The Practicability of Competing Value Framework as a Stride towards Public Service Delivery Improvement in the Health Sector

Considering its impact, organizational culture has emerged as a vital concept in organizational development. Although diagnosing organizational culture appears as one of the organizational change strategies for organizational development, it is a challenging undertaking. The dearth in the evaluation of the organizational culture of the public sector, especially in Nigeria, motivated this study with the aim of evaluating the organizational culture of the Kwara State public health sector using the Competing Value Framework (CVF). Significantly, there is mounting pressure on the state’s health sector to improve its service delivery, which is likewise strained by the effort to contain COVID-19 incidents. Hence, to assess the organizational culture and identify the areas of improvement for an effective proposed organizational reform, this study collected data by administering questionnaires to 256 participants. The study found that the prevailing culture is internally oriented and it manifests the typical culture of many public institutions. The evaluation of the current and preferred organizational culture is important to identify and create the needed change and most importantly foster a successful organizational transformation in the reality of many failed reforms. Conclusively, a successful change is anticipated to achieve the national goal of the health sector identified as one of the global sustainable development goals.


Introduction
Health defines the worth of a nation's human capital, labor force and is a critical factor for the growth and development of the economy (Bamidele and Okafor, 2021; Abimbola, 2020). The significance of healthcare in the economy cannot be overstated, as the nation's first wealth is its health. The growth and productivity of a nation are largely dependent on the health of the populace, which is measured by the health sector's performance. Therefore, the government must be willing to invest resources in the enhancement of the health sector (Abimbola, 2020). Quality issues in the healthcare sector have been raised in developed countries like the United Kingdom (UK) and the United States of America (USA) and have propelled the prioritization of quality improvement as a key policy subject (Davies, Nutley and Mannion, 2000). Prominently, the health sector in developing countries is commonly beset by glitches of poor access, poor financing, and poor maintenance among others. These challenges are considered as not mere weaknesses but a system-deficiency that affects service delivery and the general performance of the health sector. More so, the challenges are identified as barriers to the attainment of the United Nations (UN) health-related Sustainable Development Goals (SDGs) (Mbau and Gilson, 2018;Aregbeshola, 2019). Unfortunately, there are lags in the development and maintenance of the Nigerian health sector, which have resulted in the underperformance of the management of the sector. The sector has experienced abandonment, especially with regard to financial desertion and hoary health equipment that has crippled the progressive capabilities of the health system and the quality of services provided (Abimbola, 2020).
From a discussion of the achievement of quality health care, organizational change is noted as a requirement to attain quality improvement in health care (Aregbeshola, 2019). However, the organizational change could be managed when the culture in which excellence can flourish is built. In essence, structural reorganization should be implemented alongside cultural change to transform the health system. Therefore, to achieve a strategic and successful transformation of the health sector, it is important to emphasize a cultural transformation promotable by the assessment of the nature and characteristics of the organization's culture to identify the attributes that support good performance and service delivery. In addition, there must be expectations from a proposed cultural change to confirm the prospect of improved performance in the health sector (Davies, Nutley and Mannion, 2000).
According to Mbau and Gilson (2018), limited gains have been realized from several attempted reforms of the health sector and the focus has shifted to the intangible aspects of the organization that have a greater impact on the outcome of the sector. Hence, organizational culture is considered to have the potential of influencing how proposed reforms accomplished the intended outcome. Although literature has confirmed the influence of organizational culture on organizational performance, there are insufficient empirical data on the cultural diagnosis for the undertaking of a cultural transformation. Therefore, more empirical studies are required on the relationship between organizational culture and the improvement of the health system particularly in developing countries to unearth the understanding of the potential of organizational cultural diagnosis to influence a positive transformation in public sectors (Davies, Nutley and Mannion, 2000). Anning-Dorson, Christian and Nyamekye (2020) highlighted that excellent service delivery sprouts from an organization's culture as the alignment of the organization's service delivery orientation and its culture provides the strategic and essential tool for the development of its effectiveness.
In view of the significance of the cultural assessment of an organization as an influence on the organizational transformation, this study aimed to assess the organizational culture of the Kwara State public health sector in Nigeria using the psychometric tool of the Organizational Culture Assessment Instrument (OCAI). The OCAI was employed to understand the current and preferred culture of the organization to leverage how change can be implemented successfully in order to achieve improved performance. This next section provides the delineation of the concept of organizational cultural change.

