Clinical Governance: A Critical Need in Africa’s Healthcare System

Author: Dr Azuka Chinweokwu Ezeike, MBBS, FWACS, FMCOG, MSc (PH)

Highlights

• Clinical governance is essential for delivering consistent, high-quality healthcare, but remains largely absent across Africa.
  
  
• Lack of a structured governance framework undermines Universal Health Coverage, even when services are affordable.
  
  
• The seven pillars of clinical governance, ranging from clinical effectiveness to information management, are key to reducing preventable deaths.
  
  
• Poor management, inadequate training, and weak accountability systems hinder healthcare quality in African countries.
  
  
• Evidence-based practices and context-specific guidelines are crucial for effective implementation in low-resource settings.
  
  
• Strengthening legislation, leadership, and staff capacity can make clinical governance a reality in Africa.

Introduction

Remembering John: A Life Cut Short

John tripped and fell off a scaffold while working on a construction site. His colleagues quickly picked him up and rushed him to the nearest hospital, where he had previously been a patient. He arrived unconscious but still breathing.At the hospital, he was received by a junior doctor with little experience managing such emergencies. The doctor called a senior colleague for guidance. While waiting, he noticed a bleeding cut on John’s leg and decided to start by stitching it.

The nurse on duty was newly employed and unfamiliar with how to operate the oxygen cylinder, so she was unable to administer oxygen to the patient. The junior doctor also contacted the Radiology Department and was informed that although the X-ray machine was functional, the building’s lighting had been faulty for two days and had not yet been repaired. He requested a computed tomography (CT) scan but was told it was not operational.He sent the ward clerk to get medications from the pharmacy, but was informed that John’s medical folder was required before the drug would be dispensed.. Unfortunately, the records officer was still trying to locate it among a pile of files. The doctor decided to go to the records office himself to help with the search.

While this was happening, the nurse rushed in to report that the patient had stopped breathing. The doctor hurried back but found that John had died.He informed the relatives, who accepted the incident as an act of God and took the body home for burial. The senior doctor never arrived on time because his car broke down on the road. The folder was never found, and the matter was never brought up again.

Clinical Governance: The Missing Link in Africa’s Struggle for Quality Healthcare 

Was John’s death an act of God or a consequence of a dysfunctional health system? Would John have died if this had happened in the United Kingdom (UK)? What if every patient could receive high-quality care every time? Is that possible in Africa?

Clinical governance is a framework that ensures quality healthcare delivery, yet it is often absent in many healthcare setups across Africa. As the world moves closer to the 2030 target for the Sustainable Development Goals(SDGs), access to quality healthcare remains out of reach for many, especially in low-resource settings.

Universal Health Coverage is one of the SDG targets and involves access to the full range of quality health services people need, when and where they need them, without financial hardship. The lack of a clinical governance framework means that even when services are affordable, there is no guarantee of quality.

But is this rocket science? Is clinical governance truly difficult to implement in the African health system? Is Clinical Governance the missing link?This article seeks to explore these questions.

Clinical Governance and the State of Healthcare in Africa

Having a health system that works is the responsibility of any leadership towards its citizens, and this should be a priority for leaders. Clinical governance represents the interplay between leadership, clinical systems, and patient safety systems. If countries in Africa are to achieve health equity and health security, clinical governance must be upheld.

Though some progress has been made over time, Africa still faces a high burden of preventable deaths and communicable diseases. The burden of chronic diseases like hypertension is also on the rise [1]. This calls for a strong health system and the presence of an effective clinical governance framework. Improved governance can enhance healthcare access, even when resources are limited.

The lack of quality care is not just due to limited resources; it is also a result of poor management. Many countries in Africa have not prioritised clinical governance. Even where clinical governance exists, healthcare workers often demonstrate poor knowledge of its principles and practices [2]. 

In Western countries, better access to healthcare is not solely because of abundant resources but also due to stronger management systems. It is not enough to have competent health workers; if the system is not adequately structured, unintentional harm can still happen to patients. 

