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Journal of Governance and Regulation / Volume 9, Issue 2, 2020

8

CORPORATE GOVERNANCE AND THE
ENVIRONMENT IN THE HEALTH SECTOR:

SYSTEMATIC LITERATURE REVIEW

Isabel Cristina Panziera Marques *, Zélia Maria da Silva
Serrasqueiro Teixeira **, Fernanda Maria Duarte Nogueira***

* Corresponding author, Management and Economics Department, Beira Interior University (UBI), Portugal

Contact details: Beira Interior University (UBI), Pólo IV, Estrada do Sineiro, 6200-209, Covilhã, Portugal
** Management and Economics Department, Beira Interior University (UBI), Portugal

*** Higher Institute of Social and Political Sciences of the University of Lisbon (ISCSP-ULisboa), Portugal

Abstract

How to cite this paper: Marques, I. C. P.,

Serrasqueiro, Z., & Nogueira, F. (2020).

Corporate governance and the

environment in the health sector:

Systematic literature review. Journal of

Governance & Regulation, 9(2), 8-33.

http://doi.org/10.22495/jgrv9i2art1

Copyright © 2020 The Authors

This work is licensed under a Creative

Commons Attribution 4.0 International

License (CC BY 4.0).

https://creativecommons.org/licenses/by/

4.0/

ISSN Print: 2220-9352

ISSN Online: 2306-6784

Received: 26.02.2020

Accepted: 17.04.2020

JEL Classification: G18, G30, G38

DOI: 10.22495/jgrv9i2art1

This study aims to explore the different forms of corporate
governance in the health sector, how they interact, and analyze the
emerging research trend through a systematic literature review
(SLR) in the period 2015-2019. The Scopus and ISI Web of Science
databases were used to select the 167 articles analyzed. The
coverage of corporate governance research was centred on
adapting the PRISMA analysis, highlighting the environment which
corporate governance belongs to and analysis of the co-occurrence
of the keywords used in the studies. Through Grounded theory, a
conceptual model was developed, emphasizing the main attributes
that influence governance at the macro-, meso- and micro-levels, in
the health area, and raising a future agenda for future research in
this area: (1) quality of health care, (2) corporate social
responsibility in health, (3) health risk management and (4) global
health governance. The results of this research aim to guide
governments towards emerging regulatory trends, warning about
the risks of the impact of corporate governance on health, or the
lack of it, on the quality of services. Analysis of the quality of
health care is intrinsically related to the environment, although
this aspect has received little attention from researchers.

Keywords: Health, Corporate Governance, Environment, PRISMA
Analysis, Regulation

Authors’ individual contribution: Conceptualization – I.C.P.M.,
Z.M.S.S.T., and F.M.D.N.; Methodology – I.C.P.M., Z.M.S.S.T., and
F.M.D.N.; Formal Analysis – I.C.P.M. and Z.M.S.S.T.; Resources –
I.C.P.M., Z.M.S.S.T., and F.M.D.N.; Data Curation – I.C.P.M., Z.M.S.S.T.,
and F.M.D.N.; Writing – Original Draft – I.C.P.M. and Z.M.S.S.T.;
Writing – Review & Editing – I.C.P.M., Z.M.S.S.T., and F.M.D.N.;
Visualization – I.C.P.M., Z.M.S.S.T., and F.M.D.N.; Supervision –
Z.M.S.S.T., and F.M.D.N.; Project Administration – I.C.P.M.,
Z.M.S.S.T., and F.M.D.N.; Funding Acquisition – Z.M.S.S.T.

Declaration of conflicting interests: The Authors declare that there is no
conflict of interest.

Acknowledgements: The Authors acknowledge the funding support of
UBI_Santander Totta Scholarship Program. The Authors acknowledge
the funding support of the National Funds of the FCT – Portuguese
Foundation for Science and Technology within the project
UIDB/04007/2020.

1. INTRODUCTION

Recent decades have witnessed increased
development of policies to cope with institutional

conflicts arising from actions which, directly or
indirectly, affect the health sector. Due to the
emerging challenges affecting the whole planet,
there is a clear need to promote health while
considering the depreciation of natural capital and

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

9

support for nature so that economics and the
natural world are not falsely separated. Policies
should balance social progress, environmental
sustainability and the economy (Whitmee et al.,
2015). The effects of environmental changes on
health represent serious challenges to gains in
global health and are likely to become increasingly
prevalent in the second half of this century. Those
strong tendencies are caused by highly inefficient
and unsustainable patterns of resource consumption
and technological development, together with
population growth.

The conceptual bases for better understanding
of the nature of corporate citizenship can be found
in the literature on corporate social responsibility
(Carroll, 2010), the capacity of corporate social
response (Clarkson, 1995), corporate social
performance (Albinger & Freeman, 2000), the theory
of the firm (McWilliams & Siegel, 2001) and
stakeholder involvement (Strand & Freeman, 2013).
Institutions are constantly faced with managing the
expectations of a society increasingly alert to the
health and environmental risks associated with
economic development (Wilshusen & MacDonald,
2017) and it is widely recognized that the
conventional relationship between environmental
concerns and companies has been opened one of
opposition for a long time and that a change in
direction towards new perspectives has been called
for (Adams, 2008).

Numerous approaches to corporate governance
in health have been followed by different authors:
quality of healthcare (Williamson, Benjamin, Devine,
Katz, & Pink, 2015; Butler, 2016; Ferguson, Power,
Stevenson, & Collison, 2017; Brown, Dickinson, &
Kelaher, 2018; Erwin, Landry, Livingston, & Dias,
2018; Berland, 2019; Kong, Shi, & Yang, 2019; Kooli,
2019; Pather & Mash, 2019; Roller, 2019; Sheard,
Clydesdale, & Maclean, 2019), corporate social
responsibility (Tuan, 2015; Edgeman, Neely, &
Eskildsen, 2016; Camilleri, 2017; Rodriguez,
Svensson, & Eriksson, 2018; Shabbir, M. S., Shariff,
Salman, Bakar, & Shabbir, M. F., 2018; Cousins,
Richter, Cordner, Brown, & Diallo, 2019; do
Nascimento Ferreira Barros, Rodrigues, & Panhoca,
2019; Hepworth, 2019; Lee, 2019), risk management
in health (Aragón Amonarriz & Iturrioz Landart,
2016; Jizi & Nehme, 2017; Ames, Hines, & Sankara,
2018; da Silva Etges, Grenon, de Souza, Kliemann
Neto, & Felix, 2018; Carter, Meinert, & Brindley, 2019;
Etges et al., 2019b) and global governance in health
(Weir, Jones, & Wright, 2015; Lee, Eckhardt, &
Holden, 2016; Slade et al., 2017; Delany, Signal, &
Thomson, 2018; Brems & McCoy, 2019; Bugbee,
2019; Gonenc & Scholtens, 2019).

Understanding the effects of corporate
governance on health institutions’ performance
through observing multiple factors is an important
step towards understanding global health issues.
Therefore, by summarising the evidence reported in
various primary source articles with the quality of
the Scopus and ISI Web of Science databases, through
applying explicit, systematized search methods,
critical appreciation and a summary of the
information selected, systematic reviews are useful
in integrating the information from a set of studies

made and classified under corporate governance
which can present conflicting and/or coincident
results. They also identify themes requiring
evidence, helping to guide future research.

Therefore, this review aims to explore the most
prominent subjects related to corporate governance
and analyse new research tendencies in health
through a systematic review of articles over the last
five years so as to make suggestions for a future
research agenda.

The innovation lies in adapting the PRISMA
analysis (Liberati et al, 2009) so as to classify those
studies according to their purpose, sources of
information, the form of research, data collection
and treatment, participants involved, type of study,
the period of longitudinal research and their setting,
as well as the construction of a conceptual model,
after analysis of key-word co-occurrence, to be able
to understand the relations between the attributes
involved in the studies.

The remainder of the article is structured as
follows. Section 2 presents the methodological
aspects, including the protocol used for the SLR, the
databases used, the method of selecting articles to
incorporate in the review and PRISMA with analyses
of the co-occurrence of keywords in the studies
selected. Section 3 presents the general results of
the analyses, with the classification of studies in the
environment, as well as the clusters of keyword co-
occurrence. Section 4 discusses the attributes
identified in the analysis of keyword co-occurrence,
culminating, through Grounded theory, informing
the conceptual model arising from the SLR. Section 5
presents the conclusions, limitations of the study
and suggestions for future research.

