Governing performance in public healthcare: a conceptual and policy framework for managerial accountability and health value

Public healthcare systems must balance organizational performance, managerial accountability, and health outcomes. However, existing performance assessment approaches remain fragmented, with limited integration between strategic governance and value-oriented delivery. This study developed an integrated framework to support governance-oriented performance management in public healthcare. The framework is grounded in public sector performance management, accountability governance, value-based healthcare, and complexity science. International models, including health system performance assessment frameworks and Balanced Scorecard perspectives, were examined to build a multidimensional, multi-level governance structure. Adopting a conceptual and policy-oriented methodology, the study combined a narrative literature review with an analysis of international policy and institutional governance documents. Sources included peer-reviewed literature and policy reports, integrated through qualitative synthesis. The resulting integrated governance framework operates across strategic, managerial, and operational levels. It incorporates key performance domains: organizational performance, quality of care, accessibility, accountability, and population health value. A continuous performance cycle links objective setting, monitoring, evaluation, and organizational learning. Illustrative applications demonstrate its support for governance and decision-making. The framework contributes to public healthcare literature by unifying accountability, managerial decision-making, and health value. It assists policymakers and healthcare managers in aligning strategic priorities with operational outcomes. Future studies should empirically validate the framework across different healthcare contexts and real-world performance management systems.