What is Clinical Governance?

The most widely accepted definition of clinical governance was provided by Scally and Donaldson in 1998. They defined clinical governance as a “system through which National Health Service (NHS) organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”[3,4].

The key components of this definition include:

• Accountability
  
  
• Quality
  
  
• Continuous improvement
  
  
• High standards
  
  
• Excellence

Clinical governance is the vehicle that enables the delivery of continuous, high-quality care.While we admire and even seek out the high-quality care available in the West, it is important to understand that developing such systems is also possible in Africa.

Origin of Clinical Governance

Clinical governance originated in the United Kingdom’s National Health Service (NHS) in the 1990s [5]. It emerged from a white paper released to support NHS organisations in implementing the NHS Act, which places a duty on them to provide quality care.

It marked a departure from traditional systems by placing greater emphasis on elements of care such as leadership, staff relationships, and interactions between clinical staff and patients. These areas had previously received little attention.

 Clinical governance also represents a unification of previously fragmented policies. Fragmented policies are a common challenge in Africa, where numerous policies are designed to solve specific problems but often fail due to a lack of synergy.

How is the Clinical Governance System Structured?

Clinical governance systems should be implemented at all levels of care, with the chief executive serving as the overall head of the clinical system. In local hospitals, the medical director acts as the lead, with oversight provided by national bodies.In the UK, the National Institute for Health and Care Excellence (NICE) and the Commission for Health Improvement play critical roles in this oversight.

At every level, there must be a governing body responsible for providing leadership in establishing a culture of safety and quality improvement, as well as assigning roles and responsibilities.In Africa, this system can be supervised by the Ministry of Health. Facility governing bodies should be established in each facility, reporting to a local governing authority. This authority then reports to the state governing body, which in turn reports to the national governing body.

Elements of Clinical Governance

The essential elements of clinical governance must be upheld throughout the healthcare system by leaders and important stakeholders.

The key elements include: 

• Accountability: Stakeholders should be fully responsible for the treatment that patients receive
• Transparency: There should be open sharing of information on patient treatment.
• Patient safety: Risks and adverse events should  be reduced to the barest minimum

Pillars of Clinical Governance

The most popular clinical governance framework consists of seven pillars, though other modifications exist.  

The seven pillars include: 

1. Clinical Effectiveness/Research
2. Clinical Audit
3. Risk Management
4. Education and Training
5. Patient and Public Involvement 
6. Information Management
7. Staffing and Staff Management

Clinical Effectiveness

The focus is on achieving the best possible outcomes for patients. It involves ensuring that all activities within the healthcare system are designed to deliver optimal results.
Simply put, clinical effectiveness means doing the right thing for the right patient, in the right place, and at the right time.Key components include:

• Ongoing research to build a strong evidence base
  
  
• Promoting evidence-based practices
  
  
• Implementing clinical guidelines
  
  
• Monitoring and evaluating healthcare processes
  
  
• Reviewing practices based on current research findings
  
  

To implement clinical effectiveness in Africa, we need homegrown evidence and context-specific guidelines that reflect the unique characteristics of African patients. This calls for leadership from healthcare research institutions, ministries of health, and professional associations in driving relevant research. Adequate funding is also essential to support high-quality research that can inform policy and practice.

Clinical Audit

Clinical audit involves the continuous monitoring and evaluation of healthcare systems against certain defined criteria.A system that is not audited cannot function effectively. An audit provides critical insights into how a service is performing and whether improvements are needed. It helps identify deficiencies in the system so that they can be addressed.In the United Kingdom(UK), clinical audits are coordinated by the National Clinical Audit and Patient Outcomes Programme (NCAPOP).Key components of clinical audit include:

• Regular review meetings to evaluate clinical practices
  
  
• Systematic analysis of processes to identify gaps
  
  
• Mortality review meetings and the implementation of necessary changes
  
  

To ensure objectivity and real-time assessment, unscheduled visits by regulatory authorities should also be conducted periodically.Having legal support also facilitates the clinical audit process. According to Ayanfe Victoria Adeyeye, a medical lawyer practising in Abuja, Nigeria, “Legal expertise strengthens this process by ensuring audits comply with regulatory requirements and mitigate risks.”

