Public administration and health system strengthening in low- and middle-income countries: exploring strategies to improve healthcare delivery and health governance.

Introduction: Health system strengthening in low- and middle-income countries (LMICs) remains a persistent challenge in LMICs, where reforms often fail to translate into sustained improvements in access, quality, and equity. While existing scholarship has largely focused on technical and financing interventions, less attention has been given to the institutional and administrative conditions that shape reform outcomes. This study addresses this gap by examining how public administration influences health system performance. Guided by Institutional Theory, the study argues that HSS is fundamentally an institutional process, mediated by the coherence and effectiveness of administrative systems. Methods: A qualitative comparative case study design was adopted, focusing on three purposively selected cases: Germany (as a governance comparator), South Africa, and India. Data were collected through documentary analysis of peer-reviewed literature, policy documents, and reports from international organisations. The analysis employed a theoretically informed thematic approach, combining inductive coding with deductive categories derived from Institutional Theory. Comparative analysis was conducted across key dimensions, including governance arrangements, decentralisation, leadership capacity, and digital health integration. Results: The findings reveal that institutional capacity and governance coherence are decisive in shaping health system outcomes. Germany demonstrates how aligned governance structures and regulatory mechanisms enable consistent policy implementation. In contrast, South Africa and India exhibit institutional fragmentation, uneven decentralisation outcomes, and variable leadership capacity, which constrain reform effectiveness. Decentralisation produces divergent outcomes depending on local institutional strength, while digital health integration remains uneven due to infrastructural and administrative limitations. Across cases, the interaction between governance, leadership, and institutional capacity emerges as a critical determinant of reform success. Discussion: The study demonstrates that public administration is not a peripheral factor but a central explanatory variable in HSS. The findings support and refine prior work on governance and health systems by showing that institutional alignment, rather than policy design alone, determines implementation outcomes. Theoretically, the study advances Institutional Theory by illustrating how formal and informal administrative arrangements shape health system performance. Practically, it highlights the need for context-sensitive reforms that prioritise institutional strengthening, leadership development, and coordinated governance. These insights contribute to both public administration and health policy debates, emphasising the necessity of integrating institutional analysis into future health system reforms in LMICs. Conclusion: This study contributes to a deeper understanding of how public administration practices can foster sustainable health system strengthening in LMICs.