The concept of organizational cultural change
Reforms in the public sector are attempts to survive within the changing environment. While several public sector reforms and policy changes centered on accountability and transparency, employee performance have resulted in profuse failures (Wang et al., 2019). The failures have been blamed on the neglect of organizational culture, namely, the core values, ethics, mission, strategies and goals of the organization (Davies and Egbuchu, 2019). It is believed that an effective organizational change necessitates supported values, emotional intelligence and improved skills, among other things (Mierke and Williamson, 2017). Hence, the cultural assessment of an organization is not an option in recent unsettled times to evade organizational ineffectiveness and inefficiency. Moreover, a change motivated through the cultural perspective is held to guarantee anticipated results and fortify the sustainability of any proposed change (Alvesson and Sveningsson, 2015).
Organizational culture is one of the most appropriate components of an organization, either public or private (Cera and Kusaku, 2020). The culture of an organization is insinuated to include the principles, assumptions, and approaches that influence its effective activities and business performance (Adekoya et al., 2019). Similarly, Schein (2010) describes culture as values, ways of thinking, unbiased and more noticeable parts of the organization. Organizational culture could improve an innovative strategy and simplify changes in an organization due to its attribute of shared values and purposes (Ahmady, Nikooravesh and Mehrpour, 2016). These definitions indicate that organizational culture has the capacity to reflect positively on the employees' attitude, perception, career satisfaction, ethical behavior, employee engagement, and work satisfaction, which all together when integrated would brace the organizational performance in the long term.
Clearly, a thorough understanding of an organization's culture and its components is critical to achieving successful cultural transformation (Alvesson and Sveningsson, 2015). However, the implementation of desirable changes has been ineffective regardless of the efforts exerted in the process because the organizational culture is overlooked (Limwichitr, Broady-Preston and Ellis, 2015). Alvesson and Sveningsson (2015) affirmed the naive disregard of the potential value of organizational culture by ample literature on the subject matter. In addition, many organizations' cultures are merely catchphrases and unrealistic dreams without the profound insight into the itemized culture. This portrays the challenges involved in getting a grip on organizational culture. According to Janićijević (2012), a good assessment and understanding of an organization's culture are capable of influencing the approach to initiate an applicable and effective change. Warrick, Milliman and Ferguson (2016) emphasized that culture influences the choice of change to be implemented in an organization and guides the management processes.
From the foregoing discussions, the need for an organizational cultural assessment has been underscored with the acknowledgment of its benefits. In light of this, it is required for leaders to be cognizant of the organizational culture prior to effecting any change (Al-Haddad and Kotnour, 2015; Ojogiwa and Qwabe, 2021). Furthermore, diagnosing the culture of an organization could offer strategic interventions as prioritized (Slack and Singh, 2018). Besides, cultural change is considered the right strategy to realize a successful change and an effective performance in the public sector (Vargas and Negro, 2019). Therefore, the cultural analysis of an organization is proposed as a strategy for the management of an effective and sustainable change to survive in the contemporary world characterized by constant changes.
Though the public sector is not much concerned about profit-making, several attempts had been made to improve its service delivery in the current changing world (Slack and Singh, 2018). The quality of the Nigerian healthcare system has been compromised through many challenges that have negatively affected service delivery (Muhammad, Abdulkareem and Chowdhury, 2017). Ojogiwa and Qwabe (2021) observed that efforts to tackle corruption have not appeared significant when the culture was not transformed. Organizational cultural change is a process of critically evaluating the culture of an organization; the process involves envisioning the organization's desired values and principles, implementing the ideal culture and reinforcing and sustaining the cultural changes within a period considered suitable by the organization (Intezari and McKenna, 2018). The next section highlights the framework of the study.