When implemented effectively, clinical audit enhances accountability, supports evidence-based practice, and fosters a culture of continuous improvement. However, it must be conducted in a non-punitive, blame-free environment to encourage openness and genuine reflection among healthcare professionals.

Risk Management

Risk management can be described as a coordinated set of activities and methods used to guide an organisation and control or mitigate potential risks. In healthcare, it involves putting systems in place to minimise harm to patients and ensure safe, high-quality service delivery.It requires proactive measures to identify, assess, and manage potential threats to patient safety, service quality, and organisational effectiveness.

Key risk management strategies include:

• Developing and adhering to standard operating procedures (SOPs)
  
  
• Routine reporting of adverse events within a blame-free culture
  
  
• Conducting root cause analyses to understand underlying problems
  
  
• Performing regular safety audits
  
  
• Maintaining a risk register to track and monitor potential risks
  
  
• Promoting continuous learning from past incidents and errors

In resource-constrained settings, adaptations of risk management systems have been implemented to suit local conditions. For example, in a district hospital in South Africa, an operating protocol requirng the creation of an admission unit was instituted, and all admitted patients were reviewed by a senior family physician within 48 hours [6]. This approach significantly reduced medical errors and misdiagnoses, demonstrating how context-specific strategies can improve patient safety and clinical outcomes. 

Education and Training

Continuous quality improvement involves having well-skilled and updated staff. Medical facts and evidence are constantly evolving, and to provide optimal care, staff must be trained on recent trends and practices. Training enhances staff competence, enabling them to deliver safe, effective, and high-quality care.

Some of the medical errors observed in healthcare facilities can be traced to inadequate training and a lack of regular retraining. In addition to improving clinical performance, training enables staff to meaningfully contribute to other pillars of clinical governance, such as risk management and clinical audit.

According to the World Health Organization, the health systems of some countries continue to struggle due to underinvestment in the training of healthcare workers. To address this, professional development should be prioritised and institutionalised.Staff training can take several forms, including:

• Mandatory Continuing Professional Development (CPD) programmes
  
  
• Participation in scientific conferences
  
  
• Regular in-house training sessions
  
  
• Objective performance appraisal systems
  
  
• Routine staff assessments
  
  

Importantly, training should cut across all cadres of staff, not just clinical teams. Administrative, maintenance, health records, and clinical departments should all have structured, mandatory training protocols. Adequate funding should be allocated for these activities, and training organisations should be contracted to support health system strengthening through capacity building.

Patient and Public Involvement (PPI)

Some of the challenges facing healthcare in Africa can be addressed by involving patients and communities in the process of developing sustainable solutions.The opinion of patients regarding their care and management should be taken into account. According to the NHS, this means enabling people to express their views, needs, and preferences. In doing so, they can contribute meaningfully to plans, proposals, and decisions about healthcare services.

Patient Public Involvement helps identify gaps where services may fall short of expectations and offers valuable insights into patients’ lived experiences.

As Ayanfe puts it, “How a facility responds to errors is just as important as preventing them.”

