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Framework for Assessing Governance of the Health System: Gateway to Good Governance. Capacity building workshop on health system development for WHO staff Eastern Mediterranean Regional Office, World Health Organization Alexandria May 20-24, 2007.

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Framework for Assessing Governance of the Health System: Gateway to Good Governance

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Framework for assessing governance of the health system gateway to good governance l.jpg

Framework for Assessing Governance of the Health System: Gateway to Good Governance

Capacity building workshop on health system development for WHO staff

Eastern Mediterranean Regional Office, World Health Organization

Alexandria May 20-24, 2007

Eastern Mediterranean Regional Office, World Health Organization, Cairo

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Social Determinants of Health



Information Support

Service provision


Governance & leadership


Health workforce

Quality, safety



Medical products, technology

Provider performance


Financial protection


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Governance, Stewardship, Leadership?


  • The exercise of political, economic and administrative authority in the management of a country’s affairs at all levels.

  • Comprises complex mechanisms, processes and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations

(UNDP 1997)

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Governance, Stewardship, Leadership?

  • Stewardship

    • Function of a government responsible for the welfare of the population and concerned about the trust and legitimacy with which its activities are viewed by the citizenry

      WHR 2000

  • Leadership

    • The art or process of influencing people so that they will strive willingly and enthusiastically towards the achievement of the group's mission

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Why the term –’Governance’?

  • Governance is better understood by those within the health system and those outside;

  • Development agencies have delineated the principles of governance that are well understood

  • Performance of the health system is dependent on overall governance of a country

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Relationship between Governance indices and health outcomes

Lewis et al 2006

KKM Index: Kaufmann, Kraay, Matruzzi Index (2005)

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Frameworks for the Analysis of Governance

  • WHO’s domains of stewardship;

  • PAHO’s Essential Public Health Functions;

  • World Bank’s six Basic Aspects of Governance;

  • UNDP’s Principles of Good Governance

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WHO’s Domains of Stewardship

  • Generation of intelligence

  • Formulating strategic policy direction

  • Ensuring tools for implementation: powers, incentives and sanctions

  • Building coalition / building partnership

  • Ensuring a fit between policy objectives and organizational structure and culture

  • Ensuring accountability

(Travis et al 2001)

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PAHO’s Essential Public Health Functions

  • Monitoring evaluation and analysis of the health situation

  • Public health surveillance, research and control of risks

  • Health promotion

  • Social participation in health

  • Policies and institutional capacity for planning and management

  • Strengthening institutional capacity for regulation and enforcement

(PAHO 2002)

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PAHO’s Essential Public Health Functions

  • Evaluation and promotion of equitable access to health services

  • Human resource development and training

  • Quality assurance in personal and population-based health services

  • Research in public health

  • Reducing impact of emergencies and disasters on health

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World Bank’s Governance Indicators

  • Process by which those in authority are selected and replaced

    • Voice and Accountability

    • Political Instability and Violence

  • Ability of the government to formulate and implement sound policies

    • Government Effectiveness

    • Regulatory Burden

  • Respect of citizens and the state for institutions which govern their interaction

    • Rule of Law

    • Graft (control of corruption)

(Kaufmann 1999)

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UNDP’s Five Principles of Good Governance

(UNDP 1997)

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Contemporary Issues in the Governance of Health Systems

  • Role of the state vs. the market in health

  • Role of the ministries of health vs. other state ministries

  • Actors in Governance – public sector, civil society and the private sector

  • Static vs. dynamic health systems

  • Health reform vs. human rights-based approach to health

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Governance of the Health System: Principles

  • Strategic vision

  • Participation and consensus orientation

  • Rule of law

  • Transparency

  • Responsiveness

  • Equity and inclusiveness

  • Effectiveness and efficiency

  • Accountability

  • Information and intelligence

  • Ethics

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Health Governance Analytical Framework

  • Governance principle

    • Domain

      • Broad question

        • Specific questions / item

  • Level of Assessment

    • National

    • MOH Policy

    • Policy Implementation

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Analytical Framework for Assessing Strategic Vision

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National budget document, report of the treasury, state bank,

