Governance and management of public health programmes

1. Governance andmanagement of publichealth programmes Faculty of Medicine Department of Community Medicine DrSudabehMohamadi

3. Introduction to governance andmanagement of public healthprogrammes • In the 2007 publication of the World Health Organization (WHO), Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes, a critical question asked is ‘Why aren’t health systems working better?’

4. ‘The world has never possessed such a sophisticated arsenal of interventions and technologies for curing disease and prolonging life. Yet the gaps in health outcomes continue to widen. The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need in a comprehensive way, and on an adequate scale’

5. The WHO proposes a framework for action to strengthen health systems. • In the health systems framework, governance and leadership, also referred to as stewardship, is the critical function.

6. Governance: • ‘the wide range of functions carried out by governments as they seek to achieve national health policy objectives’, and involves overseeing and guiding the whole health system.

7. Governance Matters, a global study on governance by the World Bank, found empirical evidence of a strong causal relationship between better governance and better developmental outcomes.

8. The elements of governance examined were: • how governments were selected • ability to formulate and implement sound policies • the institutions which govern interactions with the state.

9. There was a strong causal relationship of good governance and higher per capita incomes, lower infant mortality, and higher literacy.

10. In a subsequent study of health system efficiency, the WHO also found a positive correlation between both the health and overall efficiency measures and ‘index of government effectiveness’.

11. Public health programmes may also be part of a growing number of huge global health initiatives (GHIs) that is changing the whole global health governance landscape.

12. In 2012, The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) channeled.

13. These global public health programmesare multinational and disbursements of funds are channeled increasingly through NGOs and in direct bilateral assistance to governments rather than the traditional intergovernmental agencies such as the agencies of the United Nations (UN), the UN Population Fund (UNFPA), the UN Children’s Fund (UNICEF), and the WHO.

14. Evolution of the conceptof governance • The Oxford English Dictionary describes governance as ‘the act or manner of governing, of extending control or authority over the actions of subjects; a system of regulations’. • In recent usage, the concept of governance is no longer understood to be synonymous with government.

15. Government-the-state is conceived as one form of governance, which is highly formalized. • Governance transcends the state, and incorporates the private sector and civil society.

16. Two definitions of governance are of particular relevance to, and reflect the essence of, public health.

17. The first, the United Nations Development Programme (UNDP), defines governance as ‘the exercise of political, economic administrative authority 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.

18. The UNDP definition recognizes the political and economic nature of social life, and the roles and interdependencies of the pillars of organized society such as the state, private sector, and civil society.

19. Governance in democratic societies emphasizes: • the source legitimacy • limits of authority • the purpose for which authority given should be applied for • accountability in its exercise

20. A second, even broader, definition of governance in a conceptual review of global health governance is ‘the action and means adopted by a society to promote collective action and deliver collective solutions in the pursuit of common goals’

21. These two conceptions of governance are of particular relevance to public health, which is ‘the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of society’.

22. Public health governance:conception The broader conceptions of governance enable a holistic perspective and better understanding of: • the mechanisms in government, the private sector, and civil society • their interactions and interdependencies • their complex and dynamic nature • how they influence and enable the goal of improving the health of people

23. This perspectiveis reflected in the two following definitions: • ‘Health governance concerns the actions and means adopted by a society to organize itself in the promotion and protection of the health of its population’ • ‘Public health governance is the means by which society collectively seeks to assure the conditions under which the population can live with the highest possible level of health and well being’

24. public health governance = health governance

25. Health governance is multilayered with mechanisms at: (1) supranational, that is, global, regional, and international (2) national, that is, federal, provincial, and local levels, with close and complex interactions between the different levels

26. Public health governance: a systemsframework • Systems theory has been applied in the WHO’s framework to strengthen health systems which comprises six components, referred to as ‘building blocks’.

