Organizational Structure and Performance of Public Hospitals in Montserrado County: A Case of John Fitzgerald Kennedy Medical Centre, Liberia.

Organizational Structure and Performance of Public Hospitals in Montserrado County: A Case of John Fitzgerald Kennedy Medical Centre, Liberia.

Tom Namoi Kerkulah Sherman*, Dr. Moses O. Owino and Dr. John Kamau

School of Business, Africa Nazarene University, Kenya

*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.914MG00169

Received: 20 September 2025; Accepted: 26 September 2025; Published: 23 October 2025

ABSTRACT

The purpose of this study was to examine the influence of organisational structure on the performance of public hospitals. It used a descriptive research design to systematically analyse the characteristics of the target population without manipulating the research environment. The study focused on 214 employees of JFK Medical Centre (JFKMC) in Liberia, utilising a census method to identify respondents and purposive sampling to facilitate efficient data collection within a busy healthcare setting. Data were collected through structured questionnaires that contained both open-ended and closed-ended questions, anchored on a 5-point Likert scale. Descriptive statistics, including means and standard deviations, were used to summarise the data, while linear regression analysis was employed for inferential insights. The findings revealed that the composite mean score of 2.93 placed the overall influence of organisational structure on performance at a neutral level, with moderate variability (composite SD = 1.31) in responses. Three of the six organisational structure components, roles assigned to individuals, scope of control, and structural impact on strategy execution, were perceived to have a positive influence on performance. However, other elements such as role responsibilities, departmental operations, and teamwork reflected neutral to negative perceptions, and several items demonstrated high variability, suggesting inconsistent experiences with organisational structure across the organisation. Regression analysis showed a very strong and statistically significant relationship between organisational structure and performance. The unstandardized coefficient (B = 0.564), standardised beta (0.947), and correlation coefficient (R = 0.947) all confirmed a robust positive effect, while the R Square value (0.897) indicated that nearly 90% of the variance in hospital performance is explained by organisational structure. The model’s strong statistical significance (F = 1742.8, p = 0.000) and low standard error (0.20243) further validated the predictive accuracy of the regression equation. These findings underscore organisational structure as a critical determinant of public hospital performance, highlighting the need for structural refinement to maximise strategic effectiveness and consistency across healthcare institutions.

Keywords: Organizational culture, Organization structure, Strategy implementation, Organisational performance

INTRODUCTION

Organisational performance encompasses the evaluation of progress toward achieving specific goals (Aswar & Hafizh, 2020). It also pertains to an organisation’s capacity to fulfil its goals through robust governance, unwavering dedication to results, and effective management. Furthermore, Boru and Chen (2020) highlighted that performance can be quantified either financially, non-financially or both. These parameters are mirrored with the organisational mission and goals in the process. Thus, the assessment of performance in an organisation such as John Fitzgerald Kennedy Medical Centre (JFKMC) should account for strategic initiatives aimed at enhancing healthcare delivery, improving resource management, and fulfilling organisational objectives.

Strategy implementation is the process of transforming plans and strategies into actionable steps to achieve an organisation’s goals (Candra Susanto et al., 2023). It’s a critical phase where theoretical plans give way to practical action, ensuring that an organisation’s vision becomes a reality. Organisation structure that is determined by leadership plays a pivotal role in strategy implementation because leaders must inspire, motivate, and guide their teams, providing the support and direction needed to drive the strategy forward. Leadership also involves monitoring progress, making adjustments, and solving problems that may arise during implementation (Ackah, 2022).

The effectiveness of strategy implementation plays a crucial role in determining organisational performance. Tawse and Tabesh (2021) emphasised that well-formulated strategies must be executed properly to yield success, noting that variations in company performance often stem from differences in execution. Similarly, Dharyanti et al. (2019) identified communication, resource allocation, bureaucratic structure, and disposition as key components of effective strategy implementation in Indonesia’s healthcare sector, particularly in managing costly hospital services.

Al Humeisat and Abushattal (2022) examined strategic management during the COVID-19 pandemic in Jordan, highlighting how senior management’s adoption of short-term functional and operational strategies was vital for crisis response. In Saudi Arabia, Alomran (2019) explored strategic challenges in healthcare, emphasising regulatory reforms and private sector investment driven by rising healthcare demands.

