Explaining institutional variation in healthcare service quality: evidence from public hospitals in KwaZulu-Natal, South Africa

Purpose This study explains variation in healthcare service quality through an institutional and process-oriented lens rather than treating quality as a simple statistical comparison between hospitals. Drawing on institutional theory and Donabedian's structure-process-outcome logic, it examines whether Human Capital Development Activities (HCDA), Research Attitudes and Work Skills (RAWS) and workforce experience are associated with Service Handling Practices (SHP) in selected public hospitals in KwaZulu-Natal, South Africa. The study is positioned within Sustainable Development Goal 3, particularly target 3.8 on access to quality essential healthcare services, and African Union Agenda 2063 Goal 3 on healthy and well-nourished citizens. Design/methodology/approach A quantitative cross-sectional survey design was used. The respondent-level dataset contained 238 questionnaires. The analysis uses three measured constructs: HCDA (12 items), SHP (9 items) and RAWS (13 items), each assessed on 5-point Likert-type scales. Construct adequacy was examined using Kaiser–Meyer–Olkin statistics, Bartlett's tests, exploratory component analysis and Cronbach's alpha. Work-experience differences were assessed using one-way ANOVA with effect sizes. Multiple regression estimated SHP as the process-oriented service-quality outcome with HCDA and RAWS as predictors. Heteroscedasticity-consistent HC3 standard errors were used after diagnostic testing. Findings The regression was statistically significant overall, F(2, 231) = 4.35, p = 0.014, but explanatory power was modest (R2 = 0.036; adjusted R2 = 0.028). HCDA (B = 0.080, robust p = 0.376) and RAWS (B = 0.134, robust p = 0.152) were not independently significant after mutual adjustment. Work experience differed significantly across HCDA groups (F = 2.221, p = 0.042), but the practical effect was small (ω2 = 0.030); differences in SHP and RAWS were not significant. The results therefore do not support a simple claim that tenure or a single institutional attribute independently determines service quality. Rather, they refer to a more comprehensive institutional setting where governance procedures, organisational assistance, learning, coordination and service procedures all have a role to play. Research limitations/implications Cross-sectional, self-reported; does not suggest causality. Unfortunately, the de-identified analytic data set did not contain sufficient detail to assure reliable identification of hospitals, nor did it contain profession-specific respondent labels which would have enabled multilevel hospital effects and profession-specific comparisons. The SHP scale is a process-oriented scale and exploratory analysis indicates that the scales in the survey are multidimensional. Future studies should employ hospital-based longitudinal data and profession-stratified sampling in addition to confirmatory measurement models and objective clinical and patient-experience outcomes. Practical implications Managers must not put their trust in the age of employment of personnel as a proxy for organisational capacity. Continuous professional development should be embedded in supervision, patient-flow redesign, communication routines, accountability systems and resource-management processes. Quality-improvement dashboards should therefore combine workforce, process, governance and patient-experience indicators. Social implications Strengthening the organisational processes through which public hospitals convert staff capability and resources into reliable care supports the quality dimension of universal health coverage and the health-system aspirations of SDG 3 and Agenda 2063. Originality/value The study contributes by aligning measurable workforce and institutional conditions with a process-oriented quality outcome and by combining institutional theory with Donabedian's process logic. It shows that workforce development and work skills are enabling but insufficient conditions for service quality, supporting a systems-based rather than single-factor explanation of public-hospital performance.