28. The six system building blocks which are core functions of every health system are: (1) service delivery (2) health workforce (3) information (4) medical products, vaccines, and technologies (5) financing (6) leadership and governance

29. These six building blocks are interdependent and interrelated components of the health system.

30. Strengthening health systems, that is, making them more effective, involves improving these components and managing their interactions.

31. Systems theory provides the conceptual basis for studying, understanding, and researching how these six building blocks interrelate, and how their interdependencies can be better managed to strengthen health systems to improve health outcomes.

32. Complexity theory provides a frame for understanding of, and providing insights into, the complex and constantly evolving polyvalent relationships of the diverse actors, and the reconfigurations of influence in the multitude of networks, in global health governance.

33. The key concepts of general systems theory can be applied to health governance as a system, and comprise the following: 1. A system is composed of interrelated parts which are interconnected. 2. A system is not the sum of the components, and can only be explained in totality. 3. Systems may be open or closed, social systems are inherently open.

34. 4. Systems have boundaries which distinguish them from their environments; however, boundaries are very difficult to define in social systems. 5. There is a hierarchical relationship between the components of a system, with subsystems, and both are part of a suprasystem. 6. Open systems are in a dynamic relationship with their environment, receiving inputs which are transformed into outputs which are exported.

35. 7. Systems are subject to the forces of entropy; in open systems, however, the process can be arrested or may be reverted to a state of negative entropy by virtue of its ability to import resources from its environment and transform them into outputs. 8. Information relating to the outputs of a system, feedback into the system, and facilitating changes in the transformation process.

36. 9. Open systems tend to become more differentiated, organized, and elaborated. 10. Social systems comprise individuals and subunits, with different values and objectives and seek multiple goals. 11. Equifinality is a characteristic of open systems, which achieve their respective objectives with diverse inputs and different processes.

37. A public health governance system is part of the wider governance system of human societies (the suprasystem), wherein lie the mechanisms and actions which define the social determinants of health. • The components (the subsystems) of health governance are the entities of the state or government, the private for-profit sector, and civil society, and their respective institutions, structures, and mechanisms (subunits).

39. Three entities of the state, private sector, and civil Society can be conceived as horizontal components or subsystems each with distinct structures, institutions, organization, instruments and tools of influences, mechanisms, and processes for interactions within and between the component entities.

40. The interactions and interdependencies of these three horizontal entities, inter-digitate in a second, hierarchical dimension at either the national or supranational levels. • The organizational context of governance within the three component entities and at the two hierarchical levels is a third dimension of the system.

41. Fig. 6.8.2 Public health governance system—the entities of government, private sector, and civil society.

42. The private sector • The private sector refers to all the private business organizations and enterprises, including the informal market sector, with a profit objective.

43. The governance instruments available to the private sector are wide-ranging, and include a number of those available to government: • exhortation • expenditure • direct provision • regulations

44. The significant difference is, in traditional application of these instruments by the private sector, it is without the authority of the state, and in particular the coercive power of the state to impose penalties, withhold benefits, and restrict individual decisions. • The private sector may be given authority normally bestowed to the state.

45. ‘The privatization of governance’: • giving the private sector authority normally bestowed to the state • delegation of health professional regulations to health professions

46. ‘Private government’ has been used to describe the powerful influence of the private sector in ‘governing states’ through the threat of flight of capital as a means of getting governments to enact socioeconomic policies.

47. The private sector’s role in health governance is pervasive, as: • providers • financiers • marketers • commissioners • employers

48. Civil society • Civil society comprises individuals, and formally organized or informal groups of individuals, interacting socially, economically, and politically.

49. Civil society includes philanthropic foundations, labourunions, business forums and associations, professional associations, academic institutions, think tanks, religious groups and organizations, social and recreational clubs, cooperatives and community groups, environmental movements, lobby groups, women’s networks, youth associations, relief organizations, and media outlets.

50. Political parties are excluded if it is viewed that civil society organizations should not seek public office. • Civil society is the intermediary institution between the individual and the state.