinga e al., 2021). This obse a ion
is an ex ension o he heo y o mode a ion (Ba on & Kenny, 1986) in he a ea o heal hca e, cha ac e izing he ole o leade ship
as a p ocess enhance in he SPO model by Donabedian (1988). Wi hin he Kenyan con ex s, subg oup e ec s obse ed a MTRH
a e consis en wi h egional leade ship in e en ions ha in es ed in people, leading o imp o ed pe o mance by 28 pe cen
(Mbindyo e al, 2024).
Compa a i e analysis b ings ou global exempla s such as he clinician-led model o he Cle eland Clinic (S olle , 2023) and egional
examples such as he Ne ca e G oup's success in he use o elemedicine (Ne ca e G oup, 2023) ha , oge he , exempli y he
ans o ma i e capaci y o leade ship. In Kenya, whe e decen aliza ion poses a ious challenges (Ba asa e al., 2018), adap i e
leade ship becomes a mus -ha e ool in linking s a egies o local eali ies. The WHO CCS 2024-2030 u he adds o his impe a i e
by emphasizing leade ship in he pu sui o sys em esilience (WHO, 2024).
P ac ical Implica ions
The s udy has se e al implica ions o heal hca e s akeholde s:
Leade ship De elopmen
T ans o ma ional and adap i e leade ship aining a e u ged o be pa o he KHSSP amewo k by policymake s (MoH, 2023).
Ini ia i es such as he Ko i Annan Fellowship (A ica CDC, 2024) and he ACQUIRE Cou se (2025) could be expanded o emphasize
compe encies in s akeholde engagemen and change managemen . Gende - ocused p og ams ha embody AMPATH WIL (2025)
and In e na ional Women's Day con e ences (KHF, 2025) ackle pe sis en gende imbalances in leade ship.
S a egic Alignmen
Hospi al manage s a KNH, MTRH, and KUTRRH a e ecommended o achie e synch oniza ion o posi ioning s a egies wi h
leade ship p ac ices. Fo example, quali y-speci ic p og ams (e.g., adop ion o ISO 7101; MoH, 2025) can be accompanied wi h
ans o ma ional leade ship o imp o emen o clinical ou comes. P oac i e p ocu emen (Ochieng, 2024) and ocus s a egy
amewo ks (Kamau e al., 2024) o e wo kable bluep in s o cos e iciency.
Resou ce Op imiza ion
S a egies ha ocus on cos and con enience (lean managemen and elemedicine) should be p io i ized o educe ope a ional
bo lenecks. Leade ship can ca alyze adop ion h ough he de elopmen o a cul u e o inno a ion, such as in he case o
imp o emen s o he e e al sys ems a KNH (Omondi, 2023).
Policy In eg a ion
The indings lend suppo o Kenya's Big Fou Agenda by s essing he need o leade ship-d i en e o ms o ensu e a o dable
heal hca e (Macha ia, 2019). In es men s in leade ship capaci y building could p o ide sus ained e iciency imp o emen s, in line
wi h he Communi y Heal h S a egy 2020-2025 (MoH, 2021).
LIMITATIONS AND FUTURE RESEARCH
The s udy is limi ed by a c oss-sec ional design, which hinde s causali y; esea ch on longi udinal s udy designs could de e mine
how he posi ioning and leade ship de elop o e ime, which could e alua e he e ec s o ISO 7101 (MoH, 2025). Sel - epo ing
da a may be p one o bias, signaling he need o objec i e me ics (e.g. ac ual pa ien wai imes om HMIS). The ocus on public
e e al hospi als limi s he gene alizabili y; u u e esea ch should conduc a compa a i e analysis be ween he public and p i a e
acili ies, including s a egic con ols inco po a ed in mission hospi als (Mu hu i & Ouma, 2017). Mo eo e , explo a ion o digi al
in eg a ions such as elec onic heal h eco ds may poin o some e iciency d i e s ha ha e no been explo ed be o e, building
on HR e iciency s udies (Owuo e al., 2022). Quali a i e app oaches, such as he complexi y heo y analyses (Nzinga e al., 2021),
may help in inc easing he unde s anding o he dynamics o leade ship p ac ice.
CONCLUSION
In his s udy, i has been e iden he c i ical ole o mode n-day leade ship in mode a ing he ela ionship be ween s a egic
posi ioning and hospi al pe o mance in Kenyan na ional e e al hospi als. S a egic posi ioning complemen s clinical and
ope a ional e iciency, and leade ship inc eases i s e ec s by ha ing a ision ha ma ches execu ion. The esul s call o policy
and manage ial in es men s in leade ship de elopmen and s a egic alignmen in o de o p omo e Kenya's uni e sal heal h
co e age goals. Fu u e esea ch should in es iga e longi udinal e ec s, p i a e s. public compa isons and digi al inno a ions o
u he s eng hen he e iciency o heal hca e.
Con empo a y Leade ship, S a egic Posi ioning and Hospi al Pe o mance in Kenyan Na ional Re e al Hospi als
JEFMS, Volume 08 Issue 10 Oc obe 2025 www.ije m.co.in Page 6615
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