Reports of ministry of economics, national statistical organizations

Policy documents from MoH, analysis by international and NGOs

MoH policy/ implementation reports, media reports, external reviews

Health budget reports, budget speeches

Reviews of the health legislative process

National information policy

MoH policy/ implementation reports,

Media reports, external reviews of health policy

PRSP documents

MoH contracting manual, rules and procedures for civil servants

National statistical reports, national health reports


National and MOH policymakers,

Mid- and senior managerial staff of the MOH or its component departments,

Civil society organizations

International development agencies,

Academic institutions,

Media personnel and

Direct community representatives

Data Collection and Sources of Information

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Applying the health system governance framework to countries

Health system governance matrix of Pakistan – Strengths

  • Central level

    • Social safety nets for the poor and vulnerable;

    • Increasing role of the media and NGO’s in protecting people’s health.

  • MOH policy level

    • Preparation of draft bills to update health legislation;

    • Emerging role of the Pakistan health policy forum as a civil society organization;

    • Stable turnover of health policymakers during the last six years are positive elements

  • MOH implementation level

    • Increasing public-private interaction

    • Preventive programs, especially the LHW Program which has a strong community as well as an equity dimension

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Health governance matrix of Pakistan – Weaknesses

  • Central level

    • Lack of participatory decision making and culture of accountability;

    • Parallel streams of bureaucracy and technocracy do not work in unison

    • Adherence to rules and procedures is considered as an end;

    • Lack of consumer protection act delays or deny justice

  • MOH policy level

    • Short-term objectives override the need for focus on health outcomes;

    • Health equity is not high on the policy agenda;

    • Mechanisms to monitor transparency of decisions do not exist;

    • Decisions often tinged with personal preferences, not evidence-based;

    • Legislation on minimum standards of care is absent with lax regulation and enforcement capacity;

    • Policy, planning, health information and surveillance units are weak;

    • Delays in release and utilization of funds;

    • Accountability systems focus on procedure instead of performance;

    • Bioethics is not on the policy radar of MOH.

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Health governance matrix of Pakistan – Weaknesses

  • Policy implementation level

    • Minimal protection against hazards from personal health services;

    • Gaps exist in policy and practice for recruitment, posting and promotion of staff and rules favor seniority over meritocracy;

    • Instruments for evaluation of staff performance are improperly used;

    • Responsiveness of public sector health services is not monitored;

    • Physicians turned managers lack understanding of administrative matters while bureaucrats lack health orientation;

    • Physicians and allied staff extensively engage in private practice outside and often within public institutions;

    • Support systems function inefficiently;

    • Code of ethics exists with the professional associations but not practiced.

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Appraisal of the Framework

  • Can health governance be improved without addressing overall governance of a country?

    • Health system reforms versus broader civil service reforms

  • Health system governance assessment framework relies on qualitative approach and does not follow a scoring system

    • retains the richness of information collected

    • development of a scoring system is not precluded

  • Does the assessment framework allow for cross-country comparison of the governance function?

    • A health governance matrix can be developed for each country

  • Contemporary issues in relation to health governance included

    • Flexibility in the framework to integrate newer ones as they emerge

  • Health system governance framework does not cover

    • global health governance

    • clinical governance

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Policy Implications of Health System Governance Assessment

  • Raises awareness among policymakers about governance as a function of the health system

  • Provides an avenue for debate on a subject that is often ‘pushed under the carpet’

  • Assesses each governance principle and allows developing interventions to address them

  • Governance issues identified at three levels, allowing for measures at each

  • Improving health governance requires political commitment as well as financial resources

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Thank you

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Directly address public sector performance

Capacity development

Institutional review and strengthening

Improved information and communication

Management systems revamped

Partnership and coalition

Instill sense of greater accountability to populations

Stakeholders monitor public sector performance

Organized and empowered communities

democracy, devolution

Civil society and media have a 'watch dog’ function


Generate &synthesize evidence

Communicate to decision makers

Medical and paramedical associations

Voice and accountability

Revamped legislative and judicial system

E.g. Medical negligence

Interventions to tackle Governance of the Health System

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