Funhiro et al. (2022) reported on Zimbabwe’s public hospitals, where policy inconsistencies and inadequate strategy execution hinder quality healthcare delivery. They proposed six strategies to enhance performance, including monitoring and evaluation, PPPs, and impartial governance structures. In Kenya, Waswa and Osoro (2024) found that successful strategy implementation in private health facilities depended on aligning personnel, culture, systems, and resources. Mwangi and Kihara (2021) further noted that management commitment and cultural alignment were essential for private hospital performance.

In Liberia, Alwan et al. (2024) highlighted the need for strategic resource allocation to improve universal health coverage, often relying on donor support. Nyenswah et al. (2023) described how Liberia strengthened disease surveillance and response systems after the Ebola epidemic, though financial limitations and fragmented programs continued to pose challenges. Further, Liberia, a West African nation with a population of 4.5 million, gained independence in 1847 with support from the American Colonisation Society. Despite progress in reducing maternal mortality from 1,072 to 742 per 100,000 live births (2013–2020), haemorrhage and eclampsia remain major causes of maternal deaths. In 2019, 1.98 million DALYs were lost, primarily due to communicable, maternal, child, and nutritional diseases. Liberia’s public health sector faces major challenges, including incomplete laboratory infrastructure, underfunded healthcare budgets, and a shortage of skilled personnel. Only two of five planned regional labs are operational, and high staff turnover affects health system performance

Liberia’s JFK Medical Centre was established after President Tubman’s 1961 meeting with U.S. President Kennedy, receiving $16 million in USAID funding and $1 million from Liberia. Opened in 1971, JFKMC is the country’s main referral and teaching hospital, offering primary to tertiary care. It serves all 15 counties and is funded by the government and donors.

Statement of the Problem

Strategy implementation is vital for organisational success. Also, implementing a strategy to work throughout the organisation is, however, not an obvious process (Dadzie & Kanagasabai, 2022). Liberia’s healthcare system faces several critical challenges that impact hospital performance (Ako-Egbe et al., 2023). First is poor customer service, where there are long wait times and ineffective communication. Secondly, insufficient medical supplies and equipment (Nyenswah et al., 2023). Thirdly, a lack of adherence to standard treatment protocols (Nyenswah et al., 2023). Moreover, limited infection control practices and control measures and inadequately trained personnel (Dadzie & Kanagasabai, 2022).

Several studies have been conducted on global, regional and local scales on implementing strategy initiatives on the public hospitals’ performance. Globally, Tawse and Tabesh (2021) focused on strategy formulation and implementation in the healthcare sector in the USA. However, the study left a gap in strategy implementation on public hospital performance. Regionally, Funhiro et al. (2022) on strategies for improving how hospital management boards function in Zimbabwe left a gap in strategy implementation on public hospital performance.  Locally, the study of Alwan et al. (2024) on Universal Health Coverage indicated the challenges of strategic implementation in Liberia. This research investigated the current strategy implementation on public hospitals’ performance.

Objective of the Study

To examine the influence of organisation structure on performance at JKFMC, Montserrado County, Liberia.

Hypothesis

Organisational structure has no statistically significant influence on the performance of public hospitals in JFKMC in Montserrado County, Liberia.

LITERATURE REVIEW

Friesl et al. (2021) conducted in Germany and Norway, adopted a strategy-as-practice approach and identified five key implementation practices: structural fit, resource compatibility, supervision, framing, and bargaining. While this framework offers a nuanced understanding of how strategy is enacted at various organisational levels through different actors and tools, its relevance to the context of public hospitals in Liberia, particularly JFKMC, is limited. One major limitation is that the Friesl et al. study was situated in high-income countries with different healthcare systems, governance structures, and resource environments compared to Liberia. This raises concerns about the applicability of their findings to low-resource settings such as JFKMC. Furthermore, while the study acknowledged the role of organisational structure as one of several variables influencing strategy implementation, it did not isolate or deeply examine its specific impact on performance outcomes. In contrast, the findings at JFKMC revealed that organisational structure alone accounted for nearly 90% of the variance in hospital performance, highlighting its critical and singular role in shaping outcomes in this context. This divergence suggests that the influence of structure may be more pronounced in resource-constrained environments where clarity of roles, decision-making processes, and accountability are essential for operational effectiveness.