Key elements of PPI include:

• Shared decision-making between healthcare providers, patients, and their relatives or representatives
  
  
• Exit questionnaires to collect feedback from users of healthcare services, either through hard copies or digital formats
  
  
• Patient–provider liaison groups that foster open communication and problem-solving
  
  
• Patient surveys to assess overall patient satisfaction and perceptions of the healthcare system
  
  
• Patient forums where service users can express their  views and influence improvements
  
  
• Community stakeholder involvement in hospital boards and policy-making processes

Information Management
Healthcare quality is data-driven, and the strategic utilisation of information is critical to clinical governance. To ensure high-quality data, information technology should be well implemented.
Information management systems help monitor clinical performance, ensure clinical effectiveness, track patient outcomes, and identify areas for improvement. In John’s case, the delay in retrieving his medical folder delayed his treatment.An optimal information technology system facilitates audit and risk management. In some African healthcare settings, patient folders are sometimes found scattered throughout hospitals or, worse, completely missing. This should not be so. “Comprehensive and contemporaneous documentation of patient care, consent, and communications is a facility’s strongest legal defence,” says Ayanfe.

Implementing information management involves:

• Having a good data storage and retrieval system, including migration to an electronic records system
  
  
• Ensuring up-to-date and accurate data
  
  
• Maintaining data confidentiality to improve trust in the system
  
  
• Proper data analysis and presentation
  
  
• Using data to measure the quality of outcomes

Information management is important in the following ways:

• Monitor and improve patient safety
  
  
• Enhance clinical effectiveness through evidence-based practices
  
  
• Optimise patient experience
  
  
• Support staff development and management

Staffing and Staff Management

The quality of healthcare lies not only in the state of the facilities but also in the hands and hearts of those who deliver care. Maintaining quality healthcare requires having adequate numbers of well-motivated personnel. Clinical governance plays a vital role in ensuring that staff are both competent and committed to upholding professional standards. Ensuring adequate staffing levels is also critical to preventing burnout and safeguarding patient safety. “Fair employment practices and staff management protect the facility’s reputation and boost patient confidence,” according to Ayanfe.

This involves:

• Providing favourable working conditions
  
  
• Recruiting enough staff
  
  
• Developing staff through training
  
  
• Motivating staff to encourage retention
  
  
• Adopting sound recruitment practices
  
  

Staff retention can be encouraged through:

• Fairness and consistency
  
  
• Clarifying expectations
  
  
• Rewarding good performance
  
  
• Conducting regular appraisals
  
  
• Promoting a team culture
  
  
• Encouraging professional development

Challenges to the Implementation of Clinical Governance in Africa

One of the challenges in implementing clinical governance in Africa is the lack of understanding, which is the reason for this article. There is a paucity of research on clinical governance in Africa; however, a study conducted in South Africa shows a lack of knowledge even among health workers [2]. Another study in Iran identifies the lack of guidelines, the absence of protocols, and weak organisational structure as implementation challenges [7].

According to Dr. Iniobong Ekong, a digital health and quality improvement specialist in Abuja, Nigeria, there are major barriers to implementing clinical governance. From his experience in implementing a quality-of-care initiative in Africa, these barriers include:

• Resource constraints, such as a limited health budget
  
  
• Personnel shortages
  
  
• Lack of transparency and accountability for high-quality care, and reluctance to report mortalities or adverse events among healthcare providers due to fear of blame
  
  
• Resistance to changing age-long organisational cultures
  
  
• Inadequate health worker training and supervision with a focus on professional skills but little emphasis on clinical governance, quality improvement, and patient safety. This gap can lead frontline workers to treat patients as mere cases(symptoms) rather than adopting a holistic approach to care.
  
  
• Seeing governance as administrative rather than a clinical responsibility
  
  
• Weak Health Information Systems due to poor data collection, record-keeping, and analysis, caused by over-reliance on paper-based systems and the unavailability of quality data
  
  
• Limited use of available data for evidence-based decision-making, even in hospitals deploying Electronic Medical Records (EMR) systems
  
  
• Policy and regulatory gaps, including the absence of national frameworks for clinical governance, worsened by weak, non-transparent, and unconventional regulatory practices
  
  
• Lack of prioritisation of clinical governance and quality improvement is a major concern. “Government-to-Government” regulation is common and ineffective, as seen in the case of public hospitals regulated by Hospital Management Boards, an agency of government.

Without addressing these systemic barriers, governance initiatives will not be transformative.

