Elsevier

Health Policy

Volume 90, Issue 1, April 2009, Pages 13-25
Health Policy

Framework for assessing governance of the health system in developing countries: Gateway to good governance

https://doi.org/10.1016/j.healthpol.2008.08.005Get rights and content

Abstract

Governance is thought to be a key determinant of economic growth, social advancement and overall development, as well as for the attainment of the MDGs in low- and middle-income countries. Governance of the health system is the least well-understood aspect of health systems. A framework for assessing health system governance (HSG) at national and sub-national levels is presented, which has been applied in countries of the Eastern Mediterranean.

In developing the HSG framework key issues considered included the role of the state vs. the market; role of the ministries of health vs. other state ministries; role of actors in governance; static vs. dynamic health systems; and health reform vs. human rights-based approach to health. Four existing frameworks were considered: World Health Organization’s (WHO) domains of stewardship; Pan American Health Organization’s (PAHO) essential public health functions; World Bank’s six basic aspects of governance; and United Nations Development Programme (UNDP) principles of good governance. The proposed HSG assessment framework includes the following 10 principles—strategic vision, participation and consensus orientation, rule of law, transparency, responsiveness, equity and inclusiveness, effectiveness and efficiency, accountability, intelligence and information, and ethics.

The framework permits ‘diagnoses of the ills’ in HSG at the policy and operational levels and points to interventions for its improvement. In the case of Pakistan, where the framework was applied, a positive aspect was the growing participation and consensus orientation among stakeholders, while weaknesses were identified in relation to strategic vision, accountability, transparency, effectiveness and efficiency and rule of law.

In using the HSG framework it needs to be recognized that the principles are value driven and not normative and are to be seen in the social and political context; and the framework relies on a qualitative approach and does not follow a scoring or ranking system. It does not directly address aid effectiveness but provides insight on the ability to utilize external resources and has the ability to include the effect of global health governance on national HSG as the subject itself gets better crystallized.

The improved performance of the ministries of health and state health departments is at the heart of this framework. The framework helps raise the level of awareness among policymakers of the importance of HSG. The road to good governance in health is long and uneven. Assessing HSG is only the first step; the challenge that remains is to carry out effective governance in vastly different institutional contexts.

Introduction

Governance is thought to be a key determinant of economic growth, social advancement and overall development, as well as for the attainment of the Millennium Development Goals in low- and middle-income countries. The former Secretary General of the United Nations, Kofi Annan’s statement that “good governance is perhaps the single most important factor in eradicating poverty and promoting development” is an apt reflection its need [1]. Health is the subject of Transparency International’s Global corruption report 2006, which acknowledges the vast scale of corruption in rich and poor countries however the poor are disproportionately affected, thus reinforcing the need for good governance for better health outcomes [2].

Governance is not about governments alone. United Nations Development Programme (UNDP) defines governance as the exercise of political, economic and administrative authority in the management of a country’s affairs at all levels. Governance comprises the complex mechanisms, processes and institutions through which citizens and groups articulate their interests, mediate their differences and exercise their legal rights and obligations.

Despite the growing discourse on governance [3], [4], [5], [6], [7], [8], the literature on governance of the health system is not particularly abundant. Health systems governance concerns the actions and means adopted by a society to organize itself in the promotion and protection of the health of its population [9]. In the broadest sense, this includes the institutions – the formal and informal rules that shape behavior – and the organizations that operate within these rules to carry out the key functions of a health system [10]. The World health report 2000 proposed stewardship as one of the four main functions of the health system, along with financing, creating and managing resources, and service delivery [11]. It recognized stewardship as the function of the government responsible for the welfare of the population and concerned about the trust and legitimacy with which its activities are viewed by the citizenry [11], [12], [13], [14]. Good stewardship is thus at the essence of good governance in health. However, assessing governance and stewardship has been elusive.

Section snippets

Purpose and rationale

The purpose of this article is to present a framework developed to assess the governance of the health system at national and sub-national levels. In doing so, the paper first summarizes contemporary issues in relation to the governance of the health system. Second, the different frameworks for the assessment of health system governance are reviewed. Third, the proposed health system governance principles and the assessment framework are presented. Fourth, the findings of the application of the

Contemporary issues in the governance of the health system

Health systems governance is currently a critical concern in many countries because of increasing demand to demonstrate results and accountability in the health sector, at a time when increasing resources are being put into health systems where institutional contexts are changing rapidly. An assessment framework will need to address a number of key issues summarized below.

Existing frameworks for assessing governance

Currently, a framework for assessing health system governance in countries does not exist. Prior to developing such a framework we extensively reviewed four frameworks developed for the analysis and measurement of national governance, which are briefly explored in this section. These are: (i) World Health Organization’s (WHO) domains of stewardship; (ii) Pan American Health Organization’s (PAHO) essential public health functions (EPHF); (iii) World Bank’s six basic aspects of governance; (iv)

Principles and framework for assessing health system governance

The framework for assessing HSG while adapting the widely accepted UNDP definition and the principles of governance [3], has incorporated key parameters relevant to health as articulated in the WHO’s domains of stewardship, PAHO’s essential public health functions and World Bank’s aspects of governance.

Applying the health system governance framework in a country setting

The analytical framework has been used to assess HSG in some low- and middle-income countries the results of which are being shared in a separate paper. The primary purpose of this section is to illustrate its applicability in a country setting. The HSG matrix of Pakistan for all 10 principles at the three assessment levels is illustrated in Table 3. The assessment was undertaken by a reputed civil society organization, the Heartfile in 2006, and is based on an extensive review of documents and

Appraisal of the HSG framework

There have been efforts in the past to determine the influence of governance on specific health problems such as HIV/AIDS [36], or characteristics of effective governance in community health partnership [37]. To the best of our knowledge this is the first framework that assesses governance of a national health system. The strength of this assessment framework is that governance principles are itemized into domains, and broad and specific questions that lend themselves to assessment of HSG at

Policy implications of assessing health system governance

Assessing HSG has several policy implications since it is the gateway to good governance in health. First, it raises the level of awareness among national and health policymakers of the importance of governance as a function of the health system and its influence on all other health system functions and health outcomes. It provides an avenue for debate on a subject that is often ‘pushed under the carpet’. Second, there are policy implications of assessing each governance principle, whether it

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