This study is relevant in as much as the
environment where the studies analysed are
developed is extremely important, given the
complexity of the interactions between that
environment and activities related to healthcare,
with it being the State’s responsibility to regulate
those activities. Political leaders’ actions culminating
in regulating the health sector originate in the socio-
cultural and economic conditions in which the
research is set, promoting important guidelines that
can help to form public policies. Most studies focus
on partial aspects, directing analysis to dimensions
that could be classified as secondary, for health
policy. So there is an important gap in scientific
knowledge on the topic, with significant
consequences for assessment practices.

2. METHODOLOGY

The research method is the Systematic Literature
Review (SLR). As the aim of the review was defined
as being to analyse trends in emerging studies,
important articles were included through
orientations and strategies that increase the
specificity of searches. In selecting studies,
assessment of the titles and abstracts identified
followed the inclusion and exclusion criteria defined
as “corporate governance in health”. A general
description of the review process is presented in
Figure 1.

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

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Figure 1. Protocol of the SLR used

A search of the Scopus and ISI Web of Science

databases by the keywords of “health, corporate

governance” resulted in 906 articles which, after

limitations such as the period (2015 to 2019), type

of document (articles and reviews), in English, and

some area and category limitations, left 167 articles.

Through Grounded theory, the use of the PRISMA

meta-analysis (Liberati et al., 2009) and the analysis

of key-word co-occurrence (VOSviewer) allowed the

formulation of a conceptual model. A summary of

the method used for the selection of articles is

presented in Figure 2.

2.1. PRISMA analysis

In this study, an adaptation of the meta-analysis of
approximation (PRISMA) by Liberati et al. (2009) is
applied to the 167 studies related to corporate
governance in health. PRISMA was developed in the
field of health sciences but has been applied
successfully in research on public administration
(Thompson & Higgins, 2005; Moyson, Raaphorst,
Groeneveld, & Van de Walle, 2018). The quality of
PRISMA as a way to carry out systematic literature
reviews, its elaboration process including repeated
improvements based on deliberation among review
specialists, is due to the transparency of the
approach (Figure 3).

Identify the objective of the study:
ANALYSE RECENT STUDIES ON CORPORATE

GOVERNANCE

Identify the databases (SCOPUS, WEB OF
SCIENCE) and the search strategies

Establish the criteria for selection of articles
(HEALTH)

Apply selection criteria and make a critical
analysis of the studies included

Prepare a critical summary, from the
information provided in the articles

Present a conclusion, proposing a Conceptual
Model

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

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Figure 2. Sorting of SLR articles

Various methods can be used in a systematic

literature review, such as (1) the five-stage

methodology of Khan, Kunz, Kleijnen and Antes

(2003) (which involves framing the questions for the

review, identification of the literature, assessing the

quality of articles, summarising the studies reviewed

and interpreting the results), (2) the stages defined

by Tranfield, Denyer, and Smart (2003), which

involves ‘planning’, ‘search’, ‘sorting’ and

‘extraction/synthesis/report’, (3) the bibliometric

analysis includes mainly distribution of the results

of the search, the influence of authors and institutes

and points of access to the search, among others.

For this literature review, the PRISMA method was

chosen. All studies, including systematic reviews,

should be reported fully and transparently, to let

readers assess the strengths and weaknesses of the

research. PRISMA (Liberati et al., 2009) consists of a

list of 27 items and a flow diagram in four stages,

which may or may not use statistical methods

(depending on the aims of the analyses). There is the

risk of the topic being wide-ranging, and so the

articles were analysed case by case so that their

inclusion or exclusion could be systematic. To

minimize the risk of bias, by using the PRISMA

method, the objectives of the review were clearly

defined, with the methodology being explicit and

reproducible. In addition, the studies identified to

meet the criteria of eligibility and summaries of the

characteristics and results of the studies were

included.

165 Articles

Keywords:

“health” and “corporate”

and “governance”

Period:

From 2015 to 2019

Type of document (articles

and reviews) and language

(English)

Procedures

Areas, Categories,

Ordering

184 Documents 187 Documents

145 Articles

Scopus Web of Science

557 Documents 349 Documents

Question: SLR

Areas: Medicine,

Social Sciences,

Business,

Management and

Accountancy,

Economics,

Econometrics and

Finance: 129

articles

Categories:

Management, Health

Policy Services,

Business Finance,

Business, Health

Science Services,

Economics, Inter-

disciplinary Social

Sciences: 78 articles

Removal of duplicated articles,

book chapters, conferences,

content analysis (subject:

Health)

129 Articles 38 Articles

Total of articles included in the

SLR: 167

PRISMA meta-analysis, adapted from Liberati et

al. (2009), focusing on the environment

Analysis of key-word co-occurrence and use of

Grounded Theory

Conceptual Model

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

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Figure 3. PRISMA analysis adapted from Liberati et al. (2009)

2.2. Environment

Currently, different sectors and organisations
discuss how to define and extend knowledge about
the impact of research on the attempt to combine
economic and social results, as happens in the
health sector (Adam et al., 2018). In various ways,
many authors use analysis of the environment
(Mirzoev et al., 2017; Field, Wild, Woodward,
Macmillan, & Mackie, 2018; Harper, Maden, &
Dickson, 2019; Bodolica, 2019; Lim, Schoo, Lawn, &
Litt, 2019; Naderi, Gholamzadeh, Zarshenas, & Ebadi,
2019) as explanations or demonstrations of
consequences reflected in the interactions between
individuals, organisations and society, and the
predominant level of analysis.

Bodolica (2019) analyses different articles from
the perspective of relevant aspects for the domain of
corporate governance and leadership that can be
grouped based on their predominant level of
analysis. For the author, (1) consultations at the
macro-level examine the general advances in
corporate governance infrastructure and regulatory
developments, (2) research at the micro-level
concentrates on a set of well-defined strategies and
practices of governance and leadership that are

adopted in organisations with the aim of raising firm
performance and achieving results, and finally, (3)
research at the meso-level provides a viable nexus
between the other two levels, analysing the
effectiveness of governance initiatives led by the
state through the impact of their implementation on
micro-processes and dynamics in companies today
(Bodolica, 2019).

The description of a Model of the Impact of
Evidence was proposed by Harper et al. (2019) in
England, based on the existing concept of micro-,
meso- and macro-levels of impact in health covering
five levels: micro-level of individuals (levels 1 and 2),
teams (level 3) and organisations or local
communities (level 4), and finally, impacting at the
macro-level (level 5) to demonstrate changes in the
professional sector or in society. In the model
proposed by Harper et al. (2019), the meso-level is
not specifically designated, considering that the
authors admit there is a transition between teams
(level 3) and local organisations or communities
(level 4), and depending on the context analysed,
levels 3 and/or 4 can emerge as the meso-level. The
study by Lim et al. (2019) focuses on facilitating the
change in health-related behaviour through the use
of the motivational interview, aiming to understand

Exploratory

Interpretative

Descriptive

PURPOSE OF

THE STUDY

SOURCES OF

INFORMATION

Deductive

Inductive

FORM OF

RESEARCH

DATA

TREATMENT

DATA

COLLECTION

Quantitative

Qualitative

Mixed

PARTICIPANTS

TYPE OF STUDY

Transversal

Longitudinal

PERIOD OF

RESEARCH

PRISMA

analysis

ENVIRONMENT

Micro

Meso

Macro

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

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learning environments at levels (1) micro-clinical,
through using enabling technology, focus on patient-
centred service, (2) meso-organisational level, with
the development of a shared vision and an
organisational culture of support for continuous
learning, and (3) macro-level, with the adoption of
systemic thinking and an organised learning
approach. Other studies classify different questions
at micro-, meso-, exo- and macro-levels in the
attempt to understand multi-dimensional phenomena
(Repullo & Freire, 2016; Mirzoev et al., 2017;
Barrientos-Trigo, Vega-Vázquez, de Diego-Cordero,
Badanta-Romero, & Porcel-Gálvez, 2017; Field et al.,
2018; Harper & Dickson, 2019; Naderi et al., 2019).

The studies made by the authors, at different
levels of elaboration, seek to create knowledge
related to governance through individual,
organisational, national and international analyses
to estimate possible correlations between them. The
alignment and compatibilities of institutional and
cultural particularities are directly linked to the
successful adoption of corporate governance
policies (Bodolica & Spraggon, 2009).