The Competing Value Framework (CVF)
This study is anchored on the Competing Value Framework (CVF), which was developed from the study of Quinn and Rohrbaugh (1981) to recognize the principles of effective organizations. The framework is validated based on empirical evidence as an extensively used framework for identifying and assessing the essential cultural dimensions of an organization (Cameron and Quinn, 2019). Four dominant organizational culture types were developed from the CVF on which the foundation of the OCAI is built (Sułkowski, 2014). They are Clan, Adhocracy, Hierarchy and Market culture (Cameron and Quinn, 2011). The model provides an analytical assessment of culture centered on the investigation of shared assumptions, core values, and shared approaches to work in an organization (Davis and Cates, 2018). The four culture types could be abridged into two dimensions namely the stability-flexibility dimensions and the internal-external dimensions. Nonetheless, the four groups define the underlying assumptions and core values of organizations (Cameron and Quinn, 2011).
The dimensions of the culture typology present different quadrants (the four quarters) into which the culture types are divided. The Clan culture is located in the upper left quadrant and it emphasizes organizations with internal focus and high flexibility. The Adhocracy culture is at the upper right quadrant; it highlights an organization with external focus and high flexibility. The Hierarchy culture is at the lower left quadrant, emphasizing the internal focus and stability of an organization. The Market culture is at the lower right quadrant and it highlights the external focus and stability of an organization (Rukh and Faisal, 2018). The CVF is selected as a framework guiding this study for its ability to detect the existing culture, detect the variances between the existing and ideal culture, classify the categories of culture across sub-units of the organization, and identify the culture strength. This assessment is completed with the OCAI that is able to represent the cultural profile of the organization based on six elements of strategic emphases, dominant characteristics, criteria of success, organizational leadership, organization glue, and management of the employee.
Dominant characteristics define the focus of the organization on innovation, its goals, agendas, and emphasis on teamwork and effectiveness (Tandon,  Empirical findings support and validate that the CVF facilitates the evaluation of organizational culture. Van Huy et al. (2020) employed quantitative research methods to validate the organizational culture assessment instrument in a healthcare setting in Vietnam, which to their knowledge is a leading endeavor in a developing country as Vietnam. The study by Al Issa (2019) in selected public universities in Malaysia found that organizational culture has a significant effect on transformational leadership. The study observed the prominence of the Clan culture among all the cultural dimensions of the OCAI. In a similar study, Amran and Setyanegara (2021) investigated the OCAI's influence on the personnel's performance. The authors' found that the organizational culture influences the personnel's performance; the Hierarchical culture was found to have a greater influence on the personnel's performance. Additionally, the OCAI is of great significance in the management of the organization's change activities.

The study site
The research was carried out in Kwara State, located in the North-central geopolitical region of Nigeria. The State has 16 administrative units known as the Local Government Areas (LGAs). The LGAs are divided into three senatorial districts or zones that is, Kwara South, Kwara North and Kwara Central. Kwara State is one of the 10 poorest states in Nigeria and it shares borders with six other states: Osun, Ondo, Oyo, Niger, Kogi and Ekiti (Kuku-Shittu et al., 2016). More than 80% of the population lives in rural areas and, even though almost 90% are farmers, many live in abject poverty. The public sector, particularly the public health sector, is stricken with poor service delivery that has shifted the citizens' patronage of most public health centers to private hospitals and traditional medication (Joseph et al., 2017). The study site was selected from each senatorial zones in the state. Basic Health Centre, Sao (SBHC) is a primary health center in Moro local government from the Kwara North senatorial district. Omuaran General Hospital (GHO) is a secondary health center in Ifelodun local government representing Kwara South. Kwara State Civil Service Hospital (CSH) and General Hospital Ilorin (GHI) are secondary hospitals in Ilorin South Local government from Kwara Central. The Ministry of Health (MOH) in Ilorin South, Kwara central senatorial district regulates all the state's health institutions and it is mostly dominated by the policymakers of the state's health sector. The target population included both the clinical staff and non-clinical staff of the state health sector. This constituted administrators, directors, and heads of departments, finance, supervisors, quality evaluation, medical practitioners, and other employees in the selected public health institutions.

