Health Systems and the Governance Building Block

1. Health Systems and the Governance Building Block Derick W. Brinkerhoff Global Health Council, 37th Annual International Conference Panel on Health Systems Building Blocks: How to Build Strong Health Systems that Deliver Quality Services Washington, DC June 15, 2010

2. Where does governance fit in health systems performance?

3. Defining governance • Governance is about rules that distribute roles and responsibilities among societal actors and shape interactions among them. These rules can be: • formal, embodied in institutions (e.g., democratic elections, parliaments, courts, sectoral ministries); • and informal, reflected in behavioral patterns (e.g., trust, reciprocity, civic-mindedness). • Governance encompasses authority, power, and decision-making in the institutional arenas of: • civil society • politics • policy • public administration.

4. Health governance model

5. Health governance and power inequalities

6. Governance levels

7. Responsible health governance • Responsiveness to public health needs and clients’/citizens’ preferences • Leadership to address public health priorities • Inclusion of clients’/citizens’ voice • Clear and enforceable accountability • Transparency in policymaking, resource allocation, and performance • Evidence-based policy and decision-making • Efficient, effective, and equitable service provision, regulation, and management

8. Entry points—voice & accountability: citizens  facility PAQs (Partenariats pour l’Amélioration de la Qualité) in Rwanda Quality Assurance Partnership Committees (QAPCs) in the Philippines

9. Entry points—responsiveness, accountability, transparency: central  local, public private • Transfer of resources, authority, decision-making, accountability • Examples: • Devolution of health functions to local governments, e.g., Philippines, Rwanda, Uganda • Intergovernmental transfers, e.g., District Incentive Fund grants in Rwanda • Hospital autonomy in sub-Saharan Africa • Privatization, e.g, Family Group Practices in Kazakhstan

10. Entry points—responsiveness, efficiency & effectiveness: MOH  facility • HRH planning, e.g., workforce planning in Egyptian governorates • Financial incentives, e.g, pay-for-performance • Non-monetary incentives, e.g., operations research in Swaziland on incentives for HCT performance

11. Entry points—accountability, regulation, transparency: rule of law • Medicines Transparency Alliance (MeTA), UN Convention against Corruption (UNCAC) • Improved management control systems, e.g., electronic cash registers in Mombasa, Kenya hospital • Performance-based monitoring, e.g., Global Fund accountability system and LFA oversight • Citizen report cards on health services, e.g., India and Uganda

12. A governance perspective on HSS helps to… • Identify institutional factors influencing HSS at various levels (facility  global) • Recognize the role of power and politics • Clarify connections among HS actors • Connect the HS building blocks • Focus attention on incentives for responsiveness and sustainable performance