Additionally, Friesl et al.’s approach remained primarily conceptual and empirical, lacking a clear causal analysis of how structural elements translate into improved or diminished performance metrics in public hospitals. While their study employed census, correlation, and regression analyses, it addressed four broader variables organisational culture, resource allocation, structure, and strategic communication, without focusing in-depth on any single one. This contrasts with the JFKMC study, which used linear regression to specifically quantify the effect of organisational structure, thus offering more targeted and actionable insights.

The study by Ackah (2022) in Ghana offers relevant yet contextually distinct insights. Conducted in rural and community banks, Ackah’s research examined the effects of leadership commitment, organisational structure, and employee involvement on strategy implementation. While both studies considered organisational structure as a key variable, the institutional environments—banking versus public healthcare differ significantly in terms of operational dynamics and performance metrics. Ackah found that the adequacy of resources for planning restructuring was statistically significant and highlighted key areas of management, such as role definition, communication, involvement in structural change, and the challenge of conveying technical information. These findings resonate with the JFKMC study’s emphasis on structure but lack the quantitative depth seen in the Liberian context, where organisational structure alone explained nearly 90% of hospital performance variance. In addition, the study employed stratified simple random sampling across 15 banks with 360 participants, whereas the JFKMC study used a census method to capture data from all 214 employees, offering a more comprehensive institutional analysis. Additionally, while both studies used regression analysis, the JFKMC findings provided a more precise and statistically robust model.

Hantiro and Maina (2020) Study in Tana River County, Kenya, provides a broader perspective on strategic implementation practices but differs in scope, methodology, and context. Hantiro and Maina examined the influence of four variables: organisational structure, culture, resource allocation, and communication on performance within a county government setting. Their study was grounded in resource-based, systems, and stakeholder theories, providing a multi-theoretical framework to support their analysis. While their findings confirmed a positive and significant influence of organisational structure and other factors on performance, the study’s focus on government administrative functions presents a different institutional environment compared to public healthcare. Additionally, their methodology involved a descriptive survey design and mixed methods approach, combining both qualitative thematic analysis and quantitative regression analysis. In contrast, the JFKMC study concentrated solely on organisational structure as a single independent variable, applied a fully quantitative approach, and surveyed the entire population of 214 hospital employees using a census method. While both studies highlight the importance of structure in driving performance, the JFKMC study provides a more precise and sector-specific assessment, reinforcing the critical role that organisational structure plays in enhancing performance in public health institutions.

Also, Mohamed and Muathe (2020) provided valuable insights into the role of organisational structure in strategy implementation, albeit in a different sector. Their study focused on oil marketing companies in Kenya and examined employee perceptions of how structural elements, hierarchical levels, organisational communication, decision-making structures, and organisational culture affect strategy execution. With a sample of 148 respondents, the study concluded that all four variables significantly influence strategy implementation. While their findings align with the broader understanding that organisational structure shapes strategic outcomes, the sectoral focus and variable breadth contrast with the more targeted approach of the JFKMC study. The Liberian study concentrated exclusively on the effect of organisational structure on public hospital performance, using regression analysis on quantitative data from the entire population of hospital employees. Unlike the above study, which distributed analytical focus across multiple variables within a commercial sector, the JFKMC study offers a more focused and context-specific understanding of how structural elements directly impact performance in the healthcare sector.

THEORETICAL FRAMEWORK

Proponents of the Dynamic Capabilities View Theory (DCVT) include David Teece, Gary Pisano, and Amy Shuen, who introduced the concept (Teece et al., 1997). Teece later expanded the theory, emphasising innovation and adaptability. Scholars like Kathleen Eisenhardt and Shona Brown also contributed, applying it to fast-changing business environments and strategic management research. DCVT explains how organisations can adapt, innovate, and remain competitive in changing environments by developing internal skills and processes. Unlike traditional resource-based theories that focus on owning valuable assets, DCVT emphasises a firm’s ability to renew and reconfigure its resources in response to external shifts. This theory highlights three core components: sensing, which refers to the ability to identify and assess opportunities and threats in the environment; seizing, which involves mobilising resources to capture value from these opportunities; and transforming, which is the flexibility to realign and reorganise internal structures in order to sustain competitiveness (Schilke & Helfat, 2025).

