Health sector governance — what are we really talking about?

By Bob Fryatt, Director of USAID’s Health Finance and Governance Project

Mrs. Rabi Ibrahim holds her 4-month-old son, as nurse Karimatu Abdulmalik prepares for their maternal-child health session at the rural health clinic in Niger State, Nigeria. © 2013 Adrian Brooks, Courtesy of Photoshare

While we have long recognized the importance of governance in the health sector, we as global health researchers and practitioners still find it difficult to reach a consensus on how to define it. This in turn, impacts how we measure it or even think about how to begin strengthening it.

Its not so surprising really. Governance can be described in many ways, and many of the interventions to strengthen governance are not yet adequately categorized. The health sector, too can be quite complex, with governing entities at many different levels. For example, there are international drug classification at the global level, health financing policies at the country level, and even governing bodies at the sub-national level in those countries where the health system is highly decentralized. Even at the local level, the extent to which communities are involved in oversight of health clinics factors into health governance.

For those of us working in this area, this lack of common definition is problematic. To see if we could agree on some of the basics, I along with my colleagues, Sara Bennett from Johns Hopkins University and Agnes Soucat, from the World Health Organization got together to hash it out. We published our findings this month in BMJ Global Health.

A Village Health Worker conducts an antenatal care home visit in Jamkhed, India. © 2012 Meagan Harrison, Courtesy of Photoshare

Here’s what we came up with….

Governance is essentially ‘how societies make and implement collective decisions’. This means that individuals entrust some defined decision making responsibility to a ‘governing entity’, and rely on institutions to implement, and accountability mechanisms to monitor and assure progress on the decisions made.

What does this mean in the context of health? Well, it might include things like arrangements for stakeholder participation in health planning processes, local health service accountability mechanisms, availability of information on provider performance, the clarity of health sector legislation, enforcement of health regulations and the availability of procedures to report misuse of resources.

A health worker vaccinates a child at a health center in Nampula, Mozambique. © 2017 Arturo Sanabria, Courtesy of Photoshare

When measuring governance, consider either rules-based determinants (such as presence of policies, standards and laws) or more outcome-based performance measures (such as health worker absenteeism, proportion of government funds reaching district facilities, stock-out rates for essential drugs). Researchers have proposed many assessment approaches, including focusing more on the roles and responsibilities amongst key actors and using common ‘governance results’, such as transparency, participation and policy capacity. At this point, however, we simply do not have standardized methods for assessing health sector governance. So for now, we suggest focusing on these key areas -

STRUCTURE | whether governing entities are in place and functioning,

PROCESS | whether decisions made are being implemented, and

OUTCOME | whether there is the desired improvement in performance or health outcomes.

A Community Health Volunteer (left) in Benishangul, Ethiopia, refers a child to a district health facility. © 2011 Yolanda Barbera Lainez/IRC, Courtesy of Photoshare

Four tips for being successful in health governance

1. Don’t let the ideal be the enemy of the good: The list of interventions and ‘reforms’ required to strengthen governance can be long and daunting. Changes need to take into consideration local capacities and feasibility, and work toward ‘good enough’ rather than ideal conditions.
2. Achieve more by working together: As the arguments and evidence becomes stronger, so the international public health community can promote a broader set of governance standards for the health sector. This could involve global and regional agreements, taking lessons from other efforts such as the Framework Convention for Tobacco Control and the Open Government Partnership.
3. Prepare to disrupt the resistance: Institutions can be difficult to change with vested interests that oppose change to better governance. Disruptive innovation can be of use such as introducing collaborative forums between civil society organizations, citizens and government. Digital technologies can also help in promoting transparency, strengthening decision-making, mobilizing citizens for accountability and automating audit processes.
4. Whats good for you, may not work for me: Different interventions will work in different situations. New interventions in this areas will need to be linked to careful review and research. This will enable learning on what works and facilitate fine-tuning and adaption of approaches.

Bob Fryatt

Bob Fryatt, works with Abt Associates as the director of USAID’s Health Finance and Governance (HFG) Project. He has 25 years of experience working in public health and social policy in low-, middle-, and high-income countries and in NGO, government, and multilateral settings. Fryatt holds a Medical Doctorate on economics and tuberculosis control from the University of London, a Master’s Degree in Public Health Medicine from London University, and is a Fellow of the U.K. Faculty of Public Health.

HFG is a five-year project funded by the U.S. Agency for International Development under Cooperative Agreement No: AID-OAA-A-12–00080. The HFG project is led by Abt Associates in collaboration with Avenir Health, Broad Branch Associates, Development Alternatives Inc., Johns Hopkins Bloomberg School of Public Health, Results for Development Institute, RTI International, and Training Resources Group, Inc. For more Information visit www.HFGProject.org