2.3. Analysis of keyword co-occurrence

In 1922, E. W. Hulme proposed the expression
“statistical bibliography” in seminars on the subject
at the University of Cambridge, England (Pritchard,
1969), its aim corresponding to what would later be
proposed as the “bibliometrics” of Pritchard. Three
specific laws govern bibliometric studies, i.e., Lotka’s
law, Bradford’s law and Zipf’s law (Figueiredo,
Quelhas, Neto, & Ferreira, 2019). Lotka’s law
addresses researchers’ productivity and anticipates
that in a given period the relation between the
number of authors and the number of articles they
publish will decrease in the order of 1/n². In other
words, a few authors publish a lot, while the
majority publish little (Voos, 1974). Bradford’s law
deals with the dispersion of scientific production in
a certain area between the journals publishing in
that field. Dividing all the scientific production on a
given theme in parts with the same number of
articles, the first areas will show a lower number of
journals – more productive ones – and in the
following areas, a successively greater number of
journals publishing the same number of articles as
previous areas (Brookes, 1969). In turn, Zipf’s law is
applied to analysing the frequency (or “occurrence”)
of words in a text, so that a limited group of words
has a higher rate of occurrence, while a large

number of words has a lower frequency; those with
the greatest frequency-determining a document’s
central topic (Alvarado, 2002). This study also
mapped the work with the greatest impact, besides
the socio-metric analysis, considering the networks
of keywords co-occurrence.

The relation of co-occurrence between two
keywords is determined by the number of articles in
a base of documents in which both occur together,
in the title, abstract or the list of keywords (van Eck
& Waltman, 2014). Analysing these networks,
possible research subjects on corporate governance
in health can be mapped. The size of the node
indicates the frequency of a keywords occurrence,
and the relationship between the nodes is stronger,
the closer they are.

To facilitate viewing, the network formation, of
the 1.035 keywords, 74 co-occurred at least four
times, resulting in thirty-five nodes organised in
four clusters. So these are the words with the
greatest frequency and which, according to Zipf’s
law (Zipf, 1949), determine the central topic of a
body of documents.

In this context, this study includes an analysis
of the SLR from two perspectives: (1) that of the
environment seeking governance practices and their
implications for corporate policies, decision-making
and performance (Carney, 2011; Agrawal & Knoeber,
2012; Kaplan, 2012), according to the definitions of
Bodolica (2019) and arising from the adaptation of
the PRISMA analysis by Liberati et al. (2009) and (2)
analysis of keyword co-occurrence, where through
Grounded theory a conceptual model of governance
in health is proposed.

3. RESULTS

3.1. General analyses

Of the 167 studies analysed and distributed between
2015 and 2019, a certain uniformity of distribution
is observed, showing the growing importance of the
subject of corporate governance in health (Figure 4).

Of the five journals with the greatest number
of publications, four are in the area of health and
one addresses subjects linked to corporate
governance (Figure 5).

In the ranking of journals (the top ten) with the
highest impact factors, all appear with one
publication, except for the Journal of Business Ethics,
with three (Table 1).

Figure 4. Number of articles published by year

37
34

30
32

34

2015 2016 2017 2018 2019

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

14

Figure 5. Journals with the highest number of publications

Table 1. Journals with the highest impact factors and a number of articles.

Journal Impact factor 2018/2019 Number of articles

The Lancet 59.102 1

Global Environmental Change 10.29 1

Obesity Reviews 8.73 1

Journal of Financial Economics 7.34 1

Journal of Cleaner Production 7.32 1

Journal of Industrial Ecology 4.72 1

Journal of Business Ethics 4.46 3

British Journal of Management 4.44 1

Energy Economics 4.15 1

Safety Science 3.61 1

The Lancet is one of the oldest and best-known

medical journals in the world and considered one of
the most prestigious. It is published by Elsevier, in
the United Kingdom, by the Lancet Publishing
Group. Created in 1823, it has an Impact Factor of
59.102 (2018). These factors make the journal one
referred to widely when the subject of health is
involved, explaining the discrepancy between the
number of citations of this article compared to
others.

The United States leads the ranking with the
highest number of publications (21,56%). Articles are
classified as non-specified in the case of theoretical
studies or those involving countries in South
America, the European Union or a non-specified
international sample. Five studies were carried out
jointly (the United States and Brazil; the United
States, Australia, Canada, England, and Japan;

Indonesia and Malaysia; Norway and Sweden; the
United Kingdom, New Zealand, South Africa, and
Ghana). There was one article for the remaining
countries: Afghanistan, Sub-Saharan Africa,
Germany, Argentina, Austria, Qatar, Korea, Denmark,
France, Ghana, Ireland, Jordan, Lebanon, Lithuania,
New Zealand, Oman, Portugal, Czech Republic,
Thailand, Uganda, Uruguay and Vietnam (Figure 6).

Figure 7 presents the number of publications
versus the number of article citations per year. Of
the 167 articles, the most cited (Table 2) deal with
different topics, including the effects of
environmental changes on health, the use of
corporate social responsibility to improve
institutions’ behaviour, ethical and legal aspects, and
the association between governance and companies’
financial performance, among others.

Figure 6. Countries with the highest number of publications

36

28

11

8

7

7

6

5

4

4

4

4

3

3

3

2

2

2

U.S

(not specified)

Australia

United Kingdom

China

Italy

England

South Africa

Bangladesh

Brazil

Pakistan

India

Canada

Netherlands

Indonesia

Spain

Japan

Malaysia

5

4

4

3

3

Globalization and Health

Corporate Ownership and Control

International Journal of Health
Governance

Health Services Management
Research

Indian Journal of Public Health
Research and Development

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

15

Figure 7. Number of publications/citations by year

Table 2. Most cited articles

Author/ year Article title Journal â„– citations Subject

Whitmee et al.
(2015)

Safeguarding human health in the
Anthropocene epoch: Report of the
Rockefeller Foundation-Lancet
Commission on planetary health

The Lancet 424

Deals with the effects on health of
environmental changes that are serious
challenges to the gains in global health in
recent decades which will probably become
increasingly prominent in the second half of
this century and beyond.

Flammer and
Luo (2017)

Corporate social responsibility as
an employee governance tool:
Evidence from a quasi-experiment

Strategic
Management

Journal
50

This study examines whether companies use
corporate social responsibility to improve
employee involvement and mitigate adverse
behaviour in the workplace (evasion,
absenteeism).

Woolley et al.
(2016)

Citizen science or scientific
citizenship? Disentangling the uses
of public engagement rhetoric in
national research initiatives Donna
Dickenson, Sandra Soo-Jin Lee, and
Michael Morrison

BMC Medical
Ethics

37

Examines the ethical and social implications
of the recruitment strategy used to
encourage the public to become involved in
research undertakings.

Carter (2015)
Making the Blue Zones:
Neoliberalism and nudges in public
health promotion

Social Science
and Medicine

30

Exemplifies the process of “neoliberal
governance”, by which individuals learn to
govern themselves and their “life projects”
according to a market-based rationale.

Rossi, Nerino,
and Capasso
(2015)

Corporate governance and
financial performance of Italian
listed firms. The results of an
empirical research

Corporate
Ownership and

Control
27

Finds a possible relationship between the
corporate governance of Italian listed firms
and their financial performance.

Ntim (2016)

Corporate governance, corporate
health accounting, and firm value:
The case of HIV/AIDS disclosures
in Sub-Saharan Africa

International
Journal of

Accounting
25

Investigates the impact of corporate
governance on social and environmental
accounting, focusing specifically on
corporate health accounting.

Chung, Liu,
Wang, and
Zykaj (2015)

Institutional Monitoring: Evidence
from the F-Score

Journal of
Business

Finance and
Accounting

22

Examines the persistent role of monitoring
institutional investors and identifies the
financial aspects of a firm in which
institutional monitoring improves.

Kirat (2015)
Corporate social responsibility in
the oil and gas industry in Qatar;
perceptions and practices

Public Relations
Review

21
Analyses the perceptions and practices of
corporate social responsibility in Qatar.

Demeritt,
Rothstein,
Beaussier, and
Howard
(2015)

Mobilizing risk: Explaining policy
transfer in food and occupational
safety regulation in the UK

Environment
and Planning A

20

Explores the institutional factors moulding
the transfer and adaptation of risk-based
approaches to regulations inside and
between health and occupational safety
(HOS) regimes and food safety in the United
Kingdom.

Carmenta,
Zabala, Daeli,
and Phelps
(2017)

Perceptions across scales of
governance and the Indonesian
peatland fires

Global
Environmental

Change
18

Illustrates the importance of, and the
approaches to examining perceptions at
levels of governance (international, national,
local) and sectors (society, government,
companies).

Clapp and
Scrinis (2017)

Big Food, Nutritionism, and
Corporate Power

Globalization 18
Addresses Big Food companies’ power to
influence policy in the food sector.