DCVT is based on several key assumptions. First, it assumes that the business environment is constantly changing and unpredictable. Second, it holds that organisations must continuously adapt and evolve to remain competitive (Wilden et al., 2013). Third, it suggests that success is not solely determined by owning valuable resources, but by how effectively firms integrate, build, and reconfigure both internal and external competencies. Lastly, the theory assumes that learning, innovation, and strategic decision-making are essential for sustaining long-term organisational performance (Gonzalez, 2022).

In the context of public hospitals, the DCV theory can explain how organisational structure influences performance in dynamic healthcare environments. Public hospitals operate under constant pressure from policy changes, funding limitations, disease outbreaks, and shifting patient needs (Singh et al., 2019). Applying DCV, these hospitals must develop capabilities to sense health trends and policy shifts, seize opportunities like donor funding or technology adoption, and transform structures such as staff roles, workflows, or service delivery models (Felin & Powell, 2016). For example, a rigid, hierarchical hospital structure may hinder rapid response to emergencies or innovation. In contrast, a more flexible, decentralised structure can enhance dynamic capabilities by empowering departments to make decisions, reallocate resources, and implement changes swiftly, leading to improved efficiency and patient care outcomes.

CONCEPTUAL FRAMEWORK

The conceptual framework given in Figure 1.1 explains the relationships of the research concepts together with the constructs under study (Van Der Heijden, 2020). In this paper organisation structure is the independent variable, and the dependent variable is organization performance.

METHODOLOGY

In this study, a descriptive research design was used. This design enabled the researcher to systematically describe and analyse the characteristics of the population, phenomena, or variables under investigation without manipulating the research environment (Creswell & Creswell, 2023). The target population comprised 214 employees of JFKMC Liberia.  In addition, the study deployed the census method to identify the respondents. Also, the purposive sampling method was used as it allowed for quick and cost-effective data collection, especially in the busy healthcare environment. The research utilised structured questionnaires, incorporating both open-ended and closed-ended (Mallette & Duke, 2021). The questionnaires had a 5-point Likert scale (Flick, 2020). Descriptive statistical analysis included mean and standard deviation as measures of variability. Inferential statistical analysis involved linear regression.

FINDINGS

The descriptive statistics for the study were based on the mean and standard deviation as indicated in the Table 1.

Table 1 Descriptive statistics of Organization Structure and Performance of Public Hospitals

In Table 1, based on the analysis, the composite mean of 2.93 places the overall influence of organisational structure on performance at a neutral or borderline level. Similarly, the composite standard deviation of 1.31 indicates moderate variability in the responses. When examining individual items, three out of six statements recorded a mean above 2.93, suggesting a positive influence on organisational performance. Specifically, roles assigned to individuals (mean = 3.28, SD = 1.38), the scope of control (mean = 2.95, SD = 1.41), and the overall impact of organisational structure on strategy execution (mean = 3.03, SD = 1.27) were seen as positively influential. However, the remaining items’ responsibilities assigned during strategy implementation (mean = 2.50, SD = 1.50), working in departments (mean = 2.89, SD = 1.22), and working as a team (mean = 2.93, SD = 1.10) were perceived as having a neutral to negative influence. Notably, half of the items also showed high variability (SD > 1.31), indicating differing perceptions among respondents. These mixed results suggest that while certain structural elements support performance, others may require refinement to enhance their strategic effectiveness. The variation in responses points to inconsistency in how organisational structure is applied or experienced within the organisation.

Table 2: Inference Statistics Result of Organisation Structure and Performance of Public Hospitals

Table 2 indicates a very strong and statistically significant relationship between organisational structure and the performance of public hospitals. The unstandardized coefficient (B = 0.564) suggests that for every one-unit increase in organisational structure, the performance of public hospitals increases by 0.564 units, assuming all other factors remain constant. The constant term (2.194) represents the expected performance level when the organizational structure is at zero.

This relationship is highly statistically significant, as shown by a t-value of 41.747 and a p-value of 0.000. The extremely high t-value and very low p-value provide strong evidence that organizational structure is a significant predictor of performance. The standardized beta coefficient (Beta = 0.947) indicates a very strong positive effect of organizational structure on performance in standardized terms. Similarly, the correlation coefficient (R = 0.947) confirms a very strong linear relationship between the two variables. The R Square value of 0.897 means that 89.7% of the variance in the performance of public hospitals is explained by organisational structure. The adjusted R Square (0.896), which accounts for the number of predictors and sample size, confirms the model’s strong explanatory power. This suggests the regression model fits the data exceptionally well.

