Clinical governance and healthcare quality in conflict-affected settings: a cross-sectional study of hospitals in Yemen

Abstract Background: In fragile and conflict-affected settings, systemic disruptions chal­lenge healthcare quality. Clinical governance (CG) has emerged as a framework for accountability and quality improvement; however, empirical evidence in active conflict environments remains limited. This study examines the relationship between the implementation of clinical governance and healthcare quality (HCQ) in Yemeni hospitals, assessing the differences between the public and private sectors. Methodology: A cross-sectional analytical study was conducted in Sana’a, Yemen, between June and October 2025, involving 382 healthcare professionals from eight hospitals using proportionate stratified random sampling. Data were collected using a structured, self-administered questionnaire specifically adapted and modified for this study. Clinical governance was assessed using an adapted version of the Clinical Governance Climate Questionnaire (CGCQ), while health­care quality was assessed using a modified SERVQUAL scale. Data were analyzed using descriptive statistics, Pearson’s correlation, Welch’s t-tests, and multiple linear regression models, with analysis performed using SPSS version 26.0. Results: With a 90.9% response rate, a strong positive correlation was found between clinical governance and healthcare quality ( R = 0 . 765 , p < 0 . 001 ), with clinical governance explaining 58.5% of the variance in quality outcomes ( R 2 = 0 . 585 ). Multiple regression identified information technology (β = 0 . 271 , p < 0 . 001 ), patient involvement (β = 0 . 173 , p = 0 . 003 ), and risk man­agement (β = 0 . 156 , p = 0 . 010 ) as significant independent predictors. Private hospitals demonstrated significantly higher scores in both clinical governance and healthcare quality compared to public facilities (p < 0 . 001 for both). Conclusion: In conflict-affected settings, clinical governance functions as a critical internal stabilizer for healthcare system resilience. The dominance of information technology and risk management reflects an adaptive, crisis-driven operational logic. The public–private performance gap highlights structural inequities exacerbated by conflict, emphasizing the urgent need for targeted poli­cies to restore governance capacity in the public sector and safeguard healthcare quality amidst systemic collapse.