Ellwood and
Garcia-Lacalle
(2015)

The Influence of Presence and
Position of Women on the Boards
of Directors: The Case of NHS
Foundation Trusts

Journal of
Business Ethics

18
Examines the influence of women on boards
of administration of the National
Foundation of Health Services in England.

Camilleri
(2015)

Valuing Stakeholder Engagement
and Sustainability Reporting

Corporate
Reputation

Review
18

Conceptual study of the inter-governmental
guidelines and principles for corporate
social responsibility, corporate governance
and sustainability reports.

37 34 30 32 34

656

143 127

33 11

2015 2016 2017 2018 2019

Total articles Number of Citations

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

16

3.2. Corporate governance in health with the
PRISMA analysis and focus on the environment

Articles were classified according to the main
components focusing on the research methodology
(Table 3) with quantitative analysis regarding: (1) the
purpose of the study, (2) sources of information, (3)
form of research, (4) data treatment, (5) data
collection, (6) participants in the study, (7) type of
study, (8) period of longitudinal studies, and (9)

environment. Figure 8 illustrates the different levels
of the environment, according to the adapted
definition of Bodolica (2019). The aspects of
corporate governance, social responsibility and
inter-governmental sustainability in health are the
means covering the macro (governmental), meso
(company level) and micro (level of the functional
body) levels, influencing the interactions between
them, in a systemic, continuous process.

Figure 8. Surrounding levels

From the meta-analysis, most studies are

interpretative (45,51%), extracted from various

documents, the form of research inductive and the

collection of qualitative data appearing in 101 of the

167 studies, 83,23% are transversal studies and

16,77% longitudinal (67,86% over a period from 1 to

7 years). As for the environment, 50,9% of studies

are carried out at the meso-level (companies), 6,59%
at the micro-level (category of the functional body)

and the remaining 42,51% at the macro-level

(governmental), as presented in Table 3.

In order to summarise, the studies were

identified and grouped according to their

environmental setting (Appendix 1), leading to all

articles being presented, by level, in Figure 9 and the

annual distribution in Figure 10.

3.3. Analysis of keyword co-occurrence

The co-occurrence network showed four main lines
of research being carried out (Figure 11). Visualizing

the network reveals that each link has a strength,

represented by a positive numerical value. The

higher that value, the stronger the link, and in this

case, indicating the number of publications in which

two terms occur together (Table 4). After reading the

studies where the keywords co-occurred most in

each cluster, the nomenclature for these clusters

was established, hereafter called attributes, which

according to Zipf’s law (Zipf, 1949) determine the
central subject of a body of documents: (1) quality of

healthcare, (2) corporate social responsibility in

health, (3) risk management in health, and (4) global

governance in health.

M ACRO level

M ESO level

M I CRO level

Corporate Governance, social responsibility and intergovernmental
sustainability in health

Functional
body level

Regulation

Government
level

Expected

Practices

Standards
Global

Standards

Companies
Level

Institutional

Values

Performance

Controls /

Reporting

Ethics

Risk

Commitment

Responsibility

Safety

Quality

Shareholders /

Boards

Social

Determinants

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

17

Table 3. PRISMA meta-analysis applied to the study, adapted from Liberati et al. (2009)

Component Classification
Number of

articles
Relative

frequency (%)
Absolute

frequency (%)

Purpose of the
study

Exploratory 34 20,36

Descriptive 57 34,13

Interpretative 76 45,51 100

Information
sources

Interviews 14 8,38

Interviews and various documents 25 14,97

Interviews and questionnaires 3 1,80

Various documents 70 41,92

Questionnaires 5 2,99

Databases (MEDLINE, PubMed, Web of Science, Proquest, EMBASE,
EBSCO, PsycINFO, SCOPUS, others)

49 29,34

(Not applicable) 1 0,60 100

Form of
research

Deductive 63 37,72

Inductive 104 62,28 100

Data treatment

Statistical methods (linear regression, structural equations, uni and
multivariate analysis, means and standard deviation, Wilcoxon test)

49 29,34

Model Development 11 6,59

Qualitative content analysis and Nvivo 48 28,74

Various (gradual inductive approach, integration of topics and
concepts based on analysis of categories, Delphi and Nominal group
techniques, open and axial coding techniques, random grouping
trial contrasted with launching in phases to assess the differential
effectiveness of two conditions, Actor-Network Theory as an
analytical lens)

59 35,33 100

Data collection

Quantitative 58 34,73

Mixed 8 4,79

Qualitative 101 60,48 100

Participants

Shareholders 1 0,60

Hospital CEO 2 1,20

Board and others (managers, doctors, industry, operational team) 24 14,37

Companies (pharmaceutical, biotechnology) 30 17,96

Hospital managers 7 4,19

Governments and others (CEOs, industries, hospitals, doctors,
shareholders, community)

68 40,72

Hospital and others (industry, community, employees) 25 14,97

Doctors 3 1,80

Various (trade unions, insurers, risk committee, community) 7 4,19 100

Type of study
Transversal 139 83,23

Longitudinal 28 16,77 100

Period of
research

From 1 to 7 years 19 67,86

From 8 years or more 9 32,14 100

Environment

Micro 11 6,59

Meso 85 50,90

Macro 71 42,51 100

Figure 9. Quantitative studies by level of the environment

Figure 10. Number of articles by environment level and year of publication

5
2 1 0

3

13

17 16

24

15

19

15
13

8

16

2015 2016 2017 2018 2019

Micro level Meso level Macro level

11

85

71

Micro level

Meso level

Macro level

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

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Figure 11. Keyword co-occurrence clusters taken from VOSviewer

Table 4. The number of keywords co-occurrence and binding force (VOSviewer)

Cluster Keywords Bond strength â„– of Occurrences

3 corporate governance 62 24

2 corporate social responsibility 35 16

1 healthcare quality 70 15

1 organization and management 67 14

1 governance 43 13

4 public health 58 13

2 healthcare policy 59 12

2 governance approach 42 10

2 social responsibility 34 9

2 sustainability 13 9

1 financial management 38 8

2 decision-making 35 8

3 manager 30 8

1 clinical governance 24 7

1 leadership 28 7

1 patient safety 33 7

2 drug industry 34 7

2 health promotion 36 7

2 sustainable development 18 7

3 risk management 35 7

4 health policy 39 7

4. DISCUSSION

The main summaries are described below,
distributed according to the identified attributes
(VOSviewer) in the co-occurrence analysis of the
keywords.

4.1. “Quality of healthcare” attribute

In the “quality of healthcare” attribute (in red),
containing thirteen nodes, those occurring most
frequently are found to mention general patient

care, organisation, management, and safety.
Appendix 2 shows the number of studies and
authors/year dealing with the topic.

The importance and influence of the
pharmaceutical industry are well-known, ultimately,
in the quality of patient care as regards the
development of medicine and therapies (Butler,
2016) since the aim is to launch a drug that has been
tested and scientifically approved for consumption
(Babiarz, Melaragni, Kerr, & Kuchimanchi, 2015; Knai
et al., 2018). However, Roller (2019) points out the
standards of transparency and responsibility of

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

19

pharmaceutical companies which have sometimes
allocated larger budgets to marketing than to
research (van Luijn, Gribnau, & Leufkens, 2010). The
study by Brown (2019) contributes to the literature
on governance by detailing processes by which
corporate governance of health quality is adopted by
boards and management, highlighting that work
engagement is an important variable and can impact
on how well governance of health quality is spread,
and quality auditing should be understood as an
effective mechanism to control processes (Kooli,
2019).

Therefore, the conceptual structure provided in
the study by Pather and Mash (2019) illustrates the
main stages in developing guidelines,
contextualization, dissemination, implementation,
and assessment, as well as the interconnections
between stages and barriers or facilitators to the
progress of practices based on evidence in health
units (Sibindi & Aren, 2015).

The expression “Corporate Governance” refers
to the concept of a system in which a company’s
shareholders “govern”, that is, look after the
company (Steinberg, 2003). Other definitions appear
in the literature, such as those of a normative
character referring to “institutional arrangements
that govern relations between shareholders (or other
groups) and company administrations” (Lethridge,
1997). Since then, various definitions have been used
to conceptualize Governance, many with a more
economic focus and currently focused on
sustainability and social responsibility, and other
definitions, arising from the former, have been
incorporated in the literature, just as Clinical
Governance.

Clinical Governance was first introduced in
1997 in the National Health Service (NHS) in the
United Kingdom, representing a strategy of
modernization and improvement of the quality of
the health system (HSC, 1999). This is based on the
Model of Excellence of the European Foundation for
Quality Management (EFQM), guided by the
principles of Total Quality and forming a reference
to structure, assess and improve the quality of
organisations (Roland & Backer, 1999; Allen, 2000),
highlighting the fundamental principles of quality:
results-oriented, customer-oriented, leadership and
coherence of objectives, management of processes
and activities, collaborators’ development and
involvement, learning, innovation, and continuous
improvement, developing partnerships and social
responsibility. The major contribution of the Clinical
Governance model lay in bringing the clinical
decision to the managerial and organisational
context.