The overall model is also statistically significant, as evidenced by the F-value of 1742.8 and a p-value of 0.000, confirming that the regression equation provides a good fit for the data. Finally, the standard error of the estimate is 0.20243, which is relatively low, indicating that the model predicts performance accurately with minimal error. Organisational structure has a very strong, positive, and statistically significant effect on the performance of public hospitals, explaining nearly 90% of the variation in performance. This makes it a critical factor influencing how well public hospitals perform.

DISCUSSION

The study’s findings demonstrated that the organisational structure positively influenced the performance of public hospitals in Liberia. This aligns with the research conducted by Friesl et al. (2021), which found that well-established organisational structures significantly impact strategy implementation and overall performance. In public hospitals, an effective organisational structure ensures clarity in roles, responsibilities, and communication pathways, leading to better management of resources, improved efficiency, and enhanced patient care. The alignment between the current study and Friesl et al.’s research highlights the critical role of organisational structure in achieving strategic goals and optimising performance in healthcare settings. These insights underscore the importance of investing in robust organisational frameworks to boost public hospital performance.

Also, the study’s findings are consistent with Ackah (2022), revealing that the organisational structure and the number of resources needed for planning and restructuring were statistically significant. This alignment suggests that a well-defined organisational structure directly influences the efficiency and success of restructuring efforts in public hospitals. By ensuring proper allocation of resources and clear planning, hospitals can optimise their performance and enhance patient care. The significant correlation between organisational structure and resource planning highlights the importance of strategic management in healthcare settings. These insights emphasise the need for public hospitals to invest in robust organisational frameworks and meticulous planning to achieve their performance goals and improve overall service delivery.

The research revealed that collaboration within departments and teams during strategy implementation positively influenced organisational performance. This is consistent with the findings of Hantiro and Maina (2020), who identified a significant positive impact of organisational structure, organisational culture, resource allocation, and communication on performance. Working as cohesive units fosters better coordination, clear communication, and efficient resource use, essential for successful strategy execution. The alignment of these factors creates a robust framework that supports organisational goals, enhances productivity, and drives performance improvements. Hantiro and Maina’s study reinforces the importance of a well-structured organisation where culture, resources, and communication synergies optimise performance. These insights underscore the critical role of teamwork and structured approaches in achieving strategic objectives and improving overall organisational effectiveness.

CONCLUSION

Based on the findings presented in Table 2, it is evident that organisational structure has a very strong, positive, and statistically significant effect on the performance of public hospitals. The high unstandardized coefficient (B = 0.564), standardised beta (0.947), and correlation coefficient (R = 0.947) confirm a robust relationship. The R Square value of 0.897 indicates that nearly 90% of the variance in hospital performance can be explained by organisational structure, underscoring its critical role in driving outcomes. The overall model is statistically significant (F = 1742.8, p = 0.000), and the low standard error of 0.20243 further demonstrates the model’s precision in predicting performance. Therefore, strengthening organisational structure is essential for improving the efficiency, effectiveness, and overall service delivery of public hospitals.

RECOMMENDATIONS

Based on the findings, several key recommendations can be made to enhance the performance of public hospitals through improved organisational structure. First, there is a need to strengthen role clarity and accountability by clearly defining roles, responsibilities, and reporting lines across all levels of hospital staff. This ensures that everyone understands their function in achieving institutional goals and reduces operational confusion. Additionally, public hospitals should enhance their decision-making processes by adopting more decentralised structures. Empowering departmental leaders and frontline staff promotes faster, more responsive actions and encourages innovation in healthcare delivery. Effective communication is also crucial; therefore, hospitals should streamline their communication channels to support efficient information flow both vertically and horizontally, improving coordination and reducing delays. Investing in continuous capacity building through training and development programs will equip managers and staff with the skills required to function effectively within a structured organization. Furthermore, hospitals should conduct regular structural audits to assess and realign their organizational frameworks with current healthcare needs and policy shifts. Lastly, supportive policy and governance from relevant health authorities are essential to provide the frameworks, resources, and oversight necessary for implementing and maintaining effective organizational structures. Together, these measures can significantly enhance the performance and service delivery of public hospitals.

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