Other challenges include:

• Lack of supporting legislation
  
  
• Fragmented policies and health regulatory bodies
  
  
• Limited capacity to implement
  
  
• Inadequate infrastructure
  
  

Implementing Clinical Governance in Africa: Key Measures

Despite the challenges, it is still possible to implement clinical governance in Africa. Effective clinical governance in Africa’s public hospitals requires not only adequate resources but also cultural change, strong leadership, robust health information systems, and supportive policies, Dr Iniobong says.

“However, my experience in implementing a quality-of-care initiative shows that significant improvement in patient outcomes can be achieved even with available resources,” he says..According to Dr Iniobong, some of the practical strategies for overcoming clinical governance challenges in low-resource settings include:

• Prioritising low-cost, high-impact interventions that use existing resources efficiently
  Such initiatives include quality improvement methodology that critically analyses existing problems and quickly tests solutions for adoption or adaptation
  
  
• Data-driven selection of quality improvement focus areas, targeting priority health system challenges
  
  
• Integrating clinical governance into both pre-service and in-service training curricula for health workers
  
  
• Adopting task-shifting as well as peer-to-peer learning to help optimise the available workforce without additional costs.
  
  
• Institutionalising a culture of accurate, consistent, and timely electronic data collection, analysis, and use for decision-making.
  
  
• Instituting a culture of accountability by health workers, which should be formative (focus on learning, improvement, and growth) rather than summative (focus on judgment and punishment).
  
  
• Rewarding good practices
  
  
• Encouraging non-punitive incident reporting
  
  
• Developing policies, frameworks, and protocols with end-user input to encourage adoption
  
  
• Objective, unbiased, transparent, and formative regulation
  
  
• The Government should take responsibility for the gaps within its public health facilities
  
  
• Community engagement and partnerships with Non-governmental Organisations (NGOs)  and the development sector should be encouraged
  
  

Some other measures include:

• Creating a legal framework to support the clinical governance process in hospitals
  
  
• Establishing a clinical governance body in every hospital that reports to a central body
  
  
• Training clinical and non-clinical managers on the principles of clinical governance
  
  
• Increasing funding for research
  
  
• Encouraging evidence-based practices
  
  
• Developing standard operating protocols in all units
  
  
• Holding daily review meetings in clinical departments
  
  
• Holding weekly review meetings in non-clinical departments
  
  
• Holding monthly joint review meetings for both clinical and non-clinical units in all hospitals
  
  
• Providing an annual training package for all cadres of staff on health systems strengthening
  
  
• Making continuous professional development compulsory for clinical staff
  
  
• Routinely collecting feedback from health system users through feedback forms
  
  
• Implementing objective yearly appraisal systems for all staff
  
  
• Creating patient forums
  

Conclusion

Instituting clinical governance requires effective leadership and clear direction. This is where the leaders of African health systems have a critical role to play. Achieving health security in Africa depends on having strong health systems, and this will not be possible without clinical governance. There is a need to integrate ongoing intervention programs into a clinical governance framework to maximise their impact.

Acknowledgement

I am deeply grateful to Ayanfe Victoria Adeyeye, a medical and business compliance lawyer and Dr. Iniobong Ekong, a digital health and quality improvement expert, for generously contributing their insights and expertise to this article.

References

1. Health in Africa. Nat Commun [Internet]. 2024 Feb 1 [cited 2025 Aug 2];15(1):967. Available from: https://www.nature.com/articles/s41467-024-45268-1
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6. Naidoo M, Suthiram KT. Optimising clinical governance and risk management in resource-limited hospitals: A family medicine model. Afr J Prim Health Care Fam Med. 2025 Apr 8;17(1):e1–5. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12067574/
7. 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 Research Policy and Systems [Internet]. 2019 Jan 9 [cited 2025 Aug 7];17(1):3. Available from: https://doi.org/10.1186/s12961-018-0399-5

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Published August 16, 2025