The effectiveness of corporate governance in
hospitals can affect the fiscal stability of the health
system, and indirectly, the health policy for the
whole country (Pirozek, Komarkova, Leseticky, &
Hajdikova, 2015). As regards clinical governance,
focusing especially on hospital units, Williamson et
al. (2015) underline the importance of an
organisation’s culture and say that clinical
governance reflects corporate responsibility since
processes should be analysed from the viewpoint of
safety, assessments of clinical risk in order to form
organisational learning. Hospitals continue to be
very distinct organisations where clinical interests
must be considered (Blanco-Oliver, Veronesi, &

Kirkpatrick, 2016) and doctors should develop the
necessary competences for leadership, clinical and
corporate governance (Mash, Blitz, Malan, & von
Pressentin, 2016; Mazzone et al., 2015; Sheehan,
Kavanagh, Asher, & Harbaugh, 2016), considering
that ethical social responsibility among clinicians
activates the share of knowledge (Tuan, 2016;
Kwedza, Larkins, Johnson, & Zwar, 2017). Clinical
managers have been encouraged to use multi-
focused strategies and relation-oriented behaviour in
an attempt to create a culture promoting health
(Landstad, Hedlund, & Vinberg, 2017; Linwood et al.,
2017). The governance of health providers can have
a significant impact on the efficiency and
effectiveness of the care provided by these
organisations (Sheard et al., 2019).

Various studies have focused on the service to
patients and how corporate governance in hospitals
relates to them (Hossain et al., 2015a; Fooks et al.,
2017; Oomkens, Hoogenboom, & Knijn, 2015;
Cassels, 2016; Freeman, Millar, Mannion, & Davies,
2016; Ulijaszek & Mclennan, 2016; Wipfli, 2016;
Ferguson et al., 2017) and to employees (Sheehan et
al., 2016; Thanetsunthorn & Wuthisatian, 2017;
Brown et al., 2018; Lee & Lai, 2018; Erwin et al.,
2018), showing the need for effective mechanisms of
corporate governance to sustain their operations
and performance, eliminating factors that go against
the institution’s objectives (Afriyie et al., 2019a;
Afriyie, Kong, Danso, Ibn Musah, & Akomeah, 2019b;
Berland, 2019).

Another approach frequently adopted in
research concerns administration boards and their
contributions to governance activities (Sheaff,
Endacott, Jones, & Woodward, 2015; Ferlie, Baeza,
Addicott, & Mistry, 2016), their quantitative
composition, regarding gender or academic
background in the area of health (Bakalikwira et al.,
2017; Chambers, Harvey, & Mannion, 2017; Kaur &
Vij, 2017) and the independence and leverage
connected to companies’ performance (Bano, Tahir,
Abbas, & Ansari, 2018; Kong et al., 2019).

4.2. “Corporate social responsibility in health”
attribute

Among the thirteen nodes grouped in the attribute
of corporate social responsibility (CSR) (in green),
the authors/year presented in Appendix 3 are
highlighted. The keywords with the greatest co-
occurrence are “CSR”, “governance approach”,
“sustainability” and “care policy”.

Howard Bowen was the first to define
Corporate Social Responsibility (Carroll, 1979) and
defined it as “business-people’s obligations to follow
those policies, make those decisions or follow the
lines of action desirable in terms of the objectives
and values of our society” (Carroll, 1979, p. 497;
Hamidu, 2015, p. 84). Today, companies recognize
that besides maximizing profit and value for their
shareholders, they have a (social) responsibility to
other stakeholders, such as their employees and
customers, as well as society (Avi-Yonah, 2014),
recognizing in corporate social responsibility (CSR) a
mechanism of self-regulation (Kirat, 2015; Hossain,
Alam, Islam, & Hecimovic, 2015a), by which firms
carry out and communicate their business practices
in a socially responsible, ethical and environmentally
sustainable way (Camilleri, 2015; Hossain et al.,

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

20

2015a; Hossain, Hecimovic, & Choudhury Lema,
2015b; Islam, 2018).

However, cases of fraud and corruption in
health services (Kalesnikoff, Kalagnanam, & Bruni-
Bossio, 2015; Sample, 2015; Benmelech & Frydman,
2015; Elson & Gamble, 2016; do Nascimento Ferreira
Barros et al., 2019), conflicts of interest between the
corporate requirement to make a profit and ethical,
responsible service (Herrick, 2016; Ntim, 2016; Molk,
2016; Rapaczynski, 2016; Geiger & Cuzzocrea, 2017;
Dove, Collins, & Smith, 2018) and communication
problems (Stavinoha, 2016; Misso & Andreopoulou,
2017; Carmenta et al., 2017; Clapp & Scrinis, 2017)
have arisen, resulting in an unequal exchange
between companies and the community (Simone, La
Sala, & Baldassarra, 2018). These and other facts
contribute to corporate actions remaining
fragmented and leave wider questions of
environmental and social justice unresolved
(Cousins et al., 2019), with the urgent need for
regulations with global coverage.

Sustainable organisations, including those
operating in the field of health, have various actions
that can in fact contribute to better performance
(Nawaz & Koç, 2019) in sustainability (Rodriguez et
al., 2018), such as optimizing resources and
minimizing waste and emissions (Kumarasinghe,
Will, & Hoshino, 2018; Liang et al., 2018), commercial
and operational excellence (El-Kassar, ElGammal, &
Fahed-Sreih, 2018; Jarernsiripornkul & Pandey, 2018;
Vveinhardt, StonkutÄ—, & Sroka, 2019), corporate
citizenship and social development (Chang, Wang, &
Wang, 2018; Feng & Johansson, 2018), research and
innovation (Lee, 2015; Hepworth, 2019; Steele,
Ruskin, Sarcevic, McKee, & Stuckler, 2019),
purchasing, supply chain and logistics (Edgeman et
al., 2016), governance (Monachino & Moreira, 2016;
Kasim & Karim, 2017; Thorsteinsdóttir, Ovtcharenko,
& Kohler, 2017; Laouer, 2018), tools to manage
sustainability (Siew, 2017; Shabbir et al., 2018; Lee,
2019; Petitjean, 2019) relations with employees
(Tuan, 2015; Holland, 2017; Flammer & Luo, 2017;
Knippen, Palar, & Gentry, 2018; Lee, 2019) and
health, well-being, safety and protection (Khan, Lew,
& Park, 2015; Camilleri, 2017; Bump, 2018; Marstein
& Babich, 2018; Sharmin, Khan, & Belal, 2018; Mehta,
Raj, & Solanki, 2019).

Lock and Seele (2016) argue that institutions
have the responsibility to help to solve global public
problems, and Russo (2016) states that a responsible
organisation must assess the effects of its actions
and therefore adopt a monitoring system able to
measure its result, although only with greater
government intervention can sustainability advance
from small steps to major ones (UN, 2013).

4.3. “Risk management in health” attribute

The third attribute, risk management in health (in
blue) joins nine keywords (the most cited ones are
“risk management”, “health risks” and “risk
assessment”), with the authors/year and number of
studies being presented in Appendix 4. Although
institutional monitoring is important for a company
regarding specific corporate events, it is a
continuous effort and so should be observable at
any time (Chung et al., 2015). Rather than trying to
avoid all possible damage, risk-based approaches
only seek to limit those that exceed acceptable levels

of risk, as determined through formal assessment of
probability and consequences (OECD, 2010). To this
end, principles and policy instruments based on risk
can be used to focus not only on the objectives of
regulation but also on related inspection and
application practices regarding priority risks
(Demeritt et al., 2015; Rossi et al., 2015).

Discussing the characteristics of an integrated
approach to governance (clinical and corporate) and
its contribution to improved health service
provision, Delaney (2015) finds the greater
understanding of health strategies and
organisational objectives and their spread
throughout the organisation. The definition of risk
found here is broad and observed in different
contexts, such as behaviour and ethics (Kesselheim,
Sinha, & Joffe, 2015; Mais & Sari, 2015; Hasan,
Ayuningtyas, & Misnaniarti, 2016), risk in the quality
of the source for gathering managerial data and
information (McNulty & Akhigbe, 2015; Aragón
Amonarriz & Iturrioz Landart, 2016) to maintain
good internal control, clinical risk associated with
patient safety (Sendlhofer et al., 2015; van
Schalkwyk & Steenkamp, 2015; Ho, Lee, Lam, & Tang,
2017), risk of implementing bad regulatory policies
with doubtful benefits for society (Cumming,
Henriques, & Sadorsky, 2016; Vainieri, Gallo,
Montagano, & Nuti, 2016), affecting institutions’
financial performance (Kuntz, Pulm, & Wittland,
2016; Ngo, Duong, & Chen, 2016; Stathopoulos &
Voulgaris, 2016; Ch & Jola, 2017) and the volatility
of the return on companies’ actions (Jizi & Nehme,
2017), as well as risks associated with organisation’s
decision-making on investments and agency costs
due to retaining information (Ouyang & Hilsenrath,
2017; Shan, Razak, & Ali, 2018; Thaiyalnayaki &
Reddy, 2018; Hsu, Clarkson, & Ouyang, 2019).