Data collection
The quantitative approach was deployed to collect and analyze data. The quantitative method is employed to explore the phenomena or research subject from a wider perspective (Rajasekar, Philominathan and Chinnathambi, 2013). Numerical structured questionnaires with closed-ended questions were distributed to randomly selected participants across different departments of the organizations such as finance, human resource (HR), administration, medical, operations, and procurement. The selected institutions have a total population of 881 from the information received from the Kwara State Ministry of Health. The required sample size was determined using the guideline and formula by Krejcie and Morgan (1970), calculated at 95% confidence level. Based on the calculation, questionnaires were administered to 256 respondents that were selected randomly. The questionnaires were distributed based on the proportion of each site to the study's population such as SBHC (24), GHO (89), CSH (127), MOH (198) and GHI (443). A response rate of 255 questionnaires was, however, achieved and 2 out of the returned questionnaires were subsequently discarded and left out of the analysis because they were not completed properly. Hence, the sample of 253 responses, which represents a 98.8% response rate was derived. Quantitative data retrieved from questionnaires was transcribed into a tabular arrangement using the Statistical Package for the Social Sciences (IBM SPSS) version 23. The quantitative data were analyzed using descriptive statistics.

The measurement instrument
Cameron and Quinn's (1999) OCAI is a tool mostly used in studies that are based on the Competing Values Framework (CVF). It is concerned with the criteria for organizational effectiveness and it comprises four Competing Values (stability and control, flexibility and discretion, external focus, and internal focus) that are parallel to four organizational culture types. The OCAI uses ipsatic scoring or ipsative measurement, which allows respondents to score the four questions under each element over 100 based on their preferences (Caliskan and Zhu, 2019). According to David, Valas and Raghunathan (2018), OCAI is a validated tool for assessing organizational culture and has been employed by different researchers. It is confirmed to have better reliability and validity (Heritage, Pollock and Roberts, 2014). The OCAI consists of 24 questions categorized under six elements, which are the dominant characteristics, management of employees, organizational leadership, criteria of success, strategic emphases, and organizational glue. Each of the elements has four alternative culture types of Clan (A), Adhocracy (B), Market (C), and Hierarchy (D). For this study, the reliability test for the four-culture type was conducted using Cronbach's coefficient alpha. The Cronbach's alpha for the Clan, Adhocracy, Market, and Hierarchy are 0.705, 0.601, 0.684, and 0.774 respectively.
The instrument provided the opportunity for respondents to rate the existing and potential organizational culture of the State health sector. A strength of OCAI is that it contains psychometric properties and it is recognized as a scientific tool to investigate and evaluate organizational culture (Davis and Cates, 2018; David, Valas and Raghunathan, 2018). The use of OCAI is suggested to provide an accurate depiction of the organizations' current cultural situation, potential objectives, external and internal constraints and opportunities, and the requirement for attaining effectiveness through the noted elements (Handayani et al., 2020). Hence, assessing the culture of an organization through the lens of OCAI provides a portrait of the organizational core values and a roadmap or guide for prospective organizational change.

Results and analysis
This section presents the results and analysis of the responses collected from the study respondents. Firstly, the sociodemographic data solicited from the respondents are categorized into seven variables and presented in Table 1. The frequency distributions of the respondents' gender as depicted in Table 1 shows that the majority, 158 or 52%, of the respondents are female. The distribution of respondents by their educational qualification confirms that only 44 out of 253 respondents are holders of secondary school certificates. Additionally, the respondents' distribution by their work experience shows that over 65% had between 1 to 10 years of work experience in the Kwara State health sector. This could explain the appropriate responses provided by many of the respondents because they have a vast experience in the health sector. The distribution of respondents based on their departments shows that over 66% of respondents are clinical staff such as nursing, doctors/medicals, lab assistants/health records, and pharmacists. This could imply that most of the employees are health practitioners as these are essential personnel to promote the objectives of the Kwara State health sector. The data retrieved depicts that over 58% of the respondents occupied a leadership position and only 41% had non-leadership role. This established that the respondents had vast knowledge of the organizational culture of the Kwara State health sector and are sufficiently capable to provide appropriate answers to the questionnaires.

Evaluating the existing and preferred organization's cultural elements
To identify the existing culture of the Kwara State public health sector, the respondents were asked to rate their organization on six items with four alternatives. They were expected to divide 100 points among the four alternatives, which is the ipsative rating scale. This provides a high differentiation occurrence such that existing trade-offs in the organization are easily identified (Cameron and Quinn, 2011). The highest point is given to the most similar alternatives to their organization.
The responses were used to analyze the elements of the current organizational culture along with the preferred culture, which represents the potential organizational culture change for proposed organizational reforms and service delivery improvement. Table 2 presents the ratings of the current and preferred culture type for each element of the organizational culture of the Kwara State public health sector.