On the other hand, multi-directed efforts have
aimed to minimize those risks through stricter,
more accurate, internal organisational controls
(Ames et al., 2018; Thompson, 2018), setting up
committees or internal auditors to act in risk
management (Mais & Sari, 2015; Aragón Amonarriz
& Iturrioz Landart, 2016; Etges et al., 2018; Mustafa
& Al-Nimer, 2018; Nazir, M. S., Nazir, S., & Javaid,
2018), implementing new forms of governance
regulation for greater control, use of knowledge and
corporate responsibility (van Erp, 2017; Carter et al.,
2019; Ishikawa, Murata, & Kawaguchi, 2019; Lai,
Panfilo, & Stacchezzini, 2019) having in common
means to achieve principles with value-oriented
results (Etges, de Souza, Kliemann Neto, & Felix,
2019a; Waring, 2019).

4.4. “Global governance in health” attribute

Global governance in health, attribute 4, (in yellow),
grouped 8 nodes. Appendix 5 presents the
authors/year involved in this topic, where the most
common expressions are “health policy”, “conflict of
interest” and “global governance in health”.

A growing amount of literature deals with how
neo-liberalism affects the discourse and practice of
public health (Torrado, 2016) and how place
influences health due to socio-environmental causes
(Fry & Brannstrom, 2017; Liang et al., 2018) which
are unhealthy for employees (Foladori, 2017). For
Banasik (2015), strengthening health systems and
governance is crucial to meet expectations of

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

21

effective, efficient, equitable healthcare provision,
which requires the implementation of significant
reforms in the field (Carter, 2015; Rawlinson, 2017;
Slade et al., 2017; Gonenc & Scholtens, 2019).

Whitmee et al. (2015) state that the objectives
of sustainable development provide a great
opportunity to integrate health and sustainability
through the selection of important indicators for
human well-being, the infrastructure to favour
development and natural support systems, together
with the need for strong governance. In this context,
research on a sustainable way to exploit natural
resources becomes necessary (Krimsky, 2015;
Nelson, 2015; Russell, Wainwright, & Mamudu, 2015;
Lee et al., 2016; Lipunga, Tchereni, & Bakuwa, 2019)
as well as on good corporate governance practices
(Sibindi & Aren, 2015; Leon & Ken, 2017; Morantz,
2017; Bugbee, 2019). Governance and regulation are
inter-related, since regulation moulds governance
and is modelled simultaneously by changes in the
meaning of governance, and the emphasis on health
does not only affect the responsibilities of hospital
directors but also changes the work of state
regulators, responsible for supervising the quality of
service because they need to ensure that the
organisation’s governance comes up to standard
(Stoopendaal & van de Bovenkamp, 2015).
Governance is about the responsibilities of various
actors operating at different levels: professionals at
the micro-level, boards of administration and
supervisory councils at the meso-level; and
government regulators at the macro-level (van de

Bovenkamp, de Mul, Quartz, Weggelaar-Jancen, &
Bal, 2013; Weir et al., 2015; MacKenzie, Lee, &
LeGresley, 2016), who should observe ethical and
social implications (Woolley et al., 2016; Fry &
Brannstrom, 2017; Pulker, Trapp, Scott, & Pollard,
2018).

Common social objectives should be
prioritized, economic growth should become a
means that allows these objectives to be achieved,
rather than an end in itself (Delany et al., 2018).
Commercial and investment agreements, as well as
international standards and regulations (Esty & Bell,
2018; Shukla, 2018) should consider health, social
and environmental objectives that are the results of
good corporate governance, leadership and ethical
values (Pronk, Malan, Christie, Hajat, & Yach, 2018;
Brems & McCoy, 2019; Kumar & Firoz, 2019) and
should not give way to a variety of strategies to
promote organisational interests associated with an
apparently paradoxical business model (Faulk,
Willems, McGinnis Johnson, & Stewart, 2015; Leon &
Ken, 2019). Murphy-Gregory and Gale (2019)
propose using meta-governance, where various
organisations in global schemes of governance
become mutually responsible for the results
obtained from agreements and regulations in the
field of health (Ellwood & Garcia-Lacalle, 2015; Quak,
Heilbron, & Meijer, 2019), emerging questions that
should also involve the governance of citizens
(Shepherd et al., 2019). A summary of the studies, by
year of publication and attribute, appears in
Figure 12.

Figure 12. Quantitative studies by attribute and by year

4.5. Grounded theory and the Conceptual Model

Grounded theory is a qualitative research style that
seeks to create new theories through some basic
elements: concepts, categories, and properties. The
creation and development of these elements take
place through an interactive process, i.e., they are
not generated a priori and subsequently tested. The
emphasis of Grounded theory is on learning from
data and not from an existing theoretical vision
(Strauss & Corbin, 1990). Once researchers reach the
theoretical saturation of categories, they go on to
review, classify and integrate the numerous memos
related to the categories, their properties and the
relations between them. This procedure is called
sorting and is essential since it places fragmented
data together. The classified memos create a

conceptual framework with the main ideas and facts
about what is being studied. Therefore, the writing
phase is simply a product of the sorting procedure.

Glaser (2001) describes Grounded theory as
“paradigmatically neutral”, suitable for use in
positivist, interpretivist or critical studies (Annells,
2016; Urquhart, 2001). Setting out from Pandit
(1996), who defines the process of constructing
Grounded theory, the research was designed
(literature review and selection of cases), data were
gathered (protocol development), ordered
(categories) and analysed. Based on the main
approaches found in the studies analysed, the
concepts emerge and are organised in topics that
originate the attributes and concepts to the
properties, establishing the relationship between
them (Petrini & Pozzebon, 2009). Although
performance is a very important subject in

6

12

9

5

9

11 11
10

15

99

7

5

7 7

11

4

6
5

9

2015 2016 2017 2018 2019

Quality of Health Care Corporate Social Responsibility in Health

Health risk management Global Health Governance

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

22

managing health service systems (Marchal et al.,
2014), from the attempts by the WHO (WHO, 2000)
and OPAS (OPAS, 2001) to encourage the
development of systems to manage performance
and the adoption of a model of management by
results, few studies have described the theoretical
model to assess governance and interventions in
health. The term is often used as a synonym of
quality, effectiveness or efficiency, which alone
cannot represent the whole range of questions
covered (Brousselle, Champagne, Contandriopoulos,
& Hartz, 2011), and are not enough to promote the
development of interventions in health. So there is
an important gap in scientific knowledge on the
subject, with significant reflections in assessment
practices (Carnut & Narvai, 2016).

In this context, Figure 13 presents the
conceptual model emerging from the SLR, from the
application of Grounded theory, underlining the
importance of observing the environment the main
aspects of corporate governance in health are part
of. Notably, global governance in health, in the

macrosphere of the environment, should issue the
regulations, policies, standards and social
determinants that will influence, at the meso-level,
health institutions, which in turn also have an
influence on the quality of service provided to the
patient (micro-level). This cycle is repeated, with a
view to strengthening the whole system that
involves the dimensions of leadership, evidence-
based practices, and sustainability.

This model shows the learning in the double
loop which, caused by reviewing the guiding
principles, includes reviewing the process and finally
generating a kind of result for the system. Here, this
includes the question of reviewing principles, norms,
policies and macro objectives, forming action and its
transformation into organisational results,
culminating in reflecting on those actions to deal
with patients. “The double loop refers to the two
circuits of feedback that connect observed effects of
the action with strategies and values served by the
strategies” (Argyris & Schön, 1978, p. 21).