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The cultural element of dominant characteristics illustrates that the respondents preferred more of an external orientation, which is the Adhocracy and Market culture, as against the Clan and Hierarchy culture in the current state. Hence, the desired culture for a potential organizational change that could improve service delivery is expected to focus on innovation and be results-oriented. It can therefore be inferred that the absence of the characteristics of the preferred culture could construct biases to a potential reform or change. Moreover, the views of the respondents on the organizational leadership cultural element as a factor to influence a potential organizational culture change for service delivery improvement show a similar result with the dominant characteristic. This suggests the desire for the organization to be more innovative since innovation is a feature of externally oriented organizations (Zeb et al., 2021). The element of management of employees similarly reflects a desired culture of Market and Adhocracy respectively, which signifies a preference for the management style with an inclination towards risk-taking and innovation.
The cultural element of dominant characteristics illustrates that the respondents preferred more of an external orientation, which is the Adhocracy and Market culture, as against the Clan and Hierarchy culture in the current state. Hence, the desired culture for a potential organizational change that could improve service delivery is expected to focus on innovation and be results-oriented. It can therefore be inferred that the absence of the characteristics of the preferred culture could construct biases to a potential reform or change. Moreover, the views of the respondents on the organizational leadership cultural element as a factor to influence a potential organizational culture change for service delivery improvement show a similar result with the dominant characteristic. This suggests the desire for the organization to be more innovative since innovation is a feature of externally oriented organizations (Zeb et al., 2021). The element of management of employees similarly reflects a desired culture of Market and Adhocracy respectively, which signifies a preference for the management style with an inclination towards risk-taking and innovation.
Furthermore, as it relates to the element of organizational glue, the findings depict that the organization preferred a significant decline of the Hierarchy culture and more of Adhocracy and Clan culture. The organizational strategy shows a greater emphasis on the Market and Adhocracy culture with a comparable Clan culture type to ensure a successful proposed organizational change. The sixth element, which is the criteria of success, also reveals that the Market and the Adhocracy culture are greatly desired.

Overall evaluation of the existing and preferred organizational culture
Following the evaluation of each element of the existing and preferred organizational culture, the influence of the element of organizational leadership, dominant characteristics, management of employees, organizational glue, strategic emphases, and criteria of success on a potential organizational culture change is noticeable. The rating is presented in Table 3.
The overall rating of the organizational culture to guide a potential culture change was derived by dividing the percentages of each factor by six. Table 3 shows that the current culture has great emphasis for the Clan and Hierarchy cultures that has the mean score of 33.5 and 31 respectively. Nevertheless, the organization aspires to an improved rating of 24.3% and 23.1% (+6.1 and +4.8) for Adhocracy and Market culture that had a low rank in the current position. The figure below presents the graphical view of the results of the general evaluation of the existing culture and the preferred culture to implement a potential culture change in the Kwara State public health sector for improved organizational services.  Figure 1 indicates the state health sector desires a change towards the Adhocracy and Market culture, which stressed the external focus for improved performance. There is a desire for a shift from the Clan and Hierarchy culture, which relates to a decline in the internal focus of the organization.

Discussion
This study investigated the existing and preferred organizational culture of the Kwara State public health sector towards improving the services delivered by the sector. The result of the cultural element of dominant characteristics revealed that the potential organizational change of culture is viable with characteristics of innovation and creativity. Moreover, the current Hierarchical and Clan culture, which represents the traditional bureaucratic practices opposes the adhocracy culture of innovation (Zeb et al., 2021;Rukh and Faisal, 2018). Findings from the examination of the element of the leadership style revealed the desire for a potential change from a culture of leaders that are mere coordinators, organizers, and team builders to leaders that are visionaries, innovators, and drivers. The disparity between the existing and craved organizational leadership better explains the aversion of the current management of the sector. The findings propose a transformation with the thoughtfulness of the preferred leadership characteristics. The rationale for the exigency for the preferred Adhocracy culture type of organizational leadership could be due to the inadequate transformational and innovative plans of the current leaders. Ugoani (2017) affirmed the necessity of transformational, strategic, and visionary leadership to communicate change initiatives, innovative ideas and manage potential organizational change to realize an improved service quality and a successful organizational transformation. More so, studies have assessed and attested to prominent healthcare administration and leadership issues that have resulted in repeated strike-actions and poor service outcomes in the health sector (Oleribe et al., 2016). The implication is the need for transformational leaders to manage the organizational reform of the health sector for optimal performance (Nife and Lawal, 2018).
The management of employees' cultural elements, which described the working environment of the organization and the treatment given to the employees, revealed that the organization desires a better commitment towards goals' achievement and innovation with less control and rules governing their activities. The findings suggest the possibility of having a potential organizational culture change towards effective teamwork; effective teamwork is a vital tool to build a patient-centered and effective healthcare service delivery (Babiker et al., 2014). The cultural element of organizational glue, which is reflected as the mechanism by which members of the organization are connected to each other, shows a predominant hierarchy culture in the existing situation. It shows the organization is presently connected by the rules, formal procedures, and formal structures. Nevertheless, the result revealed a strong desire of the employees of various departments, units, and sections to be linked and connected with a focus on goals, innovativeness, and commitment to prominence. This result supports the empirical study of Alagbonsi et al. (2013) on the management of poor healthcare services in Kwara State. The study admitted that the absence of an innovative policy approach is one of the causes of the poor healthcare services in the State. Also, the element of strategic emphasis that is concerned with the organization's integration and adaptation to its external environment is currently focused on participation, trust, and openness with a high percentage score of 34.52% for the hierarchy culture. The result of the study shows that the strategy of the organization emphasizes the achievement of goals, competitiveness, and prospecting innovations.
The assessment of the element of what is identified and rewarded as success shows the potential need for a balanced culture (percentage columns in Table 1) that would identify and reward customer-focused employees, efficiency, effectiveness, novelty, and the achievement of long-term goals. The organization currently has a low belief in goals' achievement, organization's dominance and performance, which are the characteristics of the market culture type. However, as preferred criteria of success, the organization emphasizes development along with the low cost of production, good planning, and reliable service delivery. The results of the preferred culture match with Hakh, Fatahillah and Mangundjaya's (2014) cultural analysis of an organization in Indonesia. The Clan, Hierarchy, Market, and Adhocracy cultures were correspondingly preferred to initially nurture the development of its human resource and subsequently develop its competitiveness and the quality of the services provided. The study, however, noted some challenges associated with the choice of prioritizing the Clan culture before the other culture types. These challenges include less discipline, ineffective control for violation of regulations, and failure to achieve set objectives and productivity (Hakh, Fatahillah and Mangundjaya, 2014).
Ultimately, the findings on the overall organizational culture revealed that the Kwara State public health sector would like to have innovation, long-term goals, productivity, and competitiveness for improved organizational reform and performance. The findings revealed that the organization would like to have less of the existing Clan and Hierarchical culture for a proposed organizational reform as illustrated in Figure 1. However, there is a trifling focus on Adhocracy and Market in the present situation as compared to the desired situation. The choice to maintain the existing Clan culture is not surprising as Cameron and Green (2009) noted that managing and sustaining a cultural change is easier when the existing culture is not discarded as totally bad but the strength of the existing culture is capitalized upon. Therefore, a proposed reform should be mindful of the four culture-type profiles of the organization for an effective and sustainable transformation.

Conclusion
The study diagnosed the current organizational culture of the Kwara State public health sector as more tilted towards a Clan culture type and followed by the Hierarchy culture type. Based on the empirical evidence, the study found that the organization is titled away from the Adhocracy and Market culture type. The examination of the elements of the potential organizational cultural change suggests that there are noteworthy variations between the current and the desired culture with a preference for the Adhocracy and Market culture. Further analysis of the overall elements, which form the profile of the organizational culture revealed the potential to have a sense of innovation and competitiveness in the public health sector.
Therefore, it is recommended and healthier for organizations to capitalize on the strengths of the current culture to form a preferred culture. Besides forecasting and specifying desired culture or performances, it is best to diagnose the current organizational culture to identify the strengths and weaknesses of the organization and guide necessary and prompt action toward a change to improve public service delivery. The cultural strengths of the organization uphold or impede the organizational effectiveness and this is mostly dependent on the organizational leadership and strategies. Therefore, culture could be changed to accommodate an operational requirement rather than for the organization to modify its entire processes to lessen the effects of dogmatic cultures. Additionally, it is essential to manage a cultural change with recourse to the organizational values.