Figure 13. Conceptual model of corporate governance in health

5. CONCLUSION

Governance of the health system involves
supervision and orientation of the system as a
whole, not just the public system, in order to
safeguard the population’s interests (WHO, 2014),
and includes the actions and means adopted by
society to organise improvement and protection of
the population’s health (Mutale, Mwanamwenge,
Balabanova, Spicer, & Ayles, 2013). Hospitals are
special institutions (Hunter, 2014) with their own
form of organisational governance, and this
particularity presents some resources that need
special emphasis. However, the health sector covers
various types of institutions, such as care at home,

out-patient service, and others. Both the governance
and regulation of this sector are evolving and boards
and regulators in the field of health try to find ways
to gain control of service quality through integrated
risk-management systems that can be used to
ensure quality and safety in a pro-active way
(Stoopendaal & van de Bovenkamp, 2015). Global
health has moved from a focus on technical
competences to a more politicized vision of the
relations between a growing number of stakeholders
(Akhlaq et al., 2020; Beier & Früh, 2020; Byham-Gray,
Peters, & Rothpletz-Puglia, 2020; O’Hara, Baxter, &
Hardicre, 2020).

This study makes important observations after
including the different topics in the levels of the

Global Health
Governance

Regulation,
expected practices,
standards, social

determinants,
global norms

Ethics
institutional

values,
sustainability,
performance

Corporate
social

responsibility

Health risk
management

Risk
management,

risk
assessment,
clinical risk,

risk
committee

MACRO
level

MESO
level

MICRO
level

Responsibility,
commitment,
safety, quality

Quality of
Healthcare

Feedback

Feedback

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

23

environment, allowing a survey of attributes
influencing corporate governance in health. Setting
out from the micro-level, where the quality of
healthcare is influenced by factors such as the
pharmaceutical industry’s stance and its own
scenario of corporate social responsibility, including
clinical governance and the emerging need for
corporate education for medical staff, as well as the
influence of boards of administration indicating
responsibility and commitment to safe healthcare of
quality and for the patient.

Regarding health institutions (meso), corporate
social responsibility (CSR) and risk management in
health stand out. Studies on CSR show researchers’
concern about socially responsible, ethical and
environmentally sustainable business practices, and
how organisations take responsibility for the effects
of their actions, either directly or through state-
monitored regulation. Increasingly, risk management
in health moulds the behaviour of organisations
which come under pressure from users who demand
better health services. This study addresses risks in
different aspects, including those associated with
behaviour and ethics, risk in the quality of sources
of data and information for management, to keep
good internal control of processes, the clinical risk
associated with patient safety, the risk of
implementing bad regulatory policies with doubtful
benefits for society, those affecting institutions’
financial performance and risks associated with
organisational decision-making about investments
and agency costs.

In global governance in health, at the macro-
level, national and international governance and
regulations stand out, addressing sustainable ways
to exploit resources, minimizing conflicts between
stakeholders, since global health has moved from a
focus on technical competences to a more
politicized vision between the growing number of
stakeholders and where health, social and
environmental objectives, the results of good
corporate governance, leadership and ethical values,
do not give way to strategies promoting only
organisational interests.

The results of the study and development of
the theoretical model are found to be consistent and
able to show the main contribution to the
interpretation of risk management, quality and the

responsibility of corporate governance, the state’s
role in regulations and the ultimate effect on
healthcare performance, where the evidence
indicates the need not only for regulation but for
implementation and monitoring. In this context, it is
important to study the environment in health since
the prevalence of certain patterns of actions taken
by political leaders, which culminate in health
regulations, comes from the socio-cultural and
economic conditions where investigations are
conducted, as well as from networks,
interconnections in certain communities, institutions
seem to facilitate accessibility, opportunities for
improving the quality of patient care, making it
essential to study these aspects, with the need to
pay special attention from the point of view of the
definition of public health policies.

This article contributes to the literature on
structure and interactions in the different spheres,
levels of the health environment and their impact on
patient care. At the policy level, it includes the
perspective of the influence of public policies on the
results, ultimately, inpatient care. However, this
document goes beyond the research and also
considers the intention of the structure proposed in
the conceptual model, which seeks greater
transparency and information exchange between all
those involved when forming health policies to allow
comparison between the desired health results and
perception of the results actually achieved.

Although this study brings current references
on governance and regulatory aspects in health, an
identified limitation refers to the period analysed (5
years), as this can be extended, thus allowing for
greater coverage in the determination of clusters
and a more of the determinants that influence
health regulations, both at the macro
(governmental), meso (institutions) and micro
(patient care units) levels, providing indicators that
provide greater sustainability and expand the social
responsibility of national health systems. Table 5
proposes an agenda for the future, separate studies
according to the attributes found in the SLR. A
limitation of this study concerns the fact of
analysing studies published in the last five years
since the focus was on obtaining current references
on the subject developed.

Table 5. Suggestions for future research

Attribute Suggestions for future research

Quality of
healthcare

– Deepen the discourse on governance in health systems interacting with the challenges of an aging population.
– Explore managerial perceptions of corporate governance issues which are still under-researched (example: what
is the understanding and commitment of mid-level medical managers to the implementation of evidence-based
clinical protocols).
– Extend the literature on service quality focusing not only on hospitals but covering health centres, clinics and
outpatient departments.

Corporate
social

responsibility
in health

– Promote studies establishing a relationship between sustainability and corporate responsibility with the main
stakeholders, including regulatory bodies, in order to address social, environmental, governance and economic
deficits (example: developing holistic tools for managing organizational sustainability, based on the best
practices of recognized sustainable organizations).

Risk
management

in health

– Studies addressing complex and mutual organisational characteristics with organisational performance in an
attempt to minimize different types of risk (example: like internal controls, effective tools to prevent losses and
achieve organizational goals can sustain operations and improve the performance of hospital institutions).
– Address social and environmental factors of health problems affecting society (example: analysing the social
responsibility activities of health institutions in order to find out if companies add value to the quality of
healthcare and society).

Global
governance in

health

– Develop an integrated approach to corporate governance strategies in multinational companies, incorporating
regulatory, economic and socio-cultural perspectives, as well as the perspectives of the different stakeholders.
– Provide policy advice about the corrective and preventive actions necessary to protect the health sector.

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

24

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APPENDIX 1

Table A1. Summary of articles according to the category of environment and authors according to year of
publication

Level â„– articles Author/Year of publication

Micro 11
Delaney (2015), Hossain et al. (2015b), Sendlhofer et al. (2015), Oomkens et al. (2015), Tuan (2015),
Varhegyi & Jepsen (2016), Tuan (2016), Kwedza et al. (2017), Brown (2019), Hsu et al. (2019), Lee (2019).

Meso 85

Sibindi & Aren (2015), Hossain et al. (2015a), Lee (2015), Babiarz et al. (2015), Benmelech & Frydman (2015),
Faulk et al. (2015), Williamson et al. (2015), Mais & Sari (2015), Ellwood & Garcia-Lacalle (2015), Rossi et al.
(2015), Chung et al. (2015), Khan et al. (2015), Sheaff et al. (2015), Kuntz et al. (2016), Cassels (2016),
Edgeman et al. (2016), Aragón & Iturrioz Landart (2016), Elson & Gamble (2016), Molk (2016), Ngo et al.
(2016), Rapaczynski (2016), Hasan et al. (2016), Blanco-Oliver et al. (2016), Freeman et al. (2016),
Stathopoulos & Voulgaris (2016), Butler (2016), Mazzone et al. (2016), Russo (2016), Lock & Seele (2016),
Linwood et al. (2017), Ho et al. (2017), Flammer & Luo (2017), Holland (2017), Ouyang & Hilsenrath (2017),
van Erp (2017), Kaur & Vij (2017), Ch & Jola (2017), Misso & Andreopoulou (2017), Siew (2017), Clapp &
Scrinis (2017), Thanetsunthorn & Wuthisatian (2017), Geiger & Cuzzocrea (2017), Landstad et al. (2017),
Chambers et al. (2017), Jizi & Nehme (2017), Brown et al. (2018), Liang et al. (2018), Chang et al. (2018),
Feng & Johansson (2018), Lee & Lai (2018), Rodriguez et al. (2018), Ames et al. (2018), Erwin et al. (2018),
Knippen et al. (2018), Pronk et al. (2018), Thompson (2018), da Silva Etges et al. (2018), Laouer (2018),
Thaiyalnayaki & Reddy (2018), Simone et al. (2018), Kumarasinghe et al. (2018), Mustafa & Al-Nimer (2018),
El-Kassar et al. (2018), Shan et al. (2018), Pulker et al. (2018), Bano et al. (2018), Nazir et al. (2018), Shabbir
et al. (2018), Jarernsiripornkul & Pandey (2018), Pather & Mash (2019), Etges et al. (2019b), Afriyie et al.
(2019b), Kong et al. (2019), Petitjean (2019), Kumar & Firoz (2019), Mehta et al. (2019), Hepworth (2019),
Nawaz & Koç (2019), Quak et al. (2019), Sheard et al. (2019), Kooli (2019), Carter et al. (2019).

Macro 71

Pirozek et al. (2015), van Schalkwyk & Steenkamp (2015), Banasik (2015), Hossain et al. (2015c), Kalesnikoff
et al. (2015), Kirat (2015), Carter (2015), Kesselheim et al. (2015), Krimsky (2015); McNulty & Akhigbe
(2015), Nelson (2015), Sample (2015), Stoopendaal & van de Bovenkamp (2015), Trexler & Schendler (2015),
Whitmee et al. (2015), Camilleri (2015), Demeritt et al. (2015), Weir et al. (2015), Russell et al. (2015), Fooks
et al. (2017), Herrick (2016), Mash et al. (2016), Ntim (2016), Torrado (2016), MacKenzie et al. (2016),
Sheehan et al. (2016), Woolley et al. (2016), Ferlie et al. (2016), Vainieri et al. (2016), Lee et al. (2016), Wipfli
(2016), Cumming et al. (2016), Stavinoha (2016), Monachino & Moreira (2016), Ulijaszek & Mclennan (2016),
Rawlinson (2017), Kasim & Karim (2017), Thorsteinsdóttir et al. (2017), Camilleri (2017), Fry & Brannstrom
(2017), Leon & Ken (2017), Slade et al. (2017), Carmenta et al. (2017), Ferguson et al. (2017), Morantz (2017),
Foladori (2017), Bakalikwira et al. (2017), Shukla (2018), Sharmin et al. (2018), Dove et al. (2018), Esty & Bell
(2018), Bump (2018), Delany et al. (2018), Knai et al. (2018), Marstein & Babich (2018), do Nascimento
Ferreira Barros et al. (2019), Berland (2019), Brems & McCoy (2019), Bugbee (2019), Cousins et al. (2019),
Leon & Ken (2019), Steele et al. (2019), Shepherd et al. (2019), Lai et al. (2019), Ishikawa et al. (2019),
Vveinhardt et al. (2019), Murphy-Gregory & Gale (2019), Roller, 2019, Gonenc & Scholtens (2019), Waring
(2019), Lipunga et al. (2019).

APPENDIX 2

Table A2. Summary of authors/year involved in the “quality of health care” attribute

Attribute â„– articles Author/Year of publication

Quality of
Healthcare

41

Babiarz et al. (2015), Hossain et al. (2015b), Oomkens et al. (2015), Pirozek et al. (2015), Sheaff et
al. (2015), Williamson et al. (2015), Blanco-Oliver et al. (2016), Butler (2016), Cassels (2016), Ferlie
et al. (2016), Freeman et al. (2016), Mash et al. (2016), Mazzone et al. (2016), Sheehan et al. (2016),
Tuan (2016), Ulijaszek & Mclennan (2016), Wipfli (2016), Bakalikwira et al. (2017), Chambers et al.
(2017), Ferguson et al. (2017), Fooks et al. (2015), Kaur & Vij (2017), Kwedza et al. (2017), Landstad
et al. (2017), Linwood et al. (2017), Thanetsunthorn & Wuthisatian (2017), Bano et al. (2018), Brown
et al. (2018), Erwin et al. (2018), Knai et al. (2018), Lee &, Lai (2018), Afriyie et al. (2019a), Afriyie et
al. (2019b), Berland (2019), Brown (2019), Kong et al. (2019), Kooli (2019), Pather & Mash (2019),
Roller (2019), Sheard et al. (2019).

Journal of Governance and Regulation / Volume 9, Issue 2, 2020

33

APPENDIX 3

Table A3. Summary of authors/year involved in the “corporate social responsibility in health” attribute

Attribute â„– articles Author/Year of publication

Corporate Social
Responsibility

in Health
56

Benmelech & Frydman (2015), Camilleri (2015), Kirat (2015), Hossain et al. (2015a), Hossain et al.
(2015c), Kalesnikoff et al. (2015), Khan et al. (2015), Lee (2015), Sample (2015), Trexler & Schendler
(2015), Tuan (2015), Edgeman et al. (2016), Elson & Gamble (2016), Herrick (2016), Ntim (2016),
Lock & Seele (2016), Molk (2016), Monachino & Moreira (2016), Rapaczynski (2016), Russo (2016),
Stavinoha (2016), Varhegyi & Jepsen (2016), Camilleri (2017), Geiger & Cuzzocrea (2017), Holland
(2017), Kasim & Karim (2017), Misso & Andreopoulou (2017), Carmenta et al. (2017), Siew (2017),
Thorsteinsdóttir et al. (2017), Clapp & Scrinis (2017), Flammer & Luo (2017), Bump (2018), Chang
et al. (2018), Dove et al. (2018), El-Kassar et al. (2018), Feng & Johansson (2018), Jarernsiripornkul
& Pandey (2018), Knippen et al. (2018), Kumarasinghe et al. (2018), Laouer (2018), Liang et al.
(2018), Marstein & Babich (2018), Rodriguez et al. (2018), Shabbir et al. (2018), Sharmin et al.
(2018), Simone et al. (2018), Cousins et al. (2019), do Nascimento Ferreira Barros et al. (2019),
Hepworth (2019), Lee (2019), Mehta et al. (2019), Nawaz & Koç (2019), Petitjean (2019), Steele et al.
(2019), Vveinhardt et al. (2019).

APPENDIX 4

Table A4. Summary of authors/year involved in the “health risk management” attribute

Attribute â„– articles Author/Year of publication

Health Risk
Management

35

Chung et al. (2015), Demeritt et al. (2015), Delaney (2015), Rossi et al. (2015), Kesselheim et al.
(2015), Mais & Sari (2015), McNulty & Akhigbe (2015), Sendlhofer et al. (2015), van Schalkwyk &
Steenkamp (2015), Aragón & Iturrioz Landart (2016), Cumming et al. (2016), Hasan et al. (2016),
Kuntz et al. (2016, Ngo et al. (2016), Stathopoulos & Voulgaris (2016), Vainieri et al. (2016), Ch
& Jola (2017), Ho et al. (2017), Jizi & Nehme (2017), Ouyang & Hilsenrath (2017), van Erp (2017),
Ames et al. (2018), da Silva Etges et al. (2018), Mustafa & Al-Nimer (2018), Nazir et al. (2018),
Shan et al. (2018), Thaiyalnayaki & Reddy (2018), Thompson (2018), Carter et al. (2019), Etges et
al. (2019a), Etges et al. (2019b), Hsu et al. (2019), Ishikawa et al. (2019), Lai et al. (2019), Waring
(2019).

APPENDIX 5

Table A5. Summary of authors/year involved in the “global governance in health” attribute

Attribute â„– articles Author/Year of publication

Global Health
Governance

35

Banasik (2015), Carter (2015), Ellwood & Garcia-Lacalle (2015), Faulk et al. (2015), Whitmee et al.
(2015), Krimsky (2015), Nelson (2015), Russell et al. (2015), Sibindi & Aren (2015), Stoopendaal
& van de Bovenkamp (2015), Weir et al. (2015), Lee et al. (2016), MacKenzie et al. (2016),
Woolley et al. (2016), Torrado (2016), Foladori (2017), Fry & Brannstrom (2017), Leon & Ken
(2017), Morantz (2017), Rawlinson (2017), Slade et al. (2017), Delany et al. (2018), Esty & Bell
(2018), Pronk et al. (2018), Pulker et al. (2018), Shukla (2018), Brems & McCoy (2019), Bugbee
(2019), Gonenc & Scholtens (2019), Kumar & Firoz (2019), Leon & Ken (2019), Lipunga et al.
(2019), Murphy-Gregory & Gale (2019), Quak et al. (2019), Shepherd et al. (2019).

  • CORPORATE GOVERNANCE AND THE ENVIRONMENT IN THE HEALTH SECTOR: SYSTEMATIC LITERATURE REVIEW
    • 1. INTRODUCTION
    • 2. METHODOLOGY
      • 2.1. PRISMA analysis
      • 2.2. Environment
      • 2.3. Analysis of keyword co-occurrence
    • 3. RESULTS
      • 3.1. General analyses
      • 3.2. Corporate governance in health with the PRISMA analysis and focus on the environment
      • 3.3. Analysis of keyword co-occurrence
    • 4. DISCUSSION
      • 4.1. “Quality of healthcare” attribute
      • 4.2. “Corporate social responsibility in health” attribute
      • 4.3. “Risk management in health” attribute
      • 4.4. “Global governance in health” attribute
      • 4.5. Grounded theory and the Conceptual Model
    • 5. CONCLUSION
    • REFERENCES
    • APPENDIX 1
    • APPENDIX 2
    • APPENDIX 3
    • APPENDIX 4
